Εξατομίκευση της Θεραπευτικής στρατηγικής στον μεταστατικό ορθοκολικό καρκίνο μέσω υγρών βιοψιών (ανίχνευση μεταλλάξεων στα γονίδια RAS μέσω ψηφιακής PCR)

Introduction: Metastatic colorectal cancer (mCRC) affects approximately 60% of patients with colorectal cancer and is associated with high mortality. RAS status is an important biomarker, as it guides treatment by predicting response to anti-EGFR monoclonal antibodies. However, RAS is routinely tested only on archival tumour tissue, and it is not possible to update the information on its status during the disease course, as in most patients rebiopsy is not possible or practical. Liquid biopsies are an emerging and promising alternative to tissue biopsy, as they provide an accurate real-time picture of the mutational landscape of the tumour.Aim: The study aims to use and test the high-sensitivity liquid biopsy platform BEAMing Digital PCR for RAS mutation detection in a cohort of mCRC patients in a collaborating network of Oncology centres in Greece. Moreover, it aims to study the utility of repeat liquid biopsies, alongside standard tissue testing, for the customisation of therapeutic strategy in mCRC.Methods: Clinical and molecular profiling data were prospectively collected from mCRC patient records. Plasma samples were collected from mCRC patients at the University Hospital of Ioannina, University Hospital of Larissa and the EUROMEDICA General Clinic in Thessaloniki, Greece. BEAMing Digital PCR was used to define the RAS status on ctDNA at four key timepoints: baseline, middle of first line therapy, first and second disease progressions.Results: Sixty-eight patients with mCRC were recruited between January 2018 and October 2019 with a median follow up of 13.3 months. RAS mutations were detected in tissue and ctDNA in 51.5% and 47.8% of patients, respectively, with overall percent agreement of 72.3%. Tissue-ctDNA concordance was positively associated with the presence of liver metastases (p=0.010) and negatively associated with the low sensitivity of tissue testing method (p=0.092). RAS mutational status differed between baseline and the middle of first-line treatment (p=0.046), as RAS MAF became undetectable in 28.6% of patients, and the mean RAS MAF decreased from 12.27% at baseline to 5.63% in the middle of first-line therapy (p=0.147). At first progression, new RAS mutations emerged compared to baseline (p=0.014), as 35.7% of patients developed a new RAS mutation, leading to a RAS status change from wild type to mutated in 21.4% of patients. At second progression, RAS status was preserved in 62.5% and in 100% of patients compared to baseline and first progression, respectively.Conclusions: Plasma ctDNA analysis with BEAMing Digital PCR was shown to have satisfactory concordance with tissue testing and to effectively detect even subtle differences both in RAS status and in RAS MAF at the tested timepoints. Therefore, it can be used alongside baseline tissue testing and, by capturing the dynamic RAS changes, it can inform personalised therapeutic decisions for mCRC patients and the design of future clinical trials.Εισαγωγή: Ο μεταστατατικός ορθοκολικός καρκίνος (μΟΚΚ) αφορά περίπου 60% των ασθενών με ορθοκολικό καρκίνο και σχετίζεται με υψηλή θνητότητα. Η κατάσταση των γονιδίων RAS είναι ένας σημαντικός βιοδείκτης που καθοδηγεί τη θεραπεία προβλέποντας την ανταπόκριση στα μονοκλωνικά αντισώματα έναντι του υποδοχέα του επιδερμιδικού αυξητικού παράγοντα (epidermal growth factor receptor, EGFR). Ωστόσο, η εξέταση των γονιδίων RAS πραγματοποιείται παραδοσιακά μόνο σε αρχειακό υλικό ιστού από τον όγκο, χωρίς να παρέχει ανανεωμένη πληροφορία για την κατάσταση RAS στη διάρκεια της νόσου, καθώς στους περισσότερους ασθενείς η επαναβιόψηση δεν είναι δυνατή ή πρακτική. Οι υγρές βιοψίες είναι μια αναδυόμενη και υποσχόμενη εναλλακτική στη βιοψία ιστού, καθώς παρέχουν με ακρίβεια μια εικόνα του μοριακού προφίλ του όγκου σε πραγματικό χρόνο.Σκοπός: Η μελέτη στοχεύει στη χρήση και τον έλεγχο της υψηλής ευαισθησίας πλατφόρμας υγρής βιοψίας ψηφιακής PCR BEAMing για την ανίχνευση μεταλλάξεων RAS σε μια κόορτη ασθενών με μΟΚΚ σε ένα συνεργαζόμενο δίκτυο ογκολογικών κέντρων στην Ελλάδα. Επιπρόσθετα, στοχεύει στη μελέτη της χρησιμότητας των επαναλαμβανόμενων υγρών βιοψιών, παράλληλα με τον standard έλεγχο ιστού, για την εξατομίκευση της θεραπευτικής στρατηγικής στον μΟΚΚ.Μέθοδοι: Κλινικά δεδομένα και δεδομένα μοριακής ανάλυσης συλλέχθηκαν προοπτικά από τον φάκελο των ασθενών με μΟΚΚ. Δείγματα πλάσματος συλλέχθηκαν από ασθενείς με μΟΚΚ στο Πανεπιστημιακό Γενικό Νοσοκομείο Ιωαννίνων, το Πανεπιστημιακό Γενικό Νοσοκομείο Λάρισας και τη EUROMEDICA Γενική Κλινική Θεσσαλονίκης, στην Ελλάδα. Η ψηφιακή PCR BEAMing χρησιμοποιήθηκε για τον ορισμό της κατάστασης RAS στο κυκλοφορούν DNA (circulating tumour DNA, ctDNA) του όγκου σε τέσσερα στιγμιότυπα-«κλειδιά»: διάγνωση, μέσον της θεραπείας πρώτης γραμμής, πρώτη και δεύτερη επιδείνωση.Αποτελέσματα: Εξήντα οκτώ ασθενείς με μΟΚΚ εντάχθηκαν στη μελέτη μεταξύ Ιανουαρίου 2018 και Οκτωβρίου 2019 με διάμεσο χρόνο παρακολούθησης 13.3 μήνες. Μεταλλάξεις RAS ανιχνεύτηκαν στον ιστό και στο ctDNA σε 51.5% και 47.8% των ασθενών, αντίστοιχα, με ολική ποσοστιαία συμφωνία 72.3%. Η συμφωνία ιστού-ctDNA σχετιζόταν θετικά με την ύπαρξη ηπατικών μεταστάσεων (p=0.010) και αρνητικά με τη χαμηλή ευαισθησία της μεθόδου ελέγχου ιστού (p=0.092). Η κατάσταση RAS διέφερε μεταξύ της διάγνωσης και του μέσου της θεραπείας πρώτης γραμμής (p=0.046), καθώς το κλάσμα μεταλλαγμένων αλληλομόρφων RAS (RAS mutant allele fraction, RAS MAF) έγινε μη ανιχνεύσιμο σε 28.6% των ασθενών, και ο μέσος όρος του RAS μειώθηκε από 12.27% στη διάγνωση σε 5.63% στο μέσο της θεραπείας πρώτης γραμμής (p=0.147). Στην πρώτη επιδείνωση, νέες μεταλλάξεις RAS αναδύθηκαν σε σύγκριση με τη διάγνωση (p=0.014), καθώς 35.7% των ασθενών ανέπτυξαν νέα μετάλλαξη RAS, οδηγώντας σε μεταβολή της κατάστασης RAS από φυσιολογική σε μεταλλαγμένη στο 21.4% των ασθενών. Στη δεύτερη επιδείνωση, η κατάσταση RAS διατηρήθηκε στο 62.5% και στο 100% των ασθενών σε σύγκριση με τη διάγνωση και την πρώτη επιδείνωση, αντίστοιχα.Συμπεράσματα: Η ανάλυση του ctDNA πλάσματος με την ψηφιακή PCR BEAMing βρέθηκε να έχει ικανοποιητική συμφωνία με τον ιστό και να ανιχνεύει αποτελεσματικά ακόμα και μικρές διαφορές τόσο στην κατάσταση RAS όσο και στο RAS MAF στα στιγμιότυπα που ελέγχθηκαν. Συνεπώς, μπορεί να χρησιμοποιηθεί παράλληλα με τον έλεγχο του ιστό στη διάγνωση και, αποτυπώνοντας τις δυναμικές αλλαγές RAS, μπορεί να υποβοηθήσει τη λήψη εξατομικευμένων θεραπευτικών αποφάσεων για τους ασθενείς με μΟΚΚ και τον σχεδιασμό μελλοντικών κλινικών δοκιμών

Development and Validation of a Targeted ‘Liquid’ NGS Panel for Treatment Customization in Patients with Metastatic Colorectal Cancer

The detection of actionable mutations in tumor tissue is a prerequisite for treatment customization in patients with metastatic colorectal cancer (mCRC). Analysis of circulating tumor DNA (ctDNA) for the identification of such mutations in patients’ plasma is an attractive alternative to invasive tissue biopsies. Despite having the high analytical sensitivity required for ctDNA analysis, digital polymerase chain reaction (dPCR) technologies can only detect a very limited number of hotspot mutations, whilst a broader mutation panel is currently needed for clinical decision making. Recent advances in next-generation sequencing (NGS) have led to high-sensitivity platforms that allow screening of multiple genes at a single assay. Our goal was to develop a small, cost- and time-effective NGS gene panel that could be easily integrated in the day-to-day clinical routine in the management of patients with mCRC. We designed a targeted panel comprising hotspots in six clinically relevant genes (KRAS, NRAS, MET, BRAF, ERBB2 and EGFR) and validated it in a total of 68 samples from 30 patients at diagnosis, first and second disease progression. Results from our NGS panel were compared against plasma testing with BEAMing dPCR regarding the RAS gene status. The overall percent of agreement was 83.6%, with a positive and negative percent agreement of 74.3% and 96.2%, respectively. Further comparison of plasma NGS with standard tissue testing used in the clinic showed an overall percent agreement of 86.7% for RAS status, with a positive and negative percent agreement of 81.2% and 92.8%, respectively. Thus, our study strongly supports the validity and efficiency of an affordable targeted NGS panel for the detection of clinically relevant mutations in patients with mCRC

Evaluation of the satisfaction and experiences of oncology patients and doctors using teleconsultation during the COVID-19 pandemic

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the Gustave Roussy Cancer Center introduced teleconsultation via telephone, as an alternative to face-to-face consultation to reduce patient hospital visits. This study was designed to assess patient and doctor satisfaction with this modality of care in oncology patient care during the period of the pandemic and beyond.METHODS: We designed two questionnaires based on validated scores to assess satisfaction from teleconsultation in patients (EORTC OUT-PATSAT 35 and Telemedicine Satisfaction Questionnaire [TSQ] scores) and doctors (Telehealth Usability Questionnaire [TUQ]), and anxiety levels in both groups (anxiety section of the Hospital Anxiety and Depression Scale [HADS], HADS-A). These were electronically sent to patients and doctors with experience of at least one remote consultation during the first wave of the COVID-19 pandemic.RESULTS: 239 patients and 32 doctors were eligible for the analyses. In the patient group, the mean satisfaction scores were 79.5 (SD 18.1) and 74.92 (SD 15.3) for EORTC OUT-PATSAT 35 and TSQ, respectively. In the doctor group, the mean satisfaction scores were 67.1 (SD 12.7) and 64.9 (SD 13.9) for TUQ and TUQ for Skype for Business, respectively. 65.7% of patients and 81.2% of doctors had no/low anxiety. Univariable analyses in patients showed correlation of the EORTC OUT-PATSAT 35 and TSQ scores with anxiety and gender, with lower mean scores in women compared to men. Multivariable analysis showed correlation of the EORTC OUT-PATSAT 35 and TSQ scores to anxiety in both patients and doctors.CONCLUSIONS: Teleconsultation via telephone is an acceptable modality of care for oncology patients, with high satisfaction from its implementation during the pandemic reported by patients and doctors. This was consistent across responder groups with different characteristics. An individualized approach to patients should be implemented for the safe and effective use of teleconsultation in oncology beyond the pandemic.</p

Evaluation of the satisfaction and experiences of oncology patients and doctors using teleconsultation during the COVID-19 pandemic

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the Gustave Roussy Cancer Center introduced teleconsultation via telephone, as an alternative to face-to-face consultation to reduce patient hospital visits. This study was designed to assess patient and doctor satisfaction with this modality of care in oncology patient care during the period of the pandemic and beyond.METHODS: We designed two questionnaires based on validated scores to assess satisfaction from teleconsultation in patients (EORTC OUT-PATSAT 35 and Telemedicine Satisfaction Questionnaire [TSQ] scores) and doctors (Telehealth Usability Questionnaire [TUQ]), and anxiety levels in both groups (anxiety section of the Hospital Anxiety and Depression Scale [HADS], HADS-A). These were electronically sent to patients and doctors with experience of at least one remote consultation during the first wave of the COVID-19 pandemic.RESULTS: 239 patients and 32 doctors were eligible for the analyses. In the patient group, the mean satisfaction scores were 79.5 (SD 18.1) and 74.92 (SD 15.3) for EORTC OUT-PATSAT 35 and TSQ, respectively. In the doctor group, the mean satisfaction scores were 67.1 (SD 12.7) and 64.9 (SD 13.9) for TUQ and TUQ for Skype for Business, respectively. 65.7% of patients and 81.2% of doctors had no/low anxiety. Univariable analyses in patients showed correlation of the EORTC OUT-PATSAT 35 and TSQ scores with anxiety and gender, with lower mean scores in women compared to men. Multivariable analysis showed correlation of the EORTC OUT-PATSAT 35 and TSQ scores to anxiety in both patients and doctors.CONCLUSIONS: Teleconsultation via telephone is an acceptable modality of care for oncology patients, with high satisfaction from its implementation during the pandemic reported by patients and doctors. This was consistent across responder groups with different characteristics. An individualized approach to patients should be implemented for the safe and effective use of teleconsultation in oncology beyond the pandemic.</p

sj-docx-1-jtt-10.1177_1357633X241229462 - Supplemental material for Evaluation of the satisfaction and experiences of oncology patients and doctors using teleconsultation during the COVID-19 pandemic

Supplemental material, sj-docx-1-jtt-10.1177_1357633X241229462 for Evaluation of the satisfaction and experiences of oncology patients and doctors using teleconsultation during the COVID-19 pandemic by Myrto Kastrisiou, Maryam Karimi, Evangelos AA Christou, Alexandra Bizot, Marie-Alix Ropers, Anne De-Jesus, Meriem Mokdad-Adi, Thi Hong Van To, Alessandro Viansone, Suzette Delaloge, Benjamin Besse, and Maria Kfoury in Journal of Telemedicine and Telecare</p