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Josephine Feliciano
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P1.17 - Treatment of Locoregional Disease - NSCLC (Not CME Accredited Session) (ID 949)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 9/24/2018, 16:45 - 18:00, Exhibit Hall
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P1.17-10 - Consolidation Chemotherapy in Stage III Non-Small Cell Lung Cancer: Still a Critical Piece of the Puzzle (ID 14262)
16:45 - 18:00 | Author(s): Josephine Feliciano
- Abstract
Background
Despite lack of proven survival benefit, national guidelines recommend that patients with stage III non-small cell lung cancer (NSCLC) treated with chemoradiation (CRT) using weekly regimens receive two additional cycles of full dose consolidation chemotherapy (cCT). We seek to explore the benefit of cCT in our mature annotated cohort of stage III NSCLC patients treated with modern radiation therapy (RT) and predominantly weekly carboplatin/paclitaxel-based CRT.
a9ded1e5ce5d75814730bb4caaf49419 Method
In this retrospective analysis, 355 consecutive patients with stage III NSCLC treated with either definitive CRT alone (bimodality) or followed by surgery (trimodality), between the years 2000-2013 were analyzed. Median age of the patients was 60 years (range: 30-86). Stage grouping was IIIA: 56.3%, T3/4: 49%, N2: 61.4%; N3: 21.4%. Histology was evenly distributed between squamous, adenocarcinoma, other or not specified. Concurrent CRT was delivered in 92.1% of the patients, 74% receiving weekly carboplatin/paclitaxel. Median radiation dose was 63Gy (range 10.8-81.6Gy). Data on cCT use was available in 304 patients, 69.7% receiving cCT. Logistic regression was performed to assess predictors for the use of cCT. Kaplan-Meier method and Cox proportional hazards model was used to estimate the overall (OS) and freedom-from-recurrence (FFR) adjusted for age, gender, marital status, insurance status, smoking history, COPD diagnosis, performance status, Charlson score, year of diagnosis, concurrent vs sequential CRT, RT technique, RT dose and surgery.
4c3880bb027f159e801041b1021e88e8 Result
With a median follow up of 15 months (range: 1-184 months), OS (median/5-year) with and without cCT was 30.2 months/ 30.5% and 15.3 months/ 12.9%, respectively (multivariate adjusted HR for death: 0.50; 95% CI: 0.37-0.69, p < 0.001). Corresponding values for FFR were 19 months/ 27% and 11.2 months/ 11.4% (adjusted HR: 0.54; 95% CI: 0.37-0.77, p = 0.001).
On subset analysis, the OS benefit was seen in patients undergoing bimodality therapy (HR: 0.57; 95% CI: 0.40-0.83, p = 0.003) but not for trimodality therapy (p = 0.124). Similarly, an OS benefit was seen in stage IIIA (HR: 0.35; 95% CI: 0.23-0.55, p < 0.001) but not for stage IIIB patients (p = 0.071). The only factor predicting the use of cCT was primary treatment: bimodality vs trimodality (OR: 2.2; 95% CI: 1.1-4.3, p = 0.018 favoring bimodality).
8eea62084ca7e541d918e823422bd82e Conclusion
Consolidation chemotherapy should continue to be strongly considered for stage III NSCLC patients, especially those undergoing bimodality therapy receiving weekly sensitizing doses of carboplatin-paclitaxel and with stage IIIA disease. The relative benefit of cCT in the setting of maintenance durvalumab (or other immunotherapy) needs further evaluation.
6f8b794f3246b0c1e1780bb4d4d5dc53
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P2.01 - Advanced NSCLC (Not CME Accredited Session) (ID 950)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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P2.01-103 - Neutrophil-to-Lymphocyte Ratio as a Predictor of Immunotherapy Treatment Outcomes in Advanced Non-Small Lung Cancer (ID 12633)
16:45 - 18:00 | Author(s): Josephine Feliciano
- Abstract
Background
Immune checkpoint inhibitors (ICIs) are a new class of therapy for patients with non-small cell lung cancer (NSCLC). Immunologic markers, such as serum neutrophil-to-lymphocyte ratio (NLR), are prognostic in patients with a variety of malignancies, with preliminary findings in patients on immunotherapy. In this study, we evaluate the association between NLR and ICI outcomes in NSCLC, including the development of immune-related adverse events (irAEs).
a9ded1e5ce5d75814730bb4caaf49419 Method
We conducted a retrospective analysis of advanced or recurrent NSCLC patients receiving ICI from 2011 to 2017. Demographics, disease and treatment history, and pretreatment labs were recorded. An NLR³5 was defined as high and <5 as low, based on meta-analyses. Cox proportional hazards models and univariate and multivariate regressions were used to assess the association between NLR and overall survival (OS), progression-free survival (PFS), disease control rate at 10 weeks (DCR), and irAEs.
4c3880bb027f159e801041b1021e88e8 Result
183 patients were identified: 55.2% male, 76.5% Caucasian, mean age 65.3 years (range 38–90 years). Male sex, smoking history, prior radiotherapy, and pretreatment albumin were significantly associated with high versus low NLR (p < 0.05). In univariate analyses, pretreatment NLR was a significant predictor of OS (HR 1.47, p < 0.05, Fig. 1), PFS (HR 1.44,, p < 0.05), and DCR (OR 0.49, p < 0.05), but not irAEs (OR 1.37, p = 0.33). These findings persisted with multivariate analyses (OS HR 1.76, PFS HR 1.64, DCR OR 0.24, all p < 0.01; irAE OR 1.52, p = 0.33).
8eea62084ca7e541d918e823422bd82e Conclusion
High NLR was positively associated with OS, PFS, and DCR but not irAEs in NSCLC patients receiving ICI. Our results support the use of NLR as a biomarker for clinical outcomes. Prospective studies are needed to study this measure in patients undergoing ICI therapy, and further studies to identify predictive biomarkers of irAEs are warranted.
6f8b794f3246b0c1e1780bb4d4d5dc53
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P2.10 - Prevention and Tobacco Control (Not CME Accredited Session) (ID 959)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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P2.10-01 - Success of a Pharmacy-Driven Smoking Cessation Program (ID 11315)
16:45 - 18:00 | Author(s): Josephine Feliciano
- Abstract
Background
While national oncology organizations advocate smoking cessation integrated into cancer management, only 30-40% of oncologists provide assistance with quitting. Barriers to providing this service are well documented. Pharmacy learners are poised to provide this intervention with the incorporation of smoking cessation therapies in accredited PharmD curricula. Previous pharmacist-driven programs reported 30-day quit rates of 23%. A pharmacy-driven pilot was initiated in April 2017 in a Thoracic Oncology Center of Excellence. The purpose of this study was to establish a new standardized infrastructure for a cessation program, determine its feasibility, and determine 30-day smoking cessation success rates for patients in a thoracic multidisciplinary clinic (MDC).
a9ded1e5ce5d75814730bb4caaf49419 Method
Patients seen in the thoracic MDC between April 2017 and March 2018 were included. Primary endpoints included patient capture rate in clinic, acceptance rate of tobacco assessment and smoking cessation counseling, and 30-day cessation rates. Tobacco use assessments and smoking cessation counseling were performed and documented by a pharmacy learner (pharmacy resident or student), under the supervision of a licensed pharmacist, prior to the history and physical by a health care provider. All patients who were active smokers or former smokers who quit within the last three months were offered cessation counseling and follow up. Nicotine replacement therapy was immediately available and provided to eligible patients based on tobacco use. Participants were followed up in clinic or by phone every two weeks for the first three months, at six months, nine months, and one year of program enrollment. At least two follow up phone call attempts were made until determined not successfully reached.
4c3880bb027f159e801041b1021e88e8 Result
One-hundred sixty-four of 189 patients seen in MDC were assessed by the pharmacy team. Forty-five (27%) of 164 assessed patients met eligibility criteria. Thirty-two (75%) of 45 eligible patients participated in same day counseling for smoking cessation and agreed to enroll in the follow up program. Quit rates at 30 days for enrolled patients were 44% (14/32). At one, three, and six months, 25%, 56%, and 81% of patients, respectively, were unavailable by phone.
8eea62084ca7e541d918e823422bd82e Conclusion
The majority of eligible patients enrolled in the smoking cessation program. More than 40% of enrolled patients were successful in smoking cessation at 30 days, which compares favorably to previous reports. Telephone follow up was challenging. Future efforts to expand smoking cessation in a comprehensive cancer center utilizing a pharmacy-driven intervention are warranted.
6f8b794f3246b0c1e1780bb4d4d5dc53
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P2.15 - Treatment in the Real World - Support, Survivorship, Systems Research (Not CME Accredited Session) (ID 964)
- Event: WCLC 2018
- Type: Poster Viewing in the Exhibit Hall
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
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P2.15-05 - Prescribing Patterns of Physicians and Financial Implications for Lung Cancer Treatment at the End of Life (ID 12176)
16:45 - 18:00 | Presenting Author(s): Josephine Feliciano
- Abstract
Background
Rates of systemic chemotherapy use at the end of life are estimated to be above 44%. Limited information exists on prescribing patterns of intravenous and oral treatments (immunotherapy, chemotherapy, and tyrosine kinase inhibitors) at the end of life. Use of systemic therapy in the last month of life may have a significant clinical and financial impact. This study aimed to evaluate prescribing patterns and costs associated with lung cancer treatments in the last month of life in two large academic institutions.
a9ded1e5ce5d75814730bb4caaf49419 Method
Patients (n=184) deceased between July 2016 and June 2017 who received lung cancer treatment were included in this analysis. The primary objective was characterization of prescribing patterns associated with end of life care. Patient, disease, and treatment related factors were recorded. Patient characteristics were compared between those who did and did not receive treatment in the final month of life using Wilcoxon and chi-square tests, respectively.
4c3880bb027f159e801041b1021e88e8 Result
Forty-three (23%) patients received treatment in the last 28 days of life. Patient-related factors were similar between patients who did and did not receive therapy at the end of life. Patients who did not receive therapy at the end of life were more likely to be enrolled in hospice (72% vs 40%; p =0.0035, chi-square test). Of therapies given within the last month of life, 47% were oral therapies, 35% were intravenous chemotherapy, and 16% were immunotherapy (p = <0.0001, chi-square test). Using average wholesale price, overall drug costs given in the last month of life were $422,454, of which oral agents accounted for $326,400. There were no statistical differences in patient factors, including age, creatinine, albumin, hemoglobin, Charlson Index, and ECOG performance status between patients who received therapy at the end of life and those that did not (all p-values >0.05).
8eea62084ca7e541d918e823422bd82e Conclusion
Oral therapies are the most commonly prescribed modality of treatment at the end of life compared to intravenous chemotherapy or intravenous immunotherapy. Oral therapies pose a significant financial burden to patients at the end of life. Using patient factors to determine candidates for therapy at the end of life continues to be an area of exploration. Further studies are warranted to identify when therapies should be discontinued or to identify patients who may not benefit from systemic therapy.
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