ESMO East 2023: Updates in Cancer Survivorship with Dr Jennifer Klemp
Presentation by Jennifer Klemp, PhD, MPH, MA, University of Kansas Cancer Center
At the 2023 ESMO East review conference presented by Total Health in Fort Lauderdale, Florida, Dr Jennifer Klemp, Director of Cancer Survivorship and Co-Program Leader for Cancer Prevention and Control at the University of Kansas Cancer Center, presented updates in cancer survivorship from the 2023 European Society for Medical Oncology (ESMO) Congress held in Madrid, Spain. In her presentation, Dr Klemp highlighted abstracts from the Congress on the topics of Patient Reported Outcomes (PROs) during treatment, and lifestyle considerations for patients living with and after cancer.
Patient Reported Outcomes
[Abstract 20300]: Results from the PRO-TECT trial (Alliance AFT-39) examined the use of remote symptom monitoring with electronic PROs (ePROs) for patients undergoing treatment for metastatic cancers. As a background for this topic, Dr Klemp noted that clinicians can miss up to 50% of treatment-related symptoms as a result of inadequate time with their patients and not discussing side effects. Cancer patients may also be reluctant to discuss symptoms because they don’t want to go off their treatment, or have a reduction in their dose of treatment. Among the consequences of inadequate recognition of treatment-related symptoms are avoidable hospitalizations and unnecessary holds on treatment. Notably, in a previous study of nearly 800 patients, it was shown that use of ePROs could improve survival for patients over standard symptom reporting measures.
In this study, there were 3 ways for reporting events, on the computer, on the phone, or a coordinator would call you, and Dr Klemp noted that the third option was chosen by about 1/3 of the patients, which is important to have (as not all patients are proficient on a computer or cell phone or have adequate internet connectivity). She also noted that about a third of patients in the study had high school or lower education, roughly 26% were located in rural areas, and about 20% had never used email or a computer, all of which are important factors to consider in a study of this type. A total of 91.5% of patients completed the survey, and, while overall survival in this trial was not significantly improved, there was a 6% reduction in hospitalizations, and time to first ER admission was significantly reduced with ePROs as compared with conventional care (hazard ratio [HR]=0.84; P=0.03). Dr Klemp noted that there was also significant benefit across other measures such as physical functioning, symptom control, and health-related quality of life for patients with ePRO reporting versus standard care, suggesting that ePROs can help to better recognize and address symptoms and improve outcomes for patients.
Overall results from this study demonstrated that symptom monitoring using the ePRO system was feasible for patients having advanced cancers across a range of diverse practices across the United States. While overall survival was not impacted, the intervention was nonetheless valuable, resulting in improved quality of life for patients, and a reduction in meaningful endpoints such as number of hospitalizations. Results further showed that implementation of ePROs must utilize easily accessible technologies for patients, and will require adjustment in nursing responsibilities to allow sufficient time for ePRO work, and to effectively integrate ePROs into the care process. Dr Klemp further noted the incorporation of PROs into the ESMO Treatment Guidelines, and the importance of also having resources and strategies for next steps and follow up for patients who do report bothersome symptoms, to ensure they are addressed.
[CN67]: This abstract compared guidelines for healthcare professionals (HCPs) on breast cancer patient’s perceived and reported symptoms versus those reported in their electronic medical records (EMRs), based on the premise that HCPs may underestimate symptoms experienced by breast cancer patients. The findings showed that breast cancer patients frequently reported symptoms not covered by the guidelines, and as such, current best practice guidelines might not fully encompass the breadth of symptoms noted by HCPs, with a discrepancy in frequency of commonly encountered symptoms. Dr Klemp noted, for example, that overall there was nearly 2/3 discordance between symptoms reported in the EMR versus those actually experienced by the patient. She noted that, while not necessitating making a “laundry list” of all patient’s symptoms, the results do speak to a need for prioritizing, for each patient, what are the symptoms which are most bothersome, and therefore might have the greatest impact.
[ePoster 425P]: This poster investigated health-related quality of life outcomes for breast cancer patients receiving treatment with the cyclin-dependent kinase (CDK)4/6 inhibitors (CDK4/6i), palbociclib, ribociclib, or abemaciclib, in combination with endocrine therapy (ET). Results of the study showed that, among nearly 70% of patients who had received prior chemotherapy for their breast cancer, nearly 92% considered their quality of life better while on CDK4/6i, and ~88% were overall satisfied with their treatment while on CDK4/6i. Dr Klemp noted from this small study that, overall, patients were doing well on CDK4/6i once they come off chemotherapy, however, there were still some unreported symptoms, and some patients had more adherence and side effect issues with one agent versus another.
Lifestyle Considerations
Dr Klemp then reviewed a series of abstracts on lifestyle considerations, which are important to consider in survivorship, given the wide range of interventions including intermittent fasting and use of glucagon like peptide 1 (GLP-1) mimetic drugs for weight loss.
[LBA94]: This abstract examined the impact of short-term fasting (STF) on quality of life in patients undergoing chemotherapy (CTX) for breast cancer (2 days before CTX, 1 day after). The goal was to determine whether STF could enhance quality of life outcomes and the overall efficacy of CTX, while reducing side effects. The control group in the study received a low animal protein and low refined sugar diet. Although further follow up is needed for outcomes such as remissions and long term adverse events, the results showed that STF as a supportive intervention during CTX had a positive impact on several quality of life measures, including fatigue and weight change. Dr Klemp also noted data to suggest that STF might enhance the impact of CTX on the tumor itself, and results for progression free survival will be forthcoming from the trial. She also noted that, while weight loss is generally not recommended for patients while on active therapy, more work needs to be done for overweight patients on longer term adjuvant treatments to determine which weight loss interventions are best, and at what point these strategies should be implemented, so that patient’s weight does not continue to increase.
[ePoster 2063P]: This poster examined healthy lifestyle habits in a group of patients with different cancers, with a particular focus on exercise and eating behaviors, which can have a significant impact on outcomes after cancer such as mortality, relapse risk, hospitalizations, complications, and responses to immunotherapy. The results showed that patients had a good top line awareness of how healthier eating and exercise could impact their cancer outcomes, however, there was a need to be specific about nutritional and exercise recommendations in order for patients to more efficiently integrate these strategies into their daily life. Dr Klemp noted that only about half of patients in the study reported any type of lifestyle or nutritional discussions with their provider, and that, while 80% of patients knew that such interventions were beneficial for their outcome, the vast majority were not willing to incorporate those changes. She noted the importance of ‘planting the seed’ of weight and lifestyle interventions in patient’s minds at the time of a cancer diagnosis, so they can have a sense that these strategies should be part of their overall long term treatment plan and goals.
[ePoster 2070P]: This poster examined healthy lifestyle habits such as not being/avoiding overweight, adequate sleep, and moderate physical activity (150 minutes or more /week) in breast cancer patients. Dr Klemp noted that, while the results showed that breast cancer patients were overall not sedentary, and in fact moderately active compared to the general population, there was a need to have more vigorous activity (75 minutes or more /week) such as interval training that gets the heart rate up in breast cancer patients, which can also be beneficial for cardiac health. Additional results from the study showed that rates of obesity and overweight were also higher in the metastatic and long term breast cancer survivor population, and accordingly, there is a need to improve lifestyle and other parameters such as proper sleep hygiene in this group of patients.
[ePoster 2273P and ePoster 2275P]: Dr Klemp noted that obesity has a differing impact on breast cancer risk, depending on menopausal status, with a significant positive association in postmenopausal women, but not in premenopausal women. The remaining 2 posters Dr Klemp highlighted focused on the weight-related leptin and adiponectin pathway in breast cancer patients, which may have important implications particularly for patients on popular weight loss drugs such as GLP-1 mimetics. The first poster [ePoster 2273P] examined the association between leptin and its receptor, Ob-R, in modulating levels of tumor-infiltrating lymphocytes, or TILs and expression of the programmed death receptor (PD-1) in patients with HER2 positive breast cancer. Both leptin and Ob-R are expressed at higher levels in breast cancer cells as compared with normal mammary tissues, and this pathway is known to play an important role in breast tumors. The results showed a higher expression of TILs in overweight/obese patients, but this did not correlate with patients achieving a pathologic complete response (pCR) to their breast cancer treatment. A high expression of PD-1 was also found in overweight and obese patients, which could be associated with features of TIL cell “exhaustion”. In the second poster [ePoster 2275P], the investigators examined circulating leptin and adiponectin levels in premenopausal women with and without breast cancer, who have a high body mass index (BMI), defined as >25 kg/m2. Results found that, although high leptin levels were associated with increased breast cancer risk in postmenopausal women, this was not the case in premenopausal women, and levels of adiponectin were similar in women with and without breast cancer. The findings suggest that leptin and adiponectin levels may not entirely explain the apparent protective effect of obesity on breast cancer in premenopausal women. Dr Klemp’s overall takeaway from these studies was that, while markers such as leptin and adiponectin did not correlate with breast cancer risk in the premenopausal group, there is nonetheless a need for weight loss interventions in high risk, overweight, premenopausal breast cancer patients, as they tend to gain more weight in the first year of treatment than their postmenopausal counterparts, and have a longer period of time over which they can gain weight and develop a recurrence.
Quick Summary: Survivorship Abstracts from ESMO 2023 with Dr Jennifer Klemp
Patient Reported Outcomes
Electronic Patient Reported Outcomes (ePROs) hold promise for better recognizing and addressing treatment-related symptoms, reducing hospitalizations, and improving quality of life measures for patients versus standard adverse event reporting.
Use of ePROs needs to be easily accessible for patients, and requires adjustment in nursing responsibilities and to effectively integrate ePROs into the care process workflow.
Resources and strategies need to be in place when patients report bothersome symptoms so they can be effectively addressed.
Symptoms reported in electronic medical records (EMR) are frequently discordant with those reported by patients; there is a need to prioritize treatment-related symptoms which are most bothersome for each patient.
Health related quality of life was better for patients on CDK 4/6 inhibitors (CDK4/6i) compared to prior chemotherapy, however, side effects and adherence to treatment differs among the three available CDK4/6i.
Lifestyle Considerations
Short term fasting before and after chemotherapy was a useful intervention with positive impact on quality of life measures such as fatigue and weight change while on chemotherapy.
There is a need for clinicians to be specific about nutritional and exercise recommendations in order for patients to accept and more efficiently integrate these strategies into their daily life.
Breast cancer patients are overall more active compared to the general population, but there is a need to have more vigorous activity that increases heart rate to optimize benefits in cardiac health and prevention.
Weight management continues to be an important component in breast cancer survivorship, particularly for overweight premenopausal patients.
Speaker Disclosure Information: No off label use and/or investigational use was discussed in the presentation. Dr Klemp reported the following disclosures for this presentation: Consultant: Pfizer. Employment: Caris Life Sciences.
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