Certain immune-cell related parameters in patients with advanced or metastatic clear cell renal cell carcinoma (RCC) may be tied to stronger responses with the combination of nivolumab (Opdivo) and ipilimumab (Yervoy), according to an analysis of the phase 2 TITAN-RCC clinical trial.

Results from the study were presented by Marc-Oliver Grimm, MD, of Jena University Hospital at the 2022 Genitourinary Cancers Symposium, and revealed that having 4-1BB or LAG-3–expressing T cells at baseline correlated with response to nivolumab induction. Moreover, nivolumab/ipilimumab boosts were associated with a high proportion of PD-L1-expressing myeloid cells and plasmacytoid dendritic cells (pDC) during boost cycles.

Response to immune checkpoint inhibitors in patients with RCC appears to vary from patient to patient. There is a need in the field to identify key predictors of response to immunotherapy. With consideration that a boost of nivolumab plus ipilimumab improved response compared with nivolumab monotherapy in patients with RCC treated in the TITAN-RCC clinical trial,

 investigators assessed characteristics of blood-circulating immune cell subsets within the study population to identify the markers of response.

TITAN-RCC included 207 patients with clear cell RCC whose disease was metastatic or locally advanced according to histologically confirmation. Patients were required to have intermediate or high International Metastatic RCC Database Consortium (IMDC) risk, be either untreated or previously treated with 1 prior tyrosine kinase inhibitor, and have measurable disease per RECIST v1.1, and a Karnofsky performance score ≥ 70.

Baseline characteristics of the intention-to-treat (ITT) population of 207 patients showed a median patient age of 65 years (range, 20-87), and the population was predominantly male (71%). Fifty-three percent of patients entered the study while in the first-line treatment setting and the remaining 47% were second line. In terms of IMDC risk factors, 18% of the ITT population had a Karnofsky performance score of < 80%, 65% had an initial RCC diagnosis < 12 months, and laboratory values including hemoglobin, platelet count, neutrophil, and calcium were adequate. Overall, 70% of the ITT population had intermediate-risk disease, 25% had poor-risk disease, and 4.3% had favorable-risk disease.

Among the 137 patients who received an immunotherapeutic boost during the study, the median age was 64 years (range, 20-86), and the cohort was also 71% male. Forty-eight of the patients were the first line and 52% were second line. IMDC risk factors were adequate and similar to the ITT population. Overall, 74% of the boost group had intermediate-risk disease, 21% had poor-risk disease, and 5.1% has favorable-risk disease.

“Patients received nivolumab induction until week 16 and continued with nivolumab maintenance upon remission. Patients who had stable disease or progressive disease or early progressive disease at week 8 continued up to 4 cycles,” explained Grimm during the presentation. The 4 cycles included immunotherapeutic boosts of nivolumab 3 kg/mg with ipilimumab 1 kg/mg in patients who were stable after 4 cycles. Nivolumab maintenance was then continued in these patients at multiple time point during induction and before each boost cycle.

Investigators looked at 198 samples from patients with RCC, 105 of whom were treated in the frontline setting, and 93 of whom were second line. The samples were evaluated using multiparametric flow cytometry for frequency and phenotype of T cell, monocyte, myeloid-derived suppressor cell (MDSC), and dendritic cell (DC) subsets. Further, uni- and multivariable logistic regression modeling was used to look into the association between treatment response and immune parameters.

By flow cytometry, immune response in the Mo, MDSC, CTL, Th, and Treg cells were evaluated. Further, single marker models that were adjusted for age and gender. Data showed that most of the markers investigated had some correlation with immune response except for CD8-positive T cells like TIM-1, VISTA, OX40, CD69, and CD28 compared with PD-1, LAG-3, CTLA-4, and others. In the CD4-positive T-cell category, only VISTA and CD69 were not associated with immune response.

Results for responders to nivolumab induction were split into 3 categories. First, of those with 4-1BB-positive, CD8-positive T cells at baseline, 41 responded to therapy while 106 did not respond (odds ratio [OR] 1.03; 95% CI, 1.01-1.07). Among the patients with 4-1BB-positive, CD4-positive T cells at baseline, there were 43 responders and 106 non-responders (OR, 1.05; 95% CI, 1.02-1.08). In the last category of patients with LAG-3-positive, CD4-positive T cell at baseline, 41 patients had a response to nivolumab induction while 106 did not respond (OR, 1.03; 95% CI, 1.01-1.05).

Looking at CD14-positive monocytes and pDC, at the time of the first boost cycle, patients with CD86-positive cells were most likely to respond to therapy compared with those with CD40-positive cells or PD-L1-positive cells. Also, ICOS positivity did not correlate with response to the nivolumab/ipilimumab boost.

Across the board in CD14-, e-MDSC-, and pDC-expressing cells, PD-L1 expression correlated with non-response to immunotherapy with nivolumab plus ipilimumab boost at cycle 1. Only 4 patients with PD-L1 expression in CD14-positive cells responded compared with 41 nonresponders (OR, 1.22; 95% CI, 1.06-1.58). In patients with PD-L1 expression in e-MDSC, there were 4 responders and 30 nonresponders (OR, 1.44; 95% CI, 1.02-1.41). Finally, in patients who have PD-L1-expressing pDC, there were only 7 responders versus 40 nonresponders (OR, 1.08; 95% CI, 1.01-1.17).

“These immune cell parameters may represent novel predictive biomarkers for the response to nivolumab and or nivolumab/ipilimumab therapy in clear cell RCC,” stated Grimm.

Grimm MO, Kesselmeier M, Leucht K, et al. Novel predictive biomarkers of response to immune checkpoint blockade with nivolumab ± ipilimumab in the TITAN-RCC phase 2 trial. 

. 2022;40(6):367-367. doi:10.1200/JCO.2022.40.6_suppl.367

Grimm MO, Esteban E, Barthelemy P, et al. Efficacy of nivolumab/ipilimumab in patients with initial or late progression with nivolumab: Updated analysis of a tailored approach in advanced renal cell carcinoma (TITAN-RCC) .

. 2021;39(suppl 5): 4576-4576. doi: 10.1200/JCO.2021.39.15_suppl.4576

Articles

Patients with 4-1BB or LAG-3–expressing T cells at baseline, or a high proportion of PD-L1–expressing myeloid cells and plasmacytoid dendritic cells during boost cycles, may be more likely to benefit from the combination of nivolumab and ipilimumab.

 Nivolumab/Ipilimumab Efficacy in Clear Cell RCC May Be Tied to Certain Immune-Cell Related Parameters

Ongoing research efforts are designed to understand cisplatin-induced hearing loss in young children in order to proactively prevent it, according to Bruce Carleton, PharmD, FCP, FISPE.

Specifically, Carleton, University of British Columbia, Department of Pediatrics, Division of Translational Therapeutics, and his colleagues, are investigating how cisplatin interacts with other drugs, as well as the role of genetics, in impacting the extent of 

hearing loss in children under the age of 5

 Carleton highlights how this area of research can have a profound and lasting impact on a child’s quality of life.

“Sometimes, we refer to adverse [events] (AEs), as “side effects.”I really think that minimizes the harm that is occurring. I'm not suggesting that these drugs are bad; these drugs have wonderful beneficial effects, but they're not [perfect].”

“Automobiles are the same thing. Right? They are wonderful gifts to humanity in terms of moving us from one place to another, and the convenience, but they have a dark side, which is injury that can occur—particularly when they're not operated properly. Drugs are the same way: we need to understand how to operate with them in the best possible way to maximize benefit and minimize harm.”

 that sometimes parents and providers are willing to accept the risk of hearing loss in order to preserve survival, but that it is not a choice he believes should be necessary in the future.

“That’s not the choice I think parents should have to make­—or any of us should have to make,” he said. “Why can't we have the beneficial effects without the adverse effects? That's the [research] that [my lab] is [currently] working on.”

Videos

An expert discusses the consequences of cisplatin-induced hearing loss and ongoing research efforts to eliminate this associated risk for children receiving the treatment.

More Than A “Side Effect”: Why Pediatric Hearing Loss Is So Detrimental

The FDA granted accelerated approval to asciminib (Scemblix) for the treatment of adult patients with Philadelphia chromosome–positive chronic myeloid leukemia in chronic phase (Ph+ CML-CP) who have received prior treatment with 2 or more tyrosine kinase inhibitors (TKIs), as well as for the treatment of adult patients with Ph+ CML-CP and a 

mutation. The novel agent, also known as a STAMP inhibitor, functions by binding to the ABL myristoyl pocket. The accelerated approval program dictates that continued approval is contingent upon verification and confirmatory evidence of clinical evidence.

“The introduction of TKIs 20 years ago revolutionized treatment for CML. However, there remain many patients who do not respond adequately to at least 2 available treatments and often experience challenging [adverse] effects [AEs] that add a burden to their daily lives,” Lee Greenberger, PhD, chief scientific officer of the Leukemia and Lymphoma Society, said in a press release. “The approval of Scemblix may offer hope to patients by addressing gaps in CML care.”

The approval was based on findings from the phase 2 ASCEMBL trial (NCT03106779), which showed that asciminib resulted in a major molecular response (MMR; 25%), double that of bosutinib (Bosulif; 13%) at 24 weeks (

 = .029) in previously pretreated patients with Ph+ CML-CP. In addition, 7% of the 156 patients receiving asciminib needed to discontinue treatment because of AEs, compared with 25% in the bosutinib cohort.

Notable AEs from the trial included laboratory abnormalities, upper respiratory tract infections, musculoskeletal pain, a decrease in platelet and neutrophil counts, a decrease in hemoglobin level, and an increase in triglycerides, creatine kinase, and alanine aminotransferase levels.

“CML can be difficult to treat when currently available treatments fail patients, when treatment [adverse] effects cannot be tolerated, or sometimes both,” said Michael J. Mauro, MD, hematologist and leader of the Myeloproliferative Neoplasms Program at Memorial Sloan Kettering Cancer Center. “The addition of Scemblix into the CML treatment landscape gives us a novel approach to combat this blood cancer, helping address clinical challenges in patients struggling after switching to a second treatment, as well as in patients who develop the 

 mutation and face significantly worse outcomes.”

FDA approves Novartis Scemblix (asciminib), with novel mechanism of action for the treatment of chronic myeloid leukemia. News release. Novartis; October 29, 2021. Accessed October 29, 2021. https://bit.ly/3GoBu4k

The FDA have granted an accelerated approval to acimibinib, which treats CML by binding to the ABL myristoyl pocket.


FDA Approves Asciminib for Treatment of 2 CML Subtypes

One in 6 patients with colorectal cancer (CRC) harbor genetic changes that substantially increase their risk for cancer, especially in those who are younger at the time of diagnosis, according to the data from a prospective, multicenter study published in 

A total of 361 patients with CRC enrolled on the study and underwent germline genetic testing with a panel that included approximately 80 genes known to increase risk for cancer.

 Results showed that these cancer-linked genetic changes were detected in 15.5% of patients with CRC (n = 56). Moreover, these changes predominantly occurred in high-penetrance cancer susceptibility genes like 

. A younger age at diagnosis was also linked with increased likelihood of genetic changes associated with increased susceptibility to cancer.

“Colorectal cancer is one of the most common types of cancer. Recently, we've seen an unfortunate increase in incidence among people younger than 50-years-old. Improving our understanding of who is at risk and implementing appropriate screening strategies is essential to ensuring these cancers are caught and treated earlier when outcomes are typically better,” Robert Nussbaum, MD, chief medical officer of Invitae Corporation, stated in a press release. “Access to information about inherited risk factors is also important after diagnosis, not only for the patients themselves…but also in alerting other family members of the need to be tested to see if they are also at increased risk and need more intensive surveillance to catch cancer early and prevent more serious disease.”

Hereditary factors are key players in the risk of developing several cancers. The detection of a germline predisposition can impact treatment decisions, risk-reducing interventions, cancer screening, and testing, in patients and their relatives. The impact of broad-based testing for inherited germline variants in patients with cancer vs traditional strategies of selection for genetic testing remains an open question.

In this study, investigators sought to examine the occurrence of pathogenic and likely pathogenic germline variants (PGVs) in inherited cancer susceptibility genes identified by a broad universal testing approach vs a targeted approach based on clinical guidelines. Investigators also wanted to evaluate the link between universal genetic testing and clinical management and the proportion of families who receive cascade family variant testing (FVT) when available at no cost.

For the prospective study, investigators enrolled patients with solid tumors who were receiving care at any of the 3 Mayo Clinic Cancer Centers or the Mayo Clinic Health System from April 2018 to March 2020. Patients were between 18 years and 85 years of age, had a new or active cancer diagnosis, confirmed pathologic diagnosis of carcinoma, and received treatment in medical oncology, radiation oncology, dermatology, or surgical clinics. Those with malignant hematologic cancers and those who were under surveillance following curative cancer, were not included in the study.

Participants were selected for cancer type, disease stage, family history of cancer, race/ethnicity, or age. All had undergone germline testing with a next-generation sequencing platform that tested for 83 genes; as of July 2019, it tested for 84 genes. Test results were analyzed by a certified genetic counselor; those with PGVs were offered genetic counseling. PGVs were classified as either high, intermediate, or low penetrance or recessive actionable variants; relative risk in these subsets was greater than 4, between 2 and 4, and less than 2, respectively.

“A PGV was considered incremental if it was detected based on the universal testing performed in this study and would not have been identified in targeted testing approaches recommended by published guidelines,” the study authors noted.

Additionally, free cascade FVT was offered to all blood relative of participants with PGVs within a 90-day window of the final test results. Patients were educated about the FVT program during genetic counseling; they were also provided assistance in relaying this information to their relatives via a letter and online video that detailed the benefits and risks of genetic testing.

The final analytic cohort included 2984 patients, who had a median age of 61.4 years; 53% of the patients were male. Additionally, at the time of genomic analysis, 18.6% (n = 535) of patients had stage 0/I disease, 16.7% (n = 477) had stage II disease, 20.7% (n = 593) had stage III disease, and 43.9% (n = 1257) had stage IV disease. Just over 5% (5.3%; n = 159) of patients were Hispanic/Latino, 3.7% were African American (n = 110), and 1.8% were Asian (n = 53). Moreover, 34.1% (n = 1019) of patients had a family history of cancer in a first-degree relative.

Of the 2984 total patients, 13.3% (n = 397) were found to harbor 426 PGVs. In 27 patients, more than 1 PGV variant was identified; 2 of these patients had 3 variants detected. Moreover, 149 of the PGVs had high penetrance, 133 had moderate penetrance, and 65 had low penetrance. Fifty patients were noted to harbor variants linked with recessive syndromes.

. Approximately 47% of patients (n = 1415), variants of uncertain significance. The incidence of PGVs in different cancer types ranged; the incidence was 20.6% for ovarian cancer, 15.9% for pancreatic cancer, 15.3% for colorectal cancer, 13.7% for prostate cancer, 14.7% for lung cancer, 14.5% for cholangiocarcinoma, 13.3% for endometrial cancer, and 14.2% for bladder cancer.

Notably, the variant rate by cancer stage was found to be similar; this rate was 13.7% in stage 0 to II disease and 13.1% in stage III to IV disease (

 = .24). Patients who had a family history of cancer in the same organ system were found to have a high rate of PGVs of 21.8%.

Additional data indicated that 192 cases had incremental findings that would not have been identified via phenotype or family history–based testing criteria using established guidelines; this accounted for 6.4% of the overall cases and 48.4% of the 397 patients with PGVs. Of these 192 patients, 18.2% (n = 35) had high-penetrance PGVs, 43.2% (n = 83) had low-penetrance PGVs, and 17.2% (n = 33) had recessive-penetrance PGVs. Of the 149 patients with high-penetrance PGVs, 28.2% (n = 42) experienced clinically actionable management and treatment adjustments indicated by the PGVs that were identified.

Additionally, 17.6% (n = 70) of patients with PGVs had relatives that accepted and underwent FVT within a 3-month window of their test result. Forty-five percent (n = 79) of the 176 family members had positive results.

Data from logistic regression analyses indicated that younger age at the time of cancer diagnosis was linked with a higher likelihood of having a PGV (odds ratio [OR], 1.38; 95% CI, 1.06-1.78). Although patients who had CRC, pancreatic cancer, or prostate cancer were noted to have comparable PGV prevalence vs those with breast cancer, those with melanoma were observed to have a significantly lower likelihood of having PGVs (OR, 0.58; 95% CI, 0.32-1.00).

“In this large, prospective multisite cohort study with a broad mixture of cancer types and stages, a variety of academic and community cancer practices, and patients unselected for family cancer history, universal multigene panel testing was associated with increased detection of clinically actionable, heritable variants over the predicted yield by targeted testing based on clinical guidelines,” the study authors concluded. “This study offers significant insight into the performance of multigene panel testing and has broad implications for its wide clinical implementation and acceptance in oncology practice.”

Samadder N, Johnson D, Boardman L, et al. Comparison of universal genetic testing vs guideline-directed targeted testing for patients with hereditary cancer syndrome. 

. 2021;7(2):230-237. doi:10.1001/jamaoncol.2020.6252

Study finds risk-causing genetic changes in nearly 1 in 6 patients with colorectal cancer. News release. Invitae Corporation. April 15, 2021. Accessed April 23, 2021. 

This article was originally published on OncLive as, "

Universal Genetic Testing Reveals Variants Linked With Increased Cancer Risk in CRC.

Genetic Changes Linked to Increased CRC Risk

As targeted therapies continue to evolve in the cancer space, it is essential for clinicians to understand the basics of genomics, especially when it comes to hematologic malignancies.

“There are many different lymphoma subtypes, and they’re distinguished by their histology, their immune phenotyping, and their underlying genetic abnormalities,” said Eric Hsi, section head of hemapathology and medical director of the automated hematology, flow cytometry, and immunohistochemistry laboratories in the Institute of Pathology and Laboratory Medicine at the Cleveland Clinic.

Hsi recently discussed the basics of blood cancer pathology at the 2020 NCCN Virtual Congress on Hematologic Malignancies.

There are 3 types of abnormalities that can occur in a patient’s DNA, Hsi explained. They are:

Gene copy number abnormalities: In this situation, clinicians would be looking for gains and losses. These can be detected by routine karyotyping, flourescense in situ hybridization (FISH), DNA microarrays, and next-generation sequencing (NGS).

Structural variants: This is known as translocations and rearrangements, and occurs when genes or chromosomes move. This can also show up on routine karyotyping, and FISH tests, as well as PCR-based assays and NGS-based methods.

Mutations: When a DNA sequence changes, it can alter the function of that protein. To see if a patient has a genetic mutation, clinicians will conduct Sanger sequencing, allele-specific PCR, or NGS-based methods.

Undergoing molecular testing is crucial for patients with blood cancers, because not only will it give better insight to the type of cancer the patient has, but also what the best treatment regimens may be.

Anaplastic large cell lymphoma (ALCL) is characterized by expression of CD30. However, it is also crucial to know patients’ ALK status, which can be determined by an immunohistochemical test.

“We distinguish positive and negative anaplastic large lymphomas because of the favorable prognosis of positive cases,” Hsi said. “So it’s important to know whether ALK is translocated and overexpressed in these lymphomas.”

ALK-positive ALCL tends to have a much better prognosis than ALK-negative disease, because there are treatments that target ALK, a tyrosine kinase.

Patients with follicular lymphoma should also undergo genetic testing. In June, the 

 for relapsed/refractory follicular lymphoma that harbors an EZH2 mutation.

The drug was approved alongside a companion diagnostic test that would determine if a patient has the mutation.

“This is another example of where detecting a molecular abnormality would help us select a therapy,” Hsi said.

Oncology nurses can be advocates in ensuring that their patients undergo the genetic testing that is needed for their disease type and treatment options.

“Molecular testing is routinely used by pathologists for diagnosis, prognosis, and also guiding therapy selection either for targeted or non-targeted therapies,” Hsi said.

It is imperative that patients diagnosed with blood cancer undergo the proper molecular testing, one expert says.
 

Molecular Testing Guides Diagnosis, Treatment in Blood Cancers

With the emergence of several targeted treatments that have shown efficacy in individuals with germline pathogenic variants, specifically in DNA mismatch repair, the need for germline genetic testing has become even more pronounced, according to Elena M. Stoffel, MD, MPH. Results could lead to the identification of Lynch syndrome and other hereditary cancer syndromes associated with the risk of developing colorectal cancer (CRC) and other diseases.

“We [have] information on the importance of assessing for Lynch syndrome: How to test people for Lynch syndrome, how to treat Lynch-associated cancers, and how to prevent cancers in Lynch syndrome,” said Stoffel. “However, really being able to translate [what we learn] from the studies into clinical [practice] and the care for patients is really where we are now. Building the awareness, developing the systems, and providing the education to both providers and patients is [what is needed].

One study led by investigators at Memorial Sloan Kettering Cancer Center enrolled 15,405 patients with Lynch syndrome pan-cancer with microsatellite instability—high (MSI-H) and MSI-indeterminant tumors.

The MSK-IMPACT next-generation sequencing platform was used to identify Lynch syndrome in 16.3%, 1.9%, and 0.3% of patients with MSI-H, MSI-indeterminate, and microsatellite-stable tumors, respectively (P < .001). The study also indicated that Lynch syndrome extends beyond CRC and endometrial cancers and affects numerous other tumor types, including urothelial cancers, ovarian cancers, specific sarcomas, and several other hypermutated tumors, Stoffel added.

“What we were diagnosing as Lynch syndrome, historically, was probably just the tip of the iceberg. Many more patients are out there with Lynch syndrome who remain undiagnosed,” explained Stoffel. “The potential of making that diagnosis, not only for the treatment of patients with cancer, but also for the cancer prevention in their family members is really important.”

, during the 2020 Institutional Perspectives in Cancer webinar on Precision Medicine, Stoffel, an associate professor at Michigan Medicine, University of Michigan, further discussed the importance of genetic testing in detecting Lynch syndrome and other hereditary syndromes associated with risk of CRC and other cancers.

What has been learned in recent years with regard to germline testing for Lynch syndrome cancers?

[Results from] many of the published studies have told us that the number of patients who carry germline alterations associated with genetic predisposition is actually much higher than we previously thought. The clinical presentations of some of these patients can be very different from what has been described in the original papers. Now, we know that Lynch syndrome, which is one of the most common hereditary cancer syndromes, has a population prevalence of about 1 in 300. Many patients who develop Lynch syndrome cancers could be identified if we broaden our search for these germline mutations. Given recent advances in therapy for hypermutated tumors, this is especially relevant in both cancer treatment and also prevention in these affected families.

Do any barriers to genetic counseling or germline testing exist for Lynch syndrome?

Barriers exist on multiple levels. First, the patient's physician or clinician needs to consider the possibility of Lynch syndrome, because if they don't think about that, they’re going to miss the diagnosis.

Secondly, although there are recommendations for universal tumor testing for colon and endometrial cancers, many clinical sites don't have access to testing tumors for dMMR. That universal screening only gets applied at centers where they have the pathology resources available. Thirdly, even when the providers have identified the need for genetic testing, being able to convey the importance of that to patients and make it easier for them to seek genetic evaluation remains a barrier.

Fortunately, over the past few years, many more insurances are covering genetic testing; the cost of testing has [also] decreased. Additionally, new models for accessing genetic services exist so patients no longer have to travel to a genetic specialty clinic. In many cases, providers can order the testing themselves if they're comfortable with that. They can also refer [their patients] to telehealth services, which are trying to improve access to genetic testing. [However], a patient has to be motivated to seek out that extra testing. Our ability to explain to patients why this information is important is really the key to improve access to genetic testing.

How should genetic testing be approached in a clinical practice? When should this testing take place in the treatment journey?

We can think about this in different ways. In an oncology practice, ASCO has recommended that, at the basic intake appointment, the clinician obtain a family history from patients that includes cancer diagnoses, as well as dates and ages of diagnoses for all first- and second-degree relatives. The goal of that should be to prompt the question: How likely is it that this patient's tumor developed in the context of a genetic predisposition syndrome?

If the answer to that is possibly or likely, then a discussion should take place in terms of further evaluation. For many tumor types now, testing tumors has become a part of the treatment pathway. Certainly, being able to identify whether tumors are hypermutated and whether tumors have dMMR should also be [done] early on in the treatment algorithm, as well as the diagnostic evaluation for hereditary cancer syndromes.

Now that many targeted treatments have emerged as being particularly effective in individuals who have germline pathogenic variants, specifically in DNA mismatch repair or in double-stranded DNA repair, germline genetic testing should be part of the discussion at the first intake when patients are discussing what possible treatments are in store for them.

Could you discuss the importance of testing MSI-H patients for Lynch syndrome?

Approximately 15% to 30% of all colon cancers are MSI-H. Of all colon cancers, about 3% correspond to Lynch syndrome. For several years now, universal tumor screening for dMMR has been recommended as a best practice. Doing universal tumor testing is 1 thing; following up on all those results is another. When a patient has colon cancer, what’s the mismatch repair status of the cancer? If it's dMMR, has this patient been evaluated for the possibility of Lynch syndrome? Making this part of our systematic checklist is an important way to proceed.

What studies are particularly important in this field?

First of all, Matthew Yurgelun, MD, of Dana-Farber Cancer Institute, [has a] study that was published in the Journal of Clinical Oncology and demonstrated that of all unselected CRCs, approximately 10% carry germline pathogenic variants. Of those, Lynch syndrome is the most important group of genes involving the DNA mismatch repair genes. However, other genes are there as well, including genes associated with hereditary breast and ovarian cancer, or BRCA genes. BRCA1/2 and PALB2 emerge in some individuals with CRC. It just goes to show that there is overlap among the different hereditary predisposition syndromes with regard to cancer development and risk.

Another important study was [conducted at the University of Michigan] and the Ohio State University Comprehensive Cancer Center—James. Results showed that among unselected individuals with colon cancer diagnosed at an age under 50 years, the prevalence of germline mutations is about 20%; this translates to about 1 in 5 [patients]. As such, it’s particularly important to offer germline genetic testing to that group.

Finally, the group from Memorial Sloan Kettering Cancer Center looked at the prevalence of Lynch syndrome among hypermutated tumors, which basically shows us that the spectrum of cancers associated with Lynch syndrome goes beyond CRC and endometrial cancers, which are the 2 hallmark cancers. It also extends to urothelial cancers, ovarian cancers, certain sarcomas, and several other tumors for which the diagnosis of Lynch syndrome would not have necessarily been considered, except for the fact that these tumors are hypermutated and look very different from other tumors in their group.

As with most [findings] in oncology, once there is a therapeutic implication, that tends to gain traction; even though we've known that diagnosing Lynch syndrome makes a big difference for the care of [patients with] cancer and family members, the fact that it can actually influence our treatment algorithms now makes it really important to address up front.

What significant clinical challenges remain in implementing genetic testing?

From the provider end of things, many are uncomfortable with genetic testing to the point where they're uneasy discussing it with patients because they don't have the familiarity with the process for diagnostic testing or for the interpretation of genetic test results. The more we can educate our clinical providers in what genetic testing is and why it's important, the easier it's going to be to talk to patients about it, and the more patients are going to recognize the importance of getting tested.

What is your take-home message regarding genetic testing?

For every patient we see, we should consider the likelihood that the cancer was the result of a hereditary cancer syndrome and what can be done to figure that out. Now that tumor testing has become a part of many of our treatment algorithms, that provides us with a great opportunity to be able to look for the tumor phenotypes. We can also do a better job of taking family histories from patients and think about the pattern of cancer in the family, and [whether it points to the] possibility of an underlying genetic predisposition. If we think about it, then we're less likely to miss it.

Latham A, Srinivasan P, Kemel Y, et al. Microsatellite instability is associated with the presence of lynch syndrome pan-cancer. J Clin Oncol. 2018;37(4):286-295. doi:10.1200/JCO.18.00283

Stoffel Underscores Importance of Germline Testing for Lynch Syndrome

With the emergence of several targeted treatments that have shown efficacy in individuals with germline pathogenic variants, specifically in DNA mismatch repair, the need for germline genetic testing has become even more pronounced. 

Germline Testing for Lynch Syndrome: More Important Than Ever

As genetics continue to play a major role in gynecologic cancer treatment, it is imperative that patients understand its implications. Nurses can be key in educating patients and dispelling any myths and misconceptions that they may have.

A recent study presented at the 2020 ONS Bridge virtual conference analyzed patients’ understanding of cancer in the world of oncology. Study author Rachel Pozzar, PhD, RN, of the Dana-Farber Cancer Institute, recently discussed her team’s findings with 

: Can you explain your study and its significance? 

This was a secondary analysis of data collected as part of a larger study, led by Meghan Underhill-Blazey, PhD, APRN, AOCNS, that assessed the experiences of breast and gynecologic cancer survivors who underwent genetic counseling and multigene panel testing. The purpose of this study was to better understand knowledge of cancer genetics among participants with a primary diagnosis of ovarian cancer.

Knowledge of cancer genetics in this population is an important topic because more than 20% of ovarian cancer cases are associated with an inherited pathogenic variant. From prior research, we know that individuals who are confident in their knowledge of cancer genetics are more likely to share their genetic test results with relatives. In turn, these relatives may benefit from genetic testing and certain risk-reducing interventions. 

One of our main findings was that participants who scored below the sample average on our measure of cancer genetics knowledge expressed interest in face-to-face results disclosure, visual learning aids, and simplified language in written and verbal communication. We also found that older age was significantly associated with lower cancer genetics knowledge, which is important because older adults may serve as a resource for family members who seek information about their family's health history. 

Are there misconceptions or gaps in knowledge for patients with ovarian cancer when it comes to genetics? Why?

One important gap in knowledge we observed was that only about half of participants were aware that female-specific cancer risk, such as for ovarian cancer, can be inherited from either the father or the mother. Similarly, fewer than half of participants were aware that people with an inherited risk for cancer may get cancer at a younger age, or that they may be at risk for more than one type of cancer. These misconceptions are likely common because the principles of cancer genetics are complex, and the field is rapidly evolving. 

What role does the oncology nurse play in educating patients and their families? 

The findings of this study highlight the need for nurses and other clinicians to ensure that the language and materials they use to educate patients is clear, free of jargon, and perhaps supported by a visual aid. Although genetic counselors provide much of the initial education that takes place prior to genetic testing, nurses can reinforce this teaching, identify unmet learning needs, and help the patient identify reliable sources of cancer genetics information.

What are the next steps in this line of research? Are there any unanswered questions? 

The results of this study highlight the role of patient-provider communication in cancer genetics education. My broader program of research is focused on promoting patient-provider communication that meets patients’ unique needs and preferences—what is often called “patient-centered communication.” Research suggests patient-centered communication has the potential to promote knowledge retention and to prompt family conversations about hereditary cancer risk.

One priority for nurse scientists is to develop and test strategies that promote patient-centered communication in the ovarian cancer care setting. As nurses, it’s crucial for us to ensure that all patients, regardless of age or diagnosis, understand what their genetic test results mean for themselves and their families.

Nurses play a key role in ensuring that patients with gynecologic cancer understand the results and implications of genetic testing.
 

Gynecologic Cancer Genetics: Patient-Provider Communication Is Critical

The FDA has approved Guardant360® CDx for comprehensive genomic profiling in patients with any solid malignant cancer, according to an announcement from Guardant Health, Inc.

 The assay is also approved as a companion diagnostic to detect EGFR mutations in patients with non&shy;—small cell lung cancer (NSCLC) who could potentially benefit from osimertinib (Tagrisso).

The regulatory decision was based on both clinical and analytical data from over 5,000 samples, which provided validation for the test.

“The FDA approval of Guardant CDx is a landmark decision, demonstrating the value liquid biopsy delivers to oncologists and more importantly, the patients they treat. Traditional tissue biopsy-based tumor profiling, which is often invasive and has longer turnaround times, can contribute to delays in starting treatment and possibly suboptimal therapy,” Helmy Eltoukhy, CEO of Guardant Health, stated in a press release.

“We applaud the FDA for their collaborative review process and for approving the first comprehensive genomic profiling liquid biopsy test,” added Eltouky. “We are confident that our FDA approval will help accelerate wider adoption of guideline-recommended genomic profiling, increase the number of advanced cancer patients who receive potentially life-changing treatments, and pave the way for new companion diagnostic developments for the Guardant360 CDx.”

Results from a retrospective analysis of findings from the phase 3 FLAURA and AURA3 trials showed that patients who had been identified for osimertinib treatment by the Guardant360 CDx test experienced progression-free survival (PFS) rates that proved to be consistent with those identified through the use of traditional biomarker testing, according to Guardant Health.

Data from the phase 3 FLAURA trial indicated that treatment with osimertinib led to a significant overall survival compared with erlotinib (Tarceva) or gefitinib (Iressa) in patients with EGFR-mutated locally advanced or metastatic NSCLC.2 Previously reported PFS data from the trial led to the April 2018 FDA Approval of the agent for use in this setting.

Data from the trial demonstrated that osimertinib led to a 54% reduction in the risk of progression or death compared with erlotinib or gefitinib. The median PFS with osimertinib was 18.9 months with osimertinib versus 10.2 months with standard treatment (HR, 0.46; 95% CI, 0.37-0.57; P <.0001).

A total of 556 patients with treatment-naïve EGFR-mutated locally advanced or metastatic NSCLC were enrolled on the trial. These participants were randomized to receive either osimertinib (n = 279) or erlotinib or gefitinib (n = 277). Notably, participants with central nervous system (CNS) metastases were permitted to participate. All included had exon 19 deletions or L858R mutations. Patients received oral osimertinib at 80 mg daily, or 250 mg of gefitinib or 150 mg of erlotinib daily.

Notably, the PFS benefit was found to be upheld across all of the patient subgroups analyzed. In the 116 patients with CNS metastases, the median PFS with osimertinib versus a standard TKI was 15.2 months and 9.6 months, respectively (HR, 0.47; 95% CI, 0.30-0.74; P = .0009). In the 440 participants who did not have CNS involvement, the median PFS was 19.1 months in the osimertinib arm compared with 10.9 months in the standard arm (HR, 0.46; 95% CI, 0.36-0.59; P <.0001).

Moreover, the objective response rates (ORRs) were 77% versus 69% with osimertinib and standard treatment, respectively, and the median duration of response was 17.6 months and 9.6 months, respectively.

With regard to safety, the most commonly reported toxicities with osimertinib included diarrhea (58%) and dry skin (32%); in the control group, the most common all-grade adverse effects (AEs) were diarrhea (57%) and dermatitis acneiform (48%). Grade 3 or higher effects were reported in 33.7% of patients in the investigational arm versus 44.8% of those in the control arm. Notably, those who received treatment with osimertinib were less likely to discontinue treatment because of toxicities compared with those who receive standard TKI treatment, at 13.3% versus 18.1%, respectively.

In March 2017, the FDA has granted a regular approval to osimertinib for use in patients with EGFR T790M mutation—positive NSCLC post treatment with an EGFR TKI, based on PFS data from the pivotal phase 3 AURA3 trial.

In this trial, treatment with osimertinib resulted in a median PFS of 10.1 months versus just 4.4 months with platinum-based chemotherapy (HR, 0.30; 95% CI, 0.23-0.41; P <.001). In those with CNS metastases, the median PFS with osimertinib was 8.5 months versus 4.2 months with chemotherapy (HR, 0.32; 95% CI, 0.21-0.49).

In the open-label trial, a total of 419 patients were randomly assigned 2:1 to receive either osimertinib (n = 279) versus a platinum-based chemotherapy regimen (n = 140). Oral osimertinib was given at 80 mg once daily in a 21-day treatment cycle. Those in the chemotherapy arm received either pemetrexed/carboplatin or pemetrexed/cisplatin. Pemetrexed was given at 500 mg/m2, carboplatin at a dose of 5 AU, and cisplatin at 75 mg/m

Results showed that osimertinib led to a 71% ORR compared with 31% in those who received chemotherapy (odds ratio, 5.39; 95% CI, 3.47-8.48; P <.001). Moreover, osimertinib showed a 6-month PFS rate of 69% versus 37% with chemotherapy. The 12-month PFS rates were 44% and 10% in the osimertinib and chemotherapy arms, respectively.

Regarding safety, the most common toxicities reported with osimertinib were diarrhea (41%), rash (34%), dry skin (23%), and paronychia (22%). In patients who received the chemotherapy, the most common all-grade AEs included nausea (49%), decreased appetite (36%), constipation (35), and fatigue (28%).

Grade 3 or higher toxicities occurred in 23% and 47% of those on the osimertinib and chemotherapy arms, respectively. Neutropenia (12%), anemia (12%), and thrombocytopenia (7%), were among the most commonly reported grade 3 or higher AEs experienced in the chemotherapy arm.

“Personalized medicines such as [osimertinib] have been truly life-changing for many [patients with] who have certain EGFR mutations and are most likely to benefit from this medicine,” Jhanelle Gray, MD, senior member and chair in the Department of Thoracic Oncology and co-leader of Chemical Biology & Molecular Medicine Program at Moffitt Cancer Center, added in the release. “It is crucial that all patients are comprehensively tested before starting treatment to ensure they receive the most appropriate personalized treatment option available.”

1. Guardant Health Guardant360® CDx first FDA-approved liquid biopsy for comprehensive tumor mutation profiling across all solid cancers. News release. Guardant Health, Inc. August 7, 2020. Accessed August 7, 2020. https://bit.ly/2C6asTE.

2. Tagrisso significantly improves overall survival in the Phase III FLAURA trial for 1st-line EGFR-mutated non-small cell lung cancer. AstraZeneca. Posted August 9, 2019. Accessed August 9, 2019. https://bit.ly/2ZGF7gZ.

3. Ramalingam S, Reungwetwattana T, Chewaskulyong B, et al. Osimertinib vs standard of care (SoC) EGFR-TKI as first-line therapy in patients (pts) with EGFRm advanced NSCLC: FLAURA. Ann Oncol. 2017;28(suppl 5):v635. doi:10.1093/annonc/mdx440.050

4. Mok TS, Wu YL, Ahn MJ, et al. AURA3 Investigators. Osimertinib or platinum—pemetrexed in EGFR T790M—positive lung cancer. N Engl J Med. 2017;376(7):629-640. doi:10.1056/NEJMoa1612674

FDA Approves Guardant360 CDx Liquid Biopsy for Comprehensive Genomic Profiling Across All Solid Cancers

The FDA has approved Guardant360® CDx for comprehensive genomic profiling in patients with any solid malignant cancer.

FDA Approves Guardant360 CDx Liquid Biopsy for Genomic Profiling for Solid Cancers

Genetic testing is more important now than ever before, as biomarker-driven cancer treatments continue to receive approval across many tumor types. While these personalized treatments are improving outcomes, navigating the landscape of genetic testing can leave patients with questions for their providers.

In a presentation during the 4th Annual School of Nursing Oncology virtual meeting hosted by Physicians’ Education Resource®, LLC (PER®), Emily Mazzei, MS, MPH, CGC, a licensed, certified genetic counselor, provided an overview of current recommendations for genetic counseling in oncology and discussed some of the questions commonly asked.

Mazzei reviewed the difference between somatic testing, also known as germline or tumor testing, and germline testing. Somatic changes are not hereditary, as they occur in the cancer cells themselves, according to Mazzei; germline mutations are present in a patient since birth, since they are passed down from parents to children.

“Depending on what your patient population looks like, you may be seeing that your patients have 1 of these types of genetic tests or both,” Mazzei said. “Somatic testing is becoming a little more commonplace, or [even as] routine as genetic testing. Generally speaking, panel testing is now standard of care.”

In a panel test, patients will be tested for genes associated with their cancer, as well as those that typically fall outside of their cancer type. However, patient choice also plays a role in what kind of testing they will receive, noted Mazzei.

“It also depends on the patient’s preferences. Some want to just focus on the specific cancer type that they have,” Mazzei said. “It also depends on the institution and what the genetic counselors and ordering physicians prefer.”

Genetic Findings Affect Treatment and Family Members

Genetic testing results have become crucial in determining the type of treatment a patient receives. For example, the FDA most recently approved the combination of atezolizumab (Tecentriq) plus cobimetinib (Cotellic) and vemurafenib (Zelboraf) for patients with BRAF V600 mutation—positive melanoma. Only when a mutation or alteration has been detected can a patient be considered for a potential targeted treatment.

Additionally, if a germline mutation is detected in a patient, their immediate family may also be at higher risk for cancer, according to Mazzei. Family members are then faced with the decision of whether they want to undergo testing—that is not an easy choice for many people, Mazzei explained.

“A large part of our role is providing psychosocial support to these patients,” she said. “Essentially, we give them the information they need to help them make the decisions on whether they want to pursue genetic testing when it’s medically indicated.”

The cost of genetic testing is another concern that patients and their family members often have, particularly with regard to whether it will be covered by insurance, Mazzei noted.

“Most insurance companies will cover their genetic counseling, a face-to-face appointment with a genetic counselor,” Mazzei said. “Most insurance companies will cover all, or some, of the genetic or germline testing, if ordered appropriately and clinically indicated.”

As such, Mazzei recommended that prescribing clinicians work closely with genetic counselors to ensure that testing is correctly ordered, thus increasing the chance that it will be covered by their patients’ insurance.

While the majority of patients who undergo genetic testing for cancer are adults, there are some instances when children under the age of 18 should be tested, according to Mazzei.

Children who should be tested include those with a family history of a pathogenic gene mutation, such as polyposis syndromes, multiple endocrine neoplasia type 2, and Li Fraumeni syndrome (LFS). Those with a personal history or current diagnosis of cancer may also be tested. LFS can lead to potential increased risk of sarcoma, leukemia, and brain tumors, and PTEN Hamartoma Tumor Syndrome can lead to increased risk of macrocephaly, developmental delay, or thyroid cancer.

“The reason for [this testing in this population] is for medical intervention for these specific conditions,” Mazzei said.

However, not everyone under the age of 18 should be tested, despite their relatives’ genetic testing results or cancer history. For example, there is no medical intervention for children with BRCA mutations or Lynch syndrome.

“We also want the patient or the person pursuing genetic testing to be autonomous when making this decision, so that’s why we only recommend testing these childhood conditions and not adult-onset conditions, even though the parents may be wondering whether their child does have that,” Mazzei concluded.

Mazzei E. Cancer genetic counseling. Presented at: 4th Annual School of Nursing Oncology. July 31-August 1, 2020.

Cancer and Genetic Testing: Expert Answers Common Questions

Hematologic malignancies are widely known to be among the top 10 cancer-related diagnoses and causes of mortality annually.

 However, genetic diagnostic data have been limited in the field of hematology due to the low rate of proliferation of myeloid and lymphoid malignancies. Providers have made wide use of morphological testing and immunophenotyping to guide clinical decisions when treating these disorders. Diagnostic tests currently being used include cytogenetic karyotype, fluorescent in-situ hybridization (FISH), polymerase chain reaction (PCR), gene expression profiling, and next-generation sequencing (NGS).

Cytogenetic karyotyping, used since 1882 to evaluate chromosomes, analyzes chromosome balance in hematologic malignancies as well as reciprocal translocation. Karyotyping is the most common test for diagnosing chronic myelogenous leukemia and other disorders with large structure abnormalities.

The FISH test identifies abnormalities by hybridizing a patient’s tissue sample under a fluorescent microscope. The test provides a rapid analysis when karyotyping is highly variable, which limits the ability to diagnose a hematologic malignancy. The clinical utility of FISH is used by medical providers to determine prognostic outcomes in acute and chronic illnesses.

PCR is a molecular assay for detecting genes that are fused, mutated, or cloned in hematologic malignancies. It can also provide an evaluation of chimerism between the donor and recipient of an allogeneic transplant. Gene expression profiling is a diagnostic technique that evaluates numerous genes expressed in tumors for their classification.

Although currently limited to research centers, the technique has demonstrated significant utility in the stratification of plasma cell disorders, lymphoma, and lymphoproliferative disorders.

Finally, NGS provides sequencing for millions of DNA fragments at a time. The presence of mutations such as TP53, ATM, RAS, IDH1, IDH2, DNMT3A, and SF3B1 can be discovered through this diagnostic test. Future advancements will use these abnormalities as prognostic indicators and for guidance on personalized treatment for patients.

Given the recent use of genes to determine prognosis and treatment decisions in the field of hematology, it is important for providers to collaborate with geneticists.

 Their expertise is needed to ensure a comprehensive diagnostic workup is performed and the appropriate genetic analysis exams included. It is also important to implement the following interventions to optimize patient care:

• Perform baseline complete blood count with differential

• Perform bone marrow aspiration and biopsy (cytogenetic karyotyping and molecular testing)

• Consult with experts to reduce the likelihood of delayed diagnosis

• Refer patients to a genetic counselor

• Provide targeted and systemic therapy based on national recommendations

• Discuss potential need for hematopoietic stem cell transplantation for curative intent

• Carry out clinical follow-up and surveillance based on the hematologic malignancies

As the world of genetics continues to change, it is crucial that nurses stay up to date on best practices and the newest advances.

Prakash, G., Kaur, A., Malhotra, P., Khadwal, A., Sharma, P., Suri, V., Varma, N., & Varma, S. (2016). Current role of genetics in hematologic malignancies. 

Indian Journal of Hematology and Blood Transfusions, 

32 (1), 18-31. Doi:10.1007/s12288-015-0584-4.

Fonseca, R. (2020). Clinical utility of genetic marks in the management of hematologic malignancies. 

Genetics