Although once again, the National Comprehensive Cancer Network® (NCCN®) 2021 Annual Conference could not take place on site in Orlando, researchers presented their work virtually in the form of almost 100 posters. The ASCO Post has summarized some that we found particularly interesting.
Many Surveyed Oncologists Favor Continued Use of Telemedicine
Oncologists at NCCN member institutions say that almost half of patient visits could be effectively and safely conducted postpandemic using telemedicine.1 Overall, survey respondents viewed video visits more favorably than phone visits, indicating they have greater utility over a wider range of clinical scenarios.
With the COVID-19 pandemic came the greatly expanded use of telemedicine in the oncology setting. In the summer of 2020, a team of researchers at NCCN member institutions asked whether their colleagues might view telemedicine favorably enough to continue its use once the pandemic wanes.
The NCCN EHR Oncology Advisory Group formed a working group to assess the state of telemedicine in oncology, creating a 20-question survey for all 30 NCCN member institutions to be answered by all oncology providers. The surveys were returned by 1,038 individuals from 26 institutions; respondents were largely oncologists (58%) with at least 5 years of practice experience (72%).
Amye J. Tevaarwerk, MD
Few respondents (19%) had participated in telemedicine visits of any kind prior to the pandemic, but at the time of the survey, most (84%) had conducted both telephone-based and video-based visits, and some had participated in one but not the other. Only 21 respondents (2%) had not conducted any telemedicine visits at all. The use of telemedicine was based on provider discretion (88%) and patient preference (81%).
Amye J. Tevaarwerk, MD, of the University of Wisconsin, reported these key findings:
- Absent any financial implications, respondents believed that 46% of postpandemic visits could be conducted virtually.
- A total of 93% of respondents reported “rarely” or “never” seeing an adverse event arising due to a telemedicine visit.
- Video visits were generally preferred over telephone-based visits.
- Most respondents believed that video visits were better than or equivalent to office visits for reviewing benign or reassuring data (such as labs and imaging); performing follow-up visits for patients on maintenance therapy or in surveillance; and explaining important malignancy-related clinical data.
As the complexity of the task increased, the utility of telemedicine dropped. Office visits were still preferred for making decisions on malignancy-related procedures and treatments; for assessing complications of treatment; and for establishing personal connections with patients and their families.
The respondents did acknowledge challenges to telemedicine, including patient access to technology, cumbersome workflow in support of telemedicine, and uncertainty about insurance coverage and reimbursement.
“Our interpretation of the survey is that telemedicine seems safe for appropriately selected patients and performs well for uncomplicated visits,” said Dr. Tevaarwerk. “We think careful thought should be given to modifying regulations to maintain telemedicine for use postpandemic.”
Risk Factors for Tumor-Lysis Syndrome Differ by Tumor Type
Risk factors for tumor-lysis syndrome are unique to each cancer type. Tumor types have a measurable impact on risk that can be identified and mitigated through preventive measures, researchers from Sanofi Genzyme and Integra Connect in West Palm Beach, Florida, reported.2
“We found that tumor-lysis syndrome risk is more evident in hematologic malignancies but is also a risk in solid malignancies,” said Kaustav Chatterjee, MD, of Sanofi Genzyme.
As Dr. Chatterjee noted, the risk for tumor-lysis syndrome is widely appreciated in highly proliferative cancers. Clinicians have adopted the “Howard criteria” in evaluating clinical characteristics that can increase the risk of this condition following chemotherapy, but no real-world data have been published that quantify risk factors by cancer type.
To better define these risk factors, the researchers searched the Integra database of 17 community oncology network accounts involving more than 1,900 providers. Of 41,923 patients, they excluded patients who received rasburicase for prevention of tumor-lysis syndrome and identified 816 patients for evaluation, comparing their records against those of patients with cancer who did not develop tumor-lysis syndrome.
They used a multivariate analysis to determine risk in patients with diffuse large B-cell lymphoma (DLBCL), chronic lymphocytic leukemia (CLL), low-grade B-cell lymphoma, T-cell lymphoma, multiple myeloma, and mantle cell lymphoma. A relative risk ratio was calculated, with the reference being DLBCL, which carries a widely recognized risk for tumor-lysis syndrome.
Factors associated with developing tumor-lysis syndrome differed by each tumor type:
- As compared with DLBCL, two tumor types had an increased relative risk for tumor-lysis syndrome: T-cell lymphoma (1.43) and mantle cell lymphoma (1.38).
- CLL treated with venetoclax carried a very high relative risk for tumor-lysis syndrome (2.69).
- As compared with DLBCL, multiple myeloma had a reduced risk for tumor-lysis syndrome (0.35).
- In CLL, venetoclax treatment, low potassium, and abnormal white blood cell count were associated with tumor-lysis syndrome.
- In DLBCL, poor performance status, elevated uric acid, and elevated calcium correlated with increased risk.
- In CLL, both low and high white blood cell counts correlated with tumor-lysis syndrome.
- In addition to disease type, the most common risk factor was elevated lactate dehydrogenase (LDH).
Is Adjuvant Chemotherapy Beneficial in Pulmonary Carcinoid Tumors?
Based on a literature review of the treatment of pulmonary carcinoid tumors, there appears to be no benefit for adjuvant chemotherapy after surgical resection for either the atypical or typical subtypes.3 Adjuvant chemotherapy is currently recommended in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for atypical carcinoid.
Pulmonary carcinoid is an uncommon type of neuroendocrine tumor that can be classified as typical or atypical carcinoid. The mainstay of treatment is surgical resection. When resections are incomplete, there remains clinical debate about the use of adjuvant chemotherapy.
“What makes this challenging is the lack of prospective clinical trials to help guide decision-making relative to the harms and benefits of adjuvant therapy,” said Philip Sobash, MD, of White River Health System in north-central Arkansas, who presented the poster.
Philip Sobash, MD
Nagla Abdel Karim, MD
The NCCN Guidelines currently recommend observation or chemotherapy for atypical carcinoid (category 2B). These current recommendations are based on literature showing a response to any chemotherapy. The recommendations are also extrapolated from studies performed in small cell lung cancer. The European Neuroendocrine Tumor Society suggested considering chemotherapy in tumors with a high proliferative index, he said.
Dr. Sobash and Nagla Abdel Karim, MD, of the Medical College of Georgia, reviewed 80 articles; 12 met their inclusion criteria, and 4 of them included statistical analyses. “These four studies found no benefit for using adjuvant chemotherapy after resection, and one of them showed an overall survival disadvantage,” Dr. Sobash reported. “Of 12 total studies, only 1 stated it found a benefit, though it was not statistically significant. Nodal status also had no effect on adjuvant therapy.”
“Overall, based on the available literature, we conclude there is no currently available evidence to support the current guideline of using adjuvant chemotherapy after surgical resection for atypical carcinoid, regardless of nodal status,” Dr. Sobash said.
Liver Cancer and Hepatitis C Infection: Relationship to Mortality
Patients treated for hepatitis C (HCV) infection, especially when they achieve a sustained viral response, have significantly better survival from liver cancer than patients not treated for HCV infection and those not achieving sustained viral response, Ngan Thi Kim Nguyen, DO, a hematology/oncology fellow at the University of Tennessee in Memphis, reported.4
Individuals with chronic hepatitis C infection have a 15 to 30 times increased risk for developing hepatocellular carcinoma compared with uninfected persons, but it is not clear whether being treated for hepatitis C infection and achieving sustained viral response could decrease cancer-related mortality.
Ngan Thi Kim Nguyen, DO
This was the question researchers explored via a retrospective review of 111 patients treated at the Memphis Veterans Affairs Medical Center. For hepatitis C infection, patients received interferon-based regimens or direct-acting antiviral agents. Researchers identified those who achieved a sustained viral response and those who did not.
They found that patients with hepatocellular carcinoma who were also treated for hepatitis C infection and those who achieved a sustained viral response had significantly better 5-year overall survival than those without treatment or without a sustained viral response:
- With hepatitis C treatment: 44 months vs 15 months for those without treatment (P = .0005)
- With achievement of sustained viral response: 66 months vs 16 months without sustained viral response (P < .0001)
- Progression-free survival was also improved in both those categories.
- Survival was not affected by the type of hepatitis C treatment (interferon vs antiviral).
- Model for end-stage liver disease (MELD) score > 10 and Child–Pugh class B or C status also doubled the mortality risk.
“We suggest that achieving sustained viral response status after a diagnosis of hepatitis C, MELD score and Child–Pugh class should be the potential measures to predict mortality among patients with hepatitis C–related hepatocellular carcinoma rather than the type of treatment of HCV infection,” Dr. Nguyen said.
Overtreatment Still Happens at the End of Life
Nearly 1 in 6 patients with lung cancer still receives active treatment within 30 days of death, according to a review of 1,146 patients at Johns Hopkins University and the Sidney Kimmel Comprehensive Cancer Center, Baltimore.5
As Catherine Yip, BS, and colleagues noted, studies have found that monthly cancer treatment costs are often stable until the final month before death, when costs increase regardless of survivorship status. Hospitalization is a major factor, but this also begs the question of whether “hail Mary” approaches are being sought at the end of life, the researchers noted on their poster.
“The use of chemotherapy at the end of life is associated with an overestimation of survival and a reluctance to discuss prognoses on the part of both patients and providers. Hospice care, in fact, has been significantly associated with longer survival compared to chemotherapy,” they pointed out.
The authors evaluated prescribing patterns at the end of life in patients who were treated for lung cancer at Hopkins and ultimately died of it. They identified 1,146 patients, of whom 57% lived in zip codes with median incomes between $50,000 and $100,000 and 38% in zip codes with median incomes of less than $50,000; 43% had private insurance, 37% had Medicare and secondary insurance, and the remainder had Medicare, Medicaid, or both; 2% had no form of insurance.
Treatment within 30 days of death was recorded for 174 patients. This included 39 of 209 patients (19%) with small cell lung cancer and 135 of 935 patients (14%) with non–small cell lung cancer (NSCLC).
For the patients with small cell lung cancer, the type of end-of-life treatment included intravenous chemotherapy (64%), oral chemotherapy (23%), intravenous immunotherapy (8%), and oral targeted therapy (5%). For metastatic NSCLC, treatments included intravenous chemotherapy (45%), oral targeted therapy (36%), intravenous immunotherapy (16%), and oral chemotherapy (3%).
“Many patients with lung cancer received systemic therapy within 30 days of death at our large academic institution,” Ms. Yip reported. “Intravenous chemotherapy was the most common form of treatment for small cell lung cancer and NSCLC.”
Those who did not receive systemic therapy at the end of life were significantly more likely to be older, Black, have an income less than $50,000, be former smokers, have adenocarcinoma, and have a higher performance status. In the multivariate analysis, income of more than $100,000 was associated with double the odds of receiving end-of-life care.
DISCLOSURE: Dr. Tevaarwerk reported no conflicts of interest. Dr. Chatterjee is an employee of Sanofi Genzyme. Dr. Sobash reported no conflicts of interest. Dr. Abdel Karim reported no conflicts of interest. Dr. Nguyen reported no conflicts of interest. Ms. Yip reported no conflicts of interest.
REFERENCES
1. Tevaarwerk AJ, Osterman T, Arafat W, et al: Oncology provider perspectives on telemedicine for patients with cancer: A National Comprehensive Cancer Network (NCCN®) survey. NCCN 2021 Annual Conference. Abstract BIO21-011. Presented March 18, 2021.
2. Chatterjee K, Drea E, Smith R, et al: Tumor lysis syndrome risk analysis in a US community oncology setting: A retrospective observational study in Integra Connect Network. NCCN 2021 Annual Conference. Abstract HSR21-047. Presented March 18, 2021.
3. Sobash P, Abdel Karim N: Survival benefit of adjuvant chemotherapy in pulmonary carcinoid: A systematic review. NCCN 2021 Annual Conference. Abstract BPI21-009. Presented March 18, 2021.
4. Nguyen NTK, Uhelski ACR, Patel K, et al: Antiviral therapy improves hepatocellular cancer survival. NCCN 2021 Annual Conference. Abstract CLO21-023. Presented March 18, 2021.
5. Yip C, Valilis E, Prichett L, et al: Prescribing patterns at the end of life in lung cancer. NCCN 2021 Annual Conference. Abstract EPR21-040. Presented March 18, 2021.
