2021 Accepted Spring Abstracts

* Indicates selected for podium presentation

Does Denosumab offer Survival Benefits? Our Experience with Denosumab in Metastatic Non-Small Cell Lung Cancer Patients Treated with Immune-Checkpoint Inhibitors*

Yenong Cao, MD, PhD1, Muhammad Zubair Afzal, MD, MS2, Keisuke Shirai, MD, MS2

1 Department of Internal Medicine, 2 Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center

Background: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of non-small-cell lung cancer (NSCLC). Denosumab is a humanized monoclonal antibody to RANK ligand used to prevent skeletal-related events of bone metastases in solid tumors. Denosumab has shown some anti-tumor properties. We are reporting the clinical outcomes in our NSCLC patients who received RANKL inhibitor in combination with ICIs.

Methods: This observational study used retrospective data from 2015-2020. Median overall survival (OS), progression free survival (PFS), best radiographic responses were obtained.

Results:  We identified 69 patients who all had skeletal metastasis, with 37.7% harboring brain metastases. Median duration of concomitant use of denosumab and ICI was 1.5 months.  Median OS was 6.3 months and median PFS was 2.8 months. Overall response rate was 18.8% and disease control rate was 40.6%. Median OS in patients with concomitant denosumab and ICIs more than 3 months was 11.5 months, comparing to 3.6 months in patients with < 3 months of concomitant therapy (P=0.0005). OS and PFS did not differ with respect to brain metastases or number of skeletal metastases. Among patients who achieved complete response (CR) and partial response (PR), six-month survival rate was 100% and one-year survival rate was 69.2%.

Conclusions: Patients receiving combination therapy did not perform poorly comparing to published studies despite of poor prognostic features such as brain metastases and numerous skeletal metastases. Although we observed potential benefit of the longer duration of concomitant use of ICI and denosumab, future prospective clinical trials are needed to evaluate the synergistic effect of RANKL inhibitors/ICI.

Baseline Higher Platelet-to-Lymphocyte and Neutrophil-to-Lymphocyte Ratios are Associated with Less Durable Radiographic Response to Immune Checkpoint Inhibitors in Non-Small cell Lung Cancer

Yenong  Cao, MD, PhD, John P. Palmer MD, Samer Ibrahim, DO, Natasha Dhawan, MD, Muhammad Afzal, MD, MS, Keisuke Shirai, MD, MSc

Dartmouth Hitchcock Norris Cotton Cancer Center

Background: We aim to study the effect of higher neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) on the radiographic response and its durability in non-small cell lung cancer (NSCLC) patients treated with ICIs.

Methods: We conducted a retrospective analysis on 178 NSCLC patients treated with ICIs either alone or in combination with the chemotherapy. Radiographic response and its duration, PLR and NLR were calculated at baseline and at 8 weeks since the start of ICI. The cut off for higher NLR and PLR was the median NLR and PLR value.

Results: There was statistically significant difference in median duration of response in patients with higher NLR (9.8 months vs. 18 months, P= 0.01, 95% CI 10.9 – 26.2) and higher PLR (9.0 months vs. 17 months, P= 0.03 95% CI 10.9 – 24.33) at baseline. The odd’s ratio (OR)  of response was 0.73 (P= 0.5, 95% CI 0.36 – 1.64) in higher NLR subgroup and the OR for response was 0.63 (P= 0.2, 95% CI 0.32 – 1.23) in higher PLR subgroup at baseline. However, the odds to respond to ICI decreased significantly in patients with higher NLR and PLR at 8 weeks [NLR (OR = 0.16, P= 0.0001, 95% CI 0.06 – 0.43)] and [PLR (OR= 0.27, P= 0.005, 95% CI 0.1 – 0.6).

Conclusions: NLR and PLR can be reliable surrogate markers determining the durability of the response to ICI in NSCLC patients. A serial monitoring maybe beneficial along with the standard imaging studies to monitor the response to ICIs

Using Tableau Software for visualization and analysis of our breast cancer population and comparison with the National Cancer Database (NCDB). Experience of a rural cancer center in Maine

Catherine Chodkiewicz1, Adam Curtis1, Terry Leahy1, Susan O’Connor2, Kimberly Lieber2, Sarah Sinclair2

1 Northern Light Cancer Care, 2 Northern Light Breast Surgery

Background: One of the limitations in developing quality improvement projects in cancer programs is the inability to analyze trends and patterns of care within a local cancer population. Tableau is an interactive visualization software program that allows analysis of large data sets that can be used to analyze trends and quality metrics. We used this software to compare our breast cancer population treatment timelines and outcomes to that of the NCDB.

Methods: We analyzed our breast cancer patient population between years 2016 and 2018. We created a total of 11 dashboards summarizing various aspects of our breast cancer population including demographics, treatment patterns and time intervals between critical segments of care. Each dashboard was created to be searchable by year and stage and was used to compare to results of the NCDB when available.

Results: A total of 978 patients were analyzed between year 2016 and 2018, dashboards created included, staging, histology, age distribution, first line treatment inclusive of all treatments, first line specific treatment regimen, surgery type, neoadjuvant treatment type, adjuvant hormonal therapy, oncotype Dx testing and associated patterns of treatment, time interval from biopsy to surgery, and from abnormal imaging to biopsy, location of biopsy and surgical procedure.

Conclusions: Tableau software is a tool that allows interactive visualization of data giving providers insight into trends or patterns of care for a large volume rural cancer center that can be used for quality initiatives.

Analysis of reasons for Emergency Department (ED) visits and resulting admissions for breast cancer patients from July 2019 to August 2020: Experience of a rural cancer center in Maine*

Catherine Chodkiewicz2, Anannya Patwari2, Vineel Bhatlapenumarthi2, Courtney Brann1, Jackson Waldrip1, Victoria Caruso1, Adam Curtis2

1 College of Osteopathic medicine: University of New England 2 Northern Light Eastern Maine Medical Center Cancer Center

Background: Reducing ED visits in patients with cancer is cost saving and is particularly relevant during the COVID pandemic.

Methods: We analyzed the number of ED visits that occurred in our breast cancer  population between July, 1st 2019 and August 31st,2020 including: demographics, stage distribution, treatment type within the month of ED visit, reason and time of the day, day of the week the visit occurred.

Results: A total of 101 patients had 162 visits. No visits occurred during the month of May. The 5 major reasons for ED visits were fall and injury (N=30), gastrointestinal (N=24), cardiac or chest pain (N=17), respiratory symptoms (N=14) and cancer pain (N=11). The major reasons for visits associated with abnormal blood work was neutropenic fever (N=7).  A total of 77 visits resulted in admissions. Most patient were on endocrine therapy at the time of their visit (N= 59) and 31 patients were on no treatment at all. Falls were unrelated to disease or treatment and occurred in patients above 70 years old. Visits occurred during working hours from 6AM to 5PM, with peak incidence on Mondays and Fridays.

Conclusions: Reducing ED visit in cancer patients is a worthwhile endeavor particularly in the context of the COVD pandemic. The main reason for ED visits were falls and injuries that were unrelated to disease or treatment.  As a result, we are implementing systematic physical therapy assessment for our breast cancer population.

The Creation Of An Algorithm To Assist Survivorship Clinics Identify The Rehabilitation Needs Of Cancer Survivors: An Administrative Case Report

Joseph Connor, BS, SPT, Amy J. Litterini, P.T, D.P.T

University of New England

Background: Approximately 40% of cancer survivors have unmet rehabilitation needs. Cancer survivors not receiving rehabilitation may be due to survivorship clinics struggling to identify appropriate referrals for rehabilitation. The purpose of this case report was to review the literature and create an algorithm to assist survivorship clinics with rehabilitation referrals.

Methods: A survivorship clinic in Maine was attempting to address the lack of a rehabilitation screening process. A survey done by the clinic showed approximately 40% of their survivors used rehabilitation services. To address this lack of a screening process, a literature review was conducted to identify common cancer impairments that may necessitate rehabilitation services. An algorithm was created with screening measures to identify those impairments. The initial algorithm consisted of the Pain Visual Analogue Scale, Fatigue Numerical Scale, and Short-Form 36 questionnaire.

Results: The final algorithm consisted of two aspects. First, the provider asks themselves whether the survivor can exercise without medical supervision. The second is based on the Short-Form 36 results. These answers determine eligibility for referral to rehabilitation services. An expert in oncology rehabilitation vetted the algorithm in the fall of 2020, which resulted in the final algorithm creation.

Conclusions: The original stakeholders were unavailable to evaluate the proposed algorithm or implementation into the survivorship clinic due to the Covid-19 pandemic. With the help of expert feedback, the final algorithm contributes to the growing body of literature regarding screening for oncology rehabilitation. Future research should be aimed at the implementation of algorithms into clinics.

Caring calls in the time of Covid-19*

Maureen Higgins, MA, LMT, Maggie Miller, MSW

Dempsey Center

Background: At the Dempsey Center (Lewiston & So. Portland, Maine), we make life better for people managing the impact of cancer. Our complementary therapies, counseling and support are offered free of charge. In March 2020 we closed our physical doors and pivoted to on-line services. Staff initiated a program called Caring Calls to provide continuity of connection, assess client needs, and minimize isolation.

Methods: Dempsey Center has more than 1,500 clients in its database. Beginning with current clients, staff telephoned every person. They followed a protocol of talking points, using active listening skills and reflection to engage each person and assess their needs. Staff encouraged use of Dempsey Center virtual services, provided referrals, and made note of clients’ expressed needs. Based on client distress levels, follow-up calls were also made. A total of 2,740 telephone calls resulted in more than 1,260 conversations.

Results: Cancer patients feel particularly vulnerable and isolated under Covid-19 protocols: family can no longer attend appointments, stay through chemotherapy, visit in hospitals. Caring Calls lasted an average of 15 minutes (up to 45) reflecting clients’ need for support. As one client said, “You are the only person I’ve spoken to this week.” Significant numbers engaged in Dempsey Center virtual services because of this personal encouragement.

Conclusions: The program proved so beneficial that it has evolved from a short-term bridge program to standard Dempsey Center protocol. Clients are now contacted at specified intervals throughout the year. Skilled volunteers are being trained in the Caring Calls model for sustainability.

Mindfulness Tools for Health and Wellness

Theresa Hudziak, MS, Roz Grossman, MA, Donna Smith, PT, DPT, Julia Wick, LCMHC

University of Vermont Medical Center Vermont Cancer Center 

Structure: Mindfulness Tools for Health and Wellness (MT) is a grant-funded program at the University of Vermont Medical Center (UVMMC), Vermont Cancer Center. Programs offered provide mindfulness-based interventions (MBIs) for cancer patients, survivors, caregivers, and providers.

Background/foundation: MT is based on the Mindfulness-Based Stress Reduction (MBSR) programroven to foster stress reduction, symptom management, and improved quality of life for cancer patients, caregivers, and healthcare providers. 

Addressing mental health and managing anxiety and stress have been identified among six recommendations for cancer patients during COVID-192 . Included in these recommendations are meditation and yoga, practices fundamental to MT.

Methods/project design: During the COVID-19 pandemic the MT program has been offered with live online programs.The MT program consists of three programs

  1. 8-week classes based on MBSR
  2. Friends for Life (FFL), a monthly ongoing mindfulness-support group
  3. weekly drop-in
  4. two workshops: Healthy Communication, and  Self-compassion

All classes provide a combination of didactic and experiential learning strategies to manage stress and support health and well-being. 

Results/outcome: Participation in three online classes offered in 2020 showed a three-fold increase. 

Evaluations completed for the three 2020 online classes show 1) 92% stress reduction 2) 31% pain reduction 3) 85% recommend the program. 69% of participants who completed evaluations said the online classes worked well for them.

Conclusions/future directions and relevancy During the pandemic human connection has been drastically reduced. MT offers a distinctly accessible approach to managing isolation, stress, and anxiety for those affected by cancer

Overweight or obese patients may take longer to respond and be less responsive to immune checkpoint inhibitors in non-small cell lung cancer. A retrospective review.

John P. Palmer, MD, Yenong Cao, MD, PhD, Samer Ibrahim, DO, Natasha Dhawan, MD, Muhammad Zubair Afzal, MD, MS, Keisuke Shirai, MD, MSc

Dartmouth Hitchcock Medical Center

Background: Immune checkpoint inhibitors (ICI) are the standard of care for non-small cell lung cancer (NSCLC). Recruitment of inflammatory cells in the tumor microenvironment is associated with poor responses to ICI. Obesity procures a low systemic inflammation state, potentially improving outcomes in these patients. However, interleukin-1b is elevated, decreasing ICI responsiveness. We studied the effect of increased weight on outcomes in NSCLC patients receiving ICI.

Methods: We conducted a retrospective analysis of 178 NSCLC patients treated with ICI, alone or combined with chemotherapy. Overall survival (OS), progression-free survival (PFS), best radiographic response, and time to achieve radiographic response were evaluated. Cox regression analyses were performed. Logistic regression and Chi-square tests were applied.

Results:  48.6% of patients were overweight/obese. The objective response rate (ORR) was 45.1% and the disease control rate (DCR) was 75.8%. ORR was 37% in overweight/obese patients and 52% in  normal-weight patients (p=0.06). DCR was 76% vs. 73.9%, (p= 0.7). The median time of best radiographic response was 3.7 months in overweight/obese patients compared to 2.5 months with normal weight (p=0.2). A higher proportion of overweight/obese patients progressed (80.7% vs. 69.3%, P= 0.08). There was no difference in median PFS (7.4 vs. 8.1 months, P= 0.2). Overall survival was not different (15.9 vs. 16.8 months, P= 0.5).

Conclusions: Our study suggests obesity/overweight status can result in low ICI responsiveness in NSCLC patients and can delay the best radiographic response. We did not observe significant impact on OS or PFS. A population-based study could elucidate weight’s impact on ICI responsiveness.

Baseline systemic inflammatory immune index may predict overall survival and progression-free survival in patients with non-small cell lung cancer patients on immune checkpoint inhibitors.

John P. Palmer, MD, Yenong Cao, MD, PhD, Samer Ibrahim, DO, Natasha Dhawan, MD, Muhammad Zubair Afzal, MD, MS, Keisuke Shirai, MD, MSc

Dartmouth Hitchcock Medical Center

Background: Increased inflammation within a tumor micro-environment portends lower responsiveness to immune checkpoint inhibitors (ICI). We studied the effect of systemic inflammatory immune index (SII) on outcomes in non-small cell lung cancer (NSCLC) patients receiving ICI.

Methods: We conducted a retrospective analysis of 178 patients receiving ICI alone or in combination with chemotherapy. Baseline and 8-week SIIs were obtained. Radiographic response, response duration, overall survival (OS), and progression-free survival (PFS) were evaluated. Cox regression was performed. Logistic regression, t-test, and Chi-square tests were applied.

Results: Objective response rate (ORR) was 45.1%. Disease control rate was 75.8%. ORR was 51% in patients receiving ICI first-line vs. 35% second-line. There was no difference in the baseline mean SII between responders and non-responders (2146.2 vs. 1917.5, P= 0.5). 8-week mean SII was lower in responders (1198.8 vs. 2880.2, P= 0.02). 15 (10.9%) patients showed pseudoprogression or mixed response. Among these, 11 (73.3%) had low 8-week SII (P=0.04). Median OS was higher in patients with low baseline SII (29.6 months vs. 10.1, P= 0.001 95% CI 10.6 – 22.1). There was a difference in median PFS in low-SII patients (14.6 months vs. 6.7, P= 0.002, 95% CI 5.6 – 11.6) but correlation between high or low SII on the incidence of adverse events.

Conclusions: SII may impact OS and PFS and could be serially monitored to assess response to ICI. Low SIIs could differentiate pseudoprogression vs. true progression.  Prospective studies could validate these findings. SII could be used to determine the duration of cytotoxic therapy in select patients.

COVID-19 and the administration of bamlanivimab; a cooperative effort between a community cancer center and an urgent care facility

Patrick Skeffington, PharmD, MHA, MSRA, Janice DallaCosta RN, Ian Donaghy RN, Kelly Houde RN, Kathy Moraes RN, Annmarie Santos RPH

Southcoast Center for Cancer Care

Background: Goal of Massachusetts DPH is to ensure equitable distribution to the most vulnerable at risk of poor outcomes from COVID-19 and communities with the highest incidence of COVID-19.  Hospitals should allocate available doses of bamlanivimab in a manner consistent with this guidance:

  1. Patients who meet the EUA criteria, prioritize patients age >65 and those >18 with BMI > 35(Tier 1) over others who meet criteria (Tier 2); lottery system used if supply is exceeded
  2. Patients with comorbidities (high risk) tend to do much poorer when infected with SARS-CoV2
  3. Bamlanivimab was approved under an EUA for the treatment of mild to moderate COVID-19 for those at high risk of progressing to severe COVID-19 disease
  4. Oncology and infusion centers are uniquely experienced to prepare and administer monoclonal antibodies

Southcoast Health entered into this relationship with DPH to provide patients this service.

Methods: Patients were screened by either ID or pulmonary via a telehealth visit for inclusion

Patients were scheduled for bamlanivimab in Urgent Care Center

Experienced nursing staff from various Southcoast departments were scheduled to treat patients (up to 6 per day)

Becvauses of proximity, Oncology Infusion Pharmacy prepared and delivered the bamlanivimab once patient deemed appropriate

Results: Of first 100 cases

6% inpatient admissions within 14 days

4% ED visits within 14 days

No deaths during initial 100 cases

Conclusions: Cooperative effort between the Cancer Center and Urgent Care led to positive outcomes for local COVID-19 patients.

Change in the comprehensive geriatric assessment scores at day 30 post-cancer treatment in geriatric oncology patients

Toufic Tannous, MD, Dany Debs, MD, Erkan Ceyhan, Ponnandai Somasundar, MD

Roger Williams Medical Center, Boston University

Background: The comprehensive geriatric assessment (CGA) is a multidimensional tool used for assessing the functional, cognitive, and nutritional status of oncology patients above 65 years of age. Our purpose was to evaluate the change in CGA scores in response to treatment at different time periods.

Methods: We conducted a single institution, prospective cohort registry of patients with solid cancers aged 65 or older in Rhode Island from 2013-2018. All patients underwent a CGA before starting treatment (day 0) and post-treatment (day 30). Treatment included surgery, chemotherapy, radiation, or any combination. Baseline characteristics and CGA components: TUG, MMSE, PHQ-9, IADL, PP, BMI, MNA and ADL performed at day 0 and 30 were collected. The mean for each score was obtained at both days. A student’s T test and Chi square test were used to test for significance (P<0.05)

Results: 283 patients were enrolled. The mean age was 76 (+-6.86) of which 54% were females. 92% of patients were white and 8% were black. Results are summarized in Table 1:

CGA variables Day 0  Day 30 P

BMI⁰ 26.92 (+-5.84)  26.1(+-5.45) <0.01

IADL⁰ 5.93(+-2.03) 5.2(+-2.12) <0.01

PHQ-9⁰ 5.02(+-4.3) 5.13(+-3.82) 0.72

MMSE⁰ 27.01(+-3.38) 26.91(+-3.11) 0.63

MNA⁰ 4.96(+-3.44) 5.23(+-2.81) 0.5

TUG⁰ 10.23(+-2.52) 10.11(+-1.78) 0.74

PP† 51 62 0.12

ADL† 1 7 0.03

⁰Mean score and SD


Conclusions: ADL, IADL and BMI scores showed a statistically significant worsening at Day 30 post-treatment compared to the others. This suggests that they may be used as early markers of clinical deterioration in geri-onc patients undergoing treatment.

Tocilizumab, COVID-19, Cancer: A single institution experience in RI

Toufic Tannous, Mohana Neelam, Xiuhong Lyu, Mark Curtis, John Miskovsky, Vincent Armenio, 

Todd Roberts, Kapil Meleveedu

Roger Williams Medical Center

Background: Tocilizumab (toci) is an IL-6 receptor-blocking monoclonal antibody that has been used to suppress cytokine release syndrome in SARS-CoV-2 patients.

We did a retrospective analysis to assess the mortality rate difference between cancer and non-cancer patients that were hospitalized and received toci.

Methods: Retrospective chart review of all the patients with COVID-19 who were admitted to Roger Williams Medical Center or Old Lady of Fatima hospital and received Tocilizumab were included. Basic demographics, clinical characteristics and outcomes were obtained. Descriptive statistics were used to summarize the data

Results: 144 patients were identified, of which 10 carried a cancer diagnosis. Median age was 75 years, with 8 older than 65 years. Seven were in remission and none were on active anticancer treatment at the time of COVID diagnosis. Only 2 had prior history of chemo/radiation. Nine out of 10 had hypertension as the other major comorbidity. Median CRP levels (251 mg/L) before receiving toci were higher in the cancer patients compared to others (P 0.002). There was no statistically significant difference in the rate of intubation or mortality in cancer patients compared to general population.

Conclusions: Based on our data, the mortality rate at our institutions for patients with history of cancer who received toci was 50%. We were not able to assess the incidence of COVID-19 among cancer patients as the data were selected for only patients who received toci. Small sample size and wide confidence intervals makes our finding limited and a larger cohort is required to form more generalized conclusions.

A Peculiar Case of Choriocarcinoma Syndrome

Toufic Tannous1, Matthew Keating2

1 Roger Williams Medical Center, 2 University of California, Irvine, California

Background: Choriocarcinoma syndrome (CS) occurs high risk male patients with a testicular non seminomatous germ cell tumor (TNSGCT), mostly Choriocarcinoma, with pulmonary metastasis, and an elevated B-HCG level above 50,000 mIU/ml . Characterized by acute respiratory distress syndrome (ARDS) due to Diffuse Alveolar hemorrhage (DAH) and tumor site bleeding post chemotherapy

Methods: Published cases of CS in males with TNSGCT were collected and summarized. We describe our own case of CS.

Results: A previously healthy 29-year-old male presented with one month of worsening dyspnea and scrotal swelling. His physical exam revealed tachycardia, decreased breath sounds and a right testicular mass. Labs include B-HCG level of 1,063 mIU/ml ( 0.5 - 5mIU/ml), AFP 26157 ng/ml (0 - 9 ng/ml), LDH 1,671 U/L (140 - 271 U/L), TSH<0.01 uIU/ml (0.34 - 5.6 uIU/ml). CT of the chest, abdomen and pelvis revealed multiple pulmonary masses, and an 11.7 cm testicular mass. Brain MRI showed multiple brain lesions. After orchiectomy, pathology revealed high grade mixed Germ cell tumor composed of choriocarcinoma (50%), yolk sac tumor (45%) and embryonal carcinoma (5%). After starting on etoposide, ifosfamide cisplatin (VIP) he became acutely hypoxemic developed ARDS and required intubation. Chest CT demonstrated new ground glass-glass opacities surrounding the pulmonary nodules. Bronchoscopy confirmed DAH. He eventually went into cardiac arrest.

Conclusions: Summarized in Table 1 are all the published CS findings. All the cases seen have a B-HCG level above 50,000 mIU/ml, as opposed to ours: 1,063 mIU/ml. We suggest re-evaluating the quantitative role of B-HCG in defining high risk groups.

Northern New England Clinical Oncology Society
P.O. Box 643
Sandown, NH 03873-0643
Telephone (603) 887-1948

This website brought to you by:

Powered by Wild Apricot Membership Software