Limburg, Paul J.

OBJECTIVES: Multitarget stool DNA (MT-sDNA) testing has grown as a noninvasive screening modality for colorectal cancer (CRC), but real-world clinical data are limited in the post-FDA approval setting. The effect of previous colonoscopy on MT-sDNA performance is not known. We aimed to evaluate findings of colorectal neoplasia (CRN) at diagnostic colonoscopy in patients with positive MT-sDNA testing, stratified by patient exposure to previous colonoscopy. METHODS: We identified consecutive patients completing MT-sDNA testing over a 39-month period and reviewed the records of those with positive tests for neoplastic findings at diagnostic colonoscopy. MT-sDNA test positivity rate, adherence to diagnostic colonoscopy, and the positive predictive value (PPV) of MT-sDNA for any CRN and neoplastic subtypes were calculated. RESULTS: Of 16,469 MT-sDNA tests completed, testing returned positive in 2,326 (14.1%) patients. After exclusion of patients at increased risk for CRC, 1,801 patients remained, 1,558 (87%) of whom underwent diagnostic colonoscopy; 918 of 1,558 (59%) of these patients had undergone previous colonoscopy, whereas 640 (41%) had not. Any CRN was found in 1,046 of 1,558 patients (PPV = 67%). More neoplastic lesions were found in patients without previous colonoscopy (73%); however, the rates remained high among those who had undergone previous colonoscopy (63%, P < 0.0001). The large majority (79%) of patients had right-sided neoplasia. DISCUSSION: MT-sDNA has a high PPV for any CRN regardless of exposure to previous colonoscopy. Right-sided CRN was found at colonoscopy in most patients with positive MT-sDNA testing, representing a potential advantage over other currently available screening modalities for CRC.

Objective To determine cross-sectional adherence with the multi-target stool DNA test used for colorectal cancer screening in a large, fully insured Medicare population. Methods All patients aged 65–85 with a valid multi-target stool DNA test order from 1 September 2016 to 31 August 2017 identified from the Exact Sciences Laboratories (Madison, WI; sole-source national multi-target stool DNA test provider) database were evaluated for test adherence. Cross-sectional adherence, defined as multi-target stool DNA test completion within 365 days from order date, was analyzed overall and by time to adherence, as well as by available patient (age, sex, test order date, Medicare coverage type) and provider (specialty, year of first multi-target stool DNA test order, multi-target stool DNA test order frequency, and practice location) factors. Results Among 368,494 Medicare beneficiaries (64% female), overall cross-sectional adherence was 71%. Cumulative adherence rates increased more rapidly at 30 (44%) and 60 (65%) days, followed by more gradual increases at 90 (67%), 180 (70%), and 365 (71%) days. By provider specialty, primary care clinicians represented a higher percentage of multi-target stool DNA orders than gastroenterologists (88% vs. 6%), but had a lower associated patient adherence rate (71% vs. 78%). Conclusions In this large, national sample of Medicare insured older adults, nearly three-quarters of patients adhered with a multi-target stool DNA order for colorectal cancer screening. These real-world data should inform further clinical and population health applications, reimbursement model simulations, and guideline-endorsed colorectal cancer screening strategies adherence.

Objectives The aim of this study was to compare the stress reduction effects of spending 25 minutes reclining in a SolTec™ Lounge between 2 intervention groups. Group 1 experienced the Lounge with multilayered music on an external speaker, while group 2 experienced the Lounge with multilayered music and synchronous vibration and magnetic stimulation from within the chair. Subjects In total, 110 participants with a self-reported stress level of 4 or higher on a 0- to 10-point scale were recruited from the local community including employees. Participants were randomized into receiving 1 of the 2 interventions. There were no significant differences between the group’s average stress levels prior to the interventions. Interventions Both groups received a 25-minute session in a dimly lit, quiet area on the Lounge with multilayered music. The second group also received vibration and magnetic stimulation that were synchronized with the music. Design Current stress level as well as ratings or feelings of anxiety, tenseness, energy, focus, happiness, relaxation, nervousness, creativeness, and being rested were recorded before and after the session. Results Both groups of participants reported equivalent decreased feelings of stress after using the Lounge. Participants receiving the synchronous multilayered music, vibration, and magnetic stimulation did report significantly reduced feelings of tenseness, feeling more relaxed, and feeling more creative when compared with the group that received music only. Conclusion Spending 25 minutes in the SolTec™ Lounge with multilayered music is an effective way to reduce self-reported stress in individuals who self-report having a high stress level. If confirmed by future studies, including synchronous vibration and magnetic stimulation with the multilayered music might be an effective stress reduction strategy.

INTRODUCTION: Due to the rising incidence and mortality of colorectal cancer (CRC) in individuals < 55 years (Siegel R, et al, JNCI, 2017), American Cancer Society (ACS) guidelines now recommend average-risk CRC screening beginning at age 45 years. The multi-target stool DNA (mt-sDNA) test, an FDA-approved screening test for average-risk individuals ≥50 years, is one ACS-recommended option for this age group. To minimize invasive testing in the younger age group, a screening test with high specificity is necessary to triage patients for diagnostic colonoscopy. To date, most endorsed CRC screening tests have not been rigorously studied in younger age groups. The objective of this study (the Act Now study [NCT03728348]) is to quantify the specificity of the mt-sDNA test in average risk individuals ages 45-49. METHODS: Act Now is an ongoing prospective, cross-sectional, multi-center study in subjects ages 45-49 at average risk for CRC. 942 subjects are targeted for enrollment and will complete a mt-sDNA test prior to undergoing a screening colonoscopy (blinded to mt-sDNA test results). Specificity for advanced colorectal neoplasia will be determined by comparing mt-sDNA test results to the most advanced finding on colonoscopy, based on procedure report and histopathological findings. Due to the low prevalence of CRC in this age group, mt-sDNA test sensitivity will be a secondary measure. RESULTS: To date, 480 subjects have completed a mt-sDNA test and screening colonoscopy. A total of 468 subjects (97.5%) have no first-degree relative (FDR) with CRC and 12 subjects (2.5%) have an FDR diagnosed at age ≥60 years. No subject has had a previous screening colonoscopy. The study population has a mean age of 47.4 years and is 48.8% female. Self-reported race includes 84.2% white, 11.5% black/African American, 3.3% Asian, and 1.0% other. Self-reported ethnicity includes 95.2% not Hispanic or Latino, 4.6% Hispanic or Latino, and 0.2% other. The mean BMI of subjects is 29.6 kg/m 2 . Most subjects (67.1%) have never smoked cigarettes, while 21.9% are former smokers and 11.0% are current smokers. CONCLUSION: The ongoing Act Now study will quantify the specificity of the mt-sDNA test in average risk individuals ages 45-49. Given concerns regarding the resources required to screen this age group for CRC, a noninvasive screening test with high specificity and sensitivity will help to optimize use of colonoscopy resources.

INTRODUCTION: Despite the demonstrated effectiveness of average-risk screening, colorectal cancer (CRC) remains the 2 nd leading cause of cancer death in the US. For optimal prevention, CRC screening tools should be highly accurate, user-friendly, and broadly accessible. Patient and provider adoption of the FDA-approved, guideline-endorsed multi-target stool DNA (mt-sDNA) test has grown exponentially since its launch in 2014. Toward ongoing improvement in CRC screening effectiveness, we conducted a blinded case-control study to assess the detection accuracy of a mt-sDNA panel of novel, highly discriminant methylated DNA markers (MDMs). METHODS: We selected 12 candidate MDMs from prior whole methylome discovery and validation in tissue. Stool was obtained as part of previous large, multicenter studies and collected prior to or 7 days post-colonoscopy (prior to any clinically-indicated treatment). CRC, advanced adenoma (AA; size ≥1 cm, high-grade dysplasia, or ≥25% villous morphology), non-AA, or control (no neoplasia) status was defined by colonoscopy and histopathology. Samples were blinded to operators and randomized by characterization to balance the test sets prior to assessment. MDMs were quantified by target-specific DNA capture and Long-probe Quantitative Amplified Signal assay on bisulfite-converted DNA; fecal hemoglobin was quantified by immunoassay. Bootstrapping methods were used to select a panel of 3 MDMs, which was then 10-fold cross-validated; hemoglobin was also included, as was a colon epithelium-specific MDM to normalize stool MDM levels. RESULTS: Participant samples included 117 CRC, 120 AA, 161 non-AA, and 327 controls. Median age was 67 (IQR 61, 75) years; 51% were men. The AUC with best-fit was 0.97 for CRC and 0.84 for AA, and these high AUCs held up tightly on cross-validation (Figure 1). At 92% (95% CI 88-94%) specificity, sensitivity of the panel was 92% (95% CI 86-96%) for CRC. Neither CRC stage (Figure 2) nor CRC site significantly affected performance. At the same 92% specificity, sensitivity was 65% (95% CI 56-73%) for AAs overall, 67% (38-88%) for sessile serrated polyps ≥1 cm, and 71% (57-82%) for adenomas with villous features (Figure 3). CONCLUSION: These data support highly accurate performance of a novel panel of mt-sDNA markers for detecting both CRC (including early stage lesions) and AAs at greatest risk of progression. Prospective comparative studies are warranted to further establish the clinical potential of this novel screening tool.

INTRODUCTION: Colorectal cancer (CRC) screening is broadly endorsed for individuals 50–75 years of age. Given recent increases in CRC incidence and mortality for patients <50 years old, the American Cancer Society now recommends initiation of average-risk CRC screening at age 45 (Wolf AMD CA Cancer J Clin 2018). The performance of recommended tests, including the multi-target stool DNA (mt-sDNA; marketed as Cologuard™) test, has been minimally described in populations under 50 years old. To address this knowledge gap, we conducted a retrospective study of DNA markers (KRAS, BMP3, NDRG4) included in the mt-sDNA assay to quantify and compare tissue marker levels in sporadic CRC cases and normal colon controls from patients in 45–49 and 50–64 year-old age groups. Our primary hypothesis was that mt-sDNA marker levels would be statistically similar between cases in both age groups. METHODS: Patient samples were identified from a pathology tissue archive at Mayo Clinic, excluding those with inflammatory bowel disease or familial cancer syndromes. Formalin-fixed, paraffin-embedded tissues were reviewed by a GI pathologist for 45–49 year-old (n = 90) and 50–64 year-old (n = 96) CRC cases; normal colon samples (45–49, n = 76; 50–64, n = 92) were also included for comparison. DNA extracted from core punches was blinded and processed in a randomized order. Quantitative Allele specific Realtime Target and Signal amplification (QuARTS) assays were used to quantify KRAS mutations, and BMP3 and NDRG4 methylation. Marker level in each sample was reported as the QuARTS product of mutant KRAS , methylated BMP3 or NDRG4 relative to the ACTB product in each sample, reported as a percentage. At least 60 patients per group provided sufficient power to demonstrate differences in marker levels of ±25% between case groups and between control groups using the Wilcoxon Rank Sum test. RESULTS: CRC cases in the 45–49 vs 50–64 year-old groups did not differ significantly with respect to sex ( P = 0.77) or race/ethnicity ( P = 0.06); left-sided CRC was more common in the 45–49 vs 50–64 year-old group (87% vs. 72%; P = 0.02). None of the marker levels were statistically different between cases of the younger vs older groups or between controls of these groups (Figure 1). CONCLUSION: These data support the expectation of no age-related differences in CRC detection by mt-sDNA, as the relevant molecular markers, when they occur, are present at similar levels across age groups 45–49 and 50–64 years.

Abstract Background: Immunoprevention via targeting antigens aberrantly expressed on colorectal cancers and adenomatous polyps offers the potential for a less invasive prevention strategy than endoscopic surveillance. Specificity of the immune response and long-term memory provide the potential for prolonged protection. Leveraging the infrastructure of the NCI-funded Cancer Prevention Network (CPN) consortium, we are conducting a double-blind randomized trial in individuals with a diagnosis of advanced colorectal adenomas within the previous year. We are evaluating MUC1 vaccine with the TLR-3 agonist polyICLC as an adjuvant, for its immunogenicity, ability to elicit immune memory and prevent recurrence of colorectal adenomas. Aims: We previously reported on the vaccine immunogenicity at week 12 (vaccine administered at 0, 2, and 10 weeks) compared to placebo. Here we report the ability of the vaccine to elicit long-term memory by measuring increase in anti-MUC1 antibody levels following a booster administered at one year. Methods: Subjects with endoscopically resected advanced adenoma (defined as ≥1cm, tubululovillous or villous histology, or with high grade dysplasia) were randomized. The primary endpoint was the response to the vaccine at week 12 assessed by monitoring anti-MUC1 IgG antibody titer ratio defined as t12/t0, where t0 was the titer pre-vaccination, and t12 was the titer at week 12. The key secondary endpoint was to assess anti-MUC1 IgG response at week 55 to a booster at week 52 in the vaccine arm compared to placebo. Results: 102 eligible subjects were randomized at 6 centers, 52 received MUC1 vaccine and 50 placebo. The mean age was 59.4±7.0 (range 40-70), 60.8% male, 88.2% white, and 18.6% Hispanic or Latino ethnicity. At 12 weeks the IgG ratio was ≥2.0 in 13/52 (25%) of individuals receiving vaccine (ratio range -0.5-17.3), vs. 0/50 in placebo group (2-sided p=.0001), and was ≥1.5 in 19/52 (36.5%) individuals receiving vaccine compared to 1/50 (2%) in placebo group (P&lt;.0001). To evaluate immune memory, 1-year booster data available for 95 patients (51-MUC1, 44-placebo) were analyzed. 10/13 (76.9%) of the week 12 vs. week 0 vaccine responders showed a response at week 52 vs. baseline and 11/13 (84.6%) at week 55 vs. week 52. Using an IgG ratio of 2 (per-protocol), the response rate was 33% for MUC1 vs. 5% for placebo (1-sided p=0.0003). Using a ratio of 1.5 yielded similar results (37% MUC1 vs. 9% Placebo (1-sided p=0.0008). The MUC1 arm had significantly higher IgG at week 52 (1-sided p=0.0294), week 55 (1-sided p=0.0048), and significantly higher week 55 to week 52 IgG ratio values (1-sided p=0.0293). Conclusions: Subjects with a recent history of advanced adenoma receiving a MUC1 vaccine compared with a placebo were significantly more likely to develop an immune response at week 12, confirming the vaccine’s immunogenicity, and to respond again at week 55 to a booster injection on week 52, confirming the vaccine’s ability to elicit immune memory. Follow-up colonoscopy to evaluate the vaccine’s potential to lower adenomatous polyp recurrence rates are in progress. Citation Format: Olivera J. Finn, Lisa Boardman, Marcia Cruz-Correa, Ajay Bansal, David Kastenberg, Chin Hurr, Sharon Kaufman, Colleen Akerley, Lynda Dzubinski, April Felt, Karrie Fursa, L.M. Rodriguez, Ellen Richmond, Asad Umar, Eva Szabo, John McKolanis, Ryan McMurray, Nathan Foster, Andres Salazar, Paul Limburg, Robert Schoen. Randomized, double-blind, placebo-controlled trial of preventative MUC1 vaccine in patients with newly diagnosed advanced adenomas: Results from one-year booster [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT236.

Abstract Background: Smoking is the most common etiology for lung cancer. Smoking cessation, even when successful, does not eliminate risk of lung cancer. With inconsistent results of lung chemoprevention trials, an emerging area of interest is immunoprevention, in particular vaccines. MUC1 is a transmembrane glycoprotein aberrantly overexpressed in adenocarcinomas, including lung cancer. Abnormal MUC1 expression is also characteristic of premalignant lesions, including bronchial dysplasia and atypical adenomatous hyperplasia. This suggests that immunization with a MUC1 vaccine in the premalignant or high-risk setting, before the tumor and cytotoxic therapy could suppress the immune system, might be effective in inducing strong immunity and reducing cancer risk. Trial design: Leveraging the infrastructure of the NCI-funded Cancer Prevention Network (CPN) consortium, we are conducting a two-center pilot trial to evaluate co-primary endpoints: immunogenicity of the MUC1 peptide plus polyICLC adjuvant vaccine (assessed at 12 weeks) and safety (assessed at up to 24 weeks) in current and former smokers who are at high risk for lung cancer. 50 participants will be screened in order to have 40 evaluable participants for baseline and 12-week immunogenicity assessments. Eligibility: Smoking history of ≥30 pack-years and either current smoker (still smoking or quit &lt; 1 year prior to pre-registration) or former smoker (quit 1-15 years prior to pre-registration); ages 55-80 years; ECOG performance status ≤1; CT scan of the chest done ≤ 6 months prior to pre-registration showing either negative findings (no nodules) or solid or part-solid nodules &lt; 6 mm in size (consistent with &lt; 1% probability of malignancy, Lung-RADs Version 1.0). Exclusion criteria are standard. Immunogenicity and safety: MUC1 peptide plus polyICLC adjuvant vaccine will be administered at week 0, 2 and 10. The primary endpoint is anti-MUC1 IgG titer that is ≥2 fold higher at week 12 compared to baseline. Based on previous studies of this vaccine, we expect that 40 evaluable participants will provide 96% power to detect immunogenicity response rate of 15% versus 40% using a 2-sided test of proportions with type I error rate of 0.05. AEs and toxicities will be monitored for up to 24 weeks from the first vaccine. Secondary Objectives: We will explore differences, if any, in vaccine immunogenicity in current vs. former smokers. Smoking induces chronic inflammation (hallmark of cancer) associated with immunosuppression. We will evaluate pre-vaccination levels of circulating myeloid derived suppressor cells (MDSC) and correlate with the response to the vaccine. We will explore the impact, if any, of this vaccine on the markers of inflammation (hsCRP, IL-6) and the effect of baseline levels of these markers on the ability to successfully vaccinate. We will also assess the relationship between COPD status and immune response in current versus former smokers. The trial is open to accrual. Citation Format: Olivera J. Finn, Julie Ward, Tami Krpata, Lisa Bengtson, John McKolanis, Sharon Kaufman, Colleen Akerley, April Felt, Karrie Fursa, Anne Holland, Nathan Foster, Andres Salazar, Malgorzata Wojtowicz, Eva Szabo, Paul Limburg, David Midthun, Arjun Pennathur. A pilot study of a MUC1 vaccine in current and former smokers at high risk for lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT222.

Abstract INTRODUCTION Participating in a clinical trial is a personal choice and an individual experience. Several barriers to recruitment of high risk men and women in chemoprevention trials have been documented; however, to our knowledge, there are no existing reports on participant satisfaction in such trials. Therefore, our aim was to describe and evaluate participants’ perception of their experience with participating in chemoprevention trials conducted by CPN by summarizing the 5-item “Was It Worth It” (WIWI) tool for each trial and across the trials, and according to race/ethnicity, sex, age, site, and organ of primary interest. METHODS Because participants who participate in chemoprevention trials tend to be at increased cancer-risk, but otherwise healthy, the WIWI tool can help answer simple questions about participants’ assessment of whether or not participation in such a trial was worthwhile. The WIWI tool was consistently administered at the end of the intervention period in each trial conducted by CPN; since 2003, 7 trials have completed the study intervention period and are included in the results reported here. RESULTS The scientific focus of the 7 trials targeted 5 organs: breast, colorectum, esophageal, hepatobiliary, and lung. Of the 485 participants registered to these 7 trials, 419 (86.4%) were non-Hispanic white, 19 (3.9%) non-Hispanic black, 32 (6.6%) Hispanic, 14 (2.9%) other race/ethnicity, and 1 (0.2%) unknown race/ethnicity; there were 120 (24.7%) females. In total, 446 (92.0%) participants completed the WIWI questionnaire at the end of their respective intervention period. Across the trials, 93% [95% CI] [90.6%, 95.4%] of the participants indicated that participation was worthwhile and 92% [89.5%, 94.5%] reported that they would participate again. Additionally, 414 (92.8%) participants indicated that they would recommend participating in the current research study to others, while 10 (2.3%) indicated that they would not and 22 (4.9%) were uncertain. Furthermore, several participants provided actionable feedback to the question “If there was one thing that could have been done to improve your experience in this research study, what would it be?” Participant feedback on overall changes in quality of life and on their expectations with participation in the trial was positive but more nuanced, varying according to trial and participant composition. CONCLUSION In this dataset of chemoprevention trial participants enrolled through the CPN consortium, highly favorable feedback was evident with respect to the overall study experience, suggesting that the recruitment and retention methods employed are facilitating success. These data can be used to help advance the NCI accrual quality improvement program in developing/enhancing strategies to improve accrual, retention, and adherence as well as enhance participant diversity in subsequent trials. Citation Format: David Zahrieh, Ryan P. McMurray, Nathan R. Foster, Paul J. Limburg, Sumithra J. Mandrekar. Participant satisfaction with cancer chemoprevention clinical trials: The Mayo Clinic Cancer Prevention Network (CPN) experience [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5092.

Abstract Purpose: BRCA1 and BRCA2 mutation carriers develop breast cancers with a tumor phenotype unique from spontaneous tumors. We surveyed documented BRCA mutation carriers to determine willingness to be contacted about participation in future breast cancer prevention research studies directed to their unique phenotype that may or may not require breast biopsies. Methods: At each of the 3 participating institutions, women at least 20 years of age with a documented germline deleterious mutation in BRCA1 or BRCA2 and no prior history of breast cancer were contacted to participate in a survey to ascertain their willingness to be contacted to participate in future prevention trials. Survey results were summarized using descriptive statistics. Results: Among 56 BRCA1 and BRCA2 mutation carriers who responded, 55.4% of women reported high or very high interest in participating in randomized control study of chemoprevention agent vs. placebo. Within this population, post-menopausal women demonstrated a higher interested in study participation (64.5%) versus pre-menopausal women (38.9%). When examining willingness to undergo breast biopsy for a chemoprevention study, women expressed near equal willingness (42.9%) and unwillingness (44.6%) for biopsy. Conclusions: BRCA1 and BRCA2 mutation carriers demonstrated significant interest in breast cancer prevention study participation involving trial agent versus placebo, and an equal expression of willingness and unwillingness to undergo breast biopsy, establishing the feasibility for future research elucidating targeted chemoprevention agents. Citation Format: Rachel M. Hurley, Vera J. Suman, Mary Daly, Funmi Olopade, Paul J. Limburg, Sandhya Pruthi. Assessment of interest for breast cancer prevention trial participation among BRCA mutation carriers. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C01.