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Kuruswamy Thurai Prasad



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    MA 03 - Chemotherapy (ID 651)

    • Event: WCLC 2017
    • Type: Mini Oral
    • Track: Advanced NSCLC
    • Presentations: 1
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      MA 03.02 - Timing of B12/Folate Supplementation in NSCLC Patients on Pemetrexed Based Chemotherapy: Final Results of the PEMVITASTART Randomized Trial (ID 7957)

      11:05 - 11:10  |  Author(s): Kuruswamy Thurai Prasad

      • Abstract
      • Presentation
      • Slides

      Background:
      Vitamin B12 and folic acid supplementation(B12-FAS) reduces the incidence and severity of hematological toxicity[HTox] in pemetrexed-based chemotherapy. It is recommended to initiate B12-FAS 5-7 days before the first cycle. Observational and prospective single-arm studies have not shown any increase in HTox when pemetrexed was started earlier than the recommended duration of B12-FAS.

      Method:
      An open-label, randomized trial (PEMVITASTART; NCT02679443) was conducted to evaluate differences in HTox between patients initiated on pemetrexed-platinum chemotherapy following 5-7 days of B12-FAS (Delayed Arm; DA) versus those receiving B12-FAS simultaneously(≤24 hours) with chemotherapy initiation (Immediate Arm; IA). Eligible patients had locally advanced/metastatic non-squamous NSCLC AND ECOG PS=0-2. Block randomization was 1:1 into DA and IA. All enrolled patients received 3-weekly pemetrexed-platinum doublet [500mg/m[2] AND cisplatin(65mg/m[2]) OR carboplatin(AUC 5.0mg/mL/min) each on D1] for maximum of six cycles. Supplementation was 1000µgm FA PO daily and 3-weekly 1000µgm i/m vitamin B12. Primary outcome was any grade HTox while secondary outcomes were grade 3/4 HTox, relative dose intensity(RDI) delivered, inter-cycle delays(ICDs), supportive therapies usage (ESA/G-CSF/PRBC transfusions) and changes in serum levels of B12/FA/homocysteine.

      Result:
      Of 161 patients recruited (81 IA, 80 DA), 150 patients (77 IA, 73 DA) received ≥1 cycle and were included in modified ITT analysis. Baseline parameters were matched except for gender (IA=10.4%, DA=23.3%, p=0.03) and baseline thrombocytopenia (IA=7.8%, DA=0%, p=0.03). Baseline anemia(Hb<12gm/dL) was present in 34.7% (IA=32.5%, DA=37.0%; p=0.56). Incidence of any grade anemia, leukopenia, neutropenia and thrombocytopenia was 87.0% vs. 87.7%(p=0.90), 37.7% vs. 28.8%(p=0.25), 20.8% vs. 15.1%(p=0.36) and 31.2% vs. 16.4%(p=0.04) in IA and DA respectively. Grade 3/4 anemia was 18.2% vs. 12.3%(p=0.32) in IA and DA respectively while other cytopenias were similar (<5% in each arm). Supportive therapies usage in IA vs. DA were 22.1% vs. 12.3% for PRBC transfusions (p=0.12), 3.9% vs. 6.8% for G-CSF (p=0.49) and 10.4% vs. 1.4% for ESAs (p=0.03). ICDs occurred in 14.3% of IA vs. 8.2% in DA (p=0.24). RDI delivered (median 93.5% for pemetrexed and 91.0% for platinum) was similar in both arms. Following continued B12-FAS, after C3(compared to baseline), serum homocysteine was lower (median 10.0µmol/L vs. 17.6µmol/L;p<0.001) while FA (median 17.9ng/ml vs. 5.7ng/ml;p<0.001) and B12 levels (mean 1926.3pg/ml vs. 880.2pg/ml;p<0.001) were higher. In DA, serum FA and B12 on Day1 of C1(following 5-7days of B12-FAS) were significantly higher than baseline but homocysteine levels were similar.

      Conclusion:
      Simultaneous B12-FAS initiation with pemetrexed-based chemotherapy is feasible with acceptable HTox profile. Serum homocysteine levels are unaffected by 5-7 days of B12-FAS.

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    P2.03 - Chemotherapy/Targeted Therapy (ID 704)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Chemotherapy/Targeted Therapy
    • Presentations: 1
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      P2.03-053 - A Five-Year Audit of EGFR and ALK Testing at a Tertiary Care Centre in North India: More Sensitive Methods Do Make a Difference! (ID 10427)

      09:30 - 09:30  |  Author(s): Kuruswamy Thurai Prasad

      • Abstract

      Background:
      Detection of targetable driver mutations in NSCLC may depend on the method employed. We carried out an audit to determine whether the EGFR mutation (EGFR-M) and ALK rearrangement (ALK-R) detection rate is dependent upon on the testing method used. We also sought to assess if EGFR-M and ALK-R was associated with baseline demographic characteristics.

      Method:
      Retrospective analysis of NSCLC patients who underwent testing for EGFR-M and ALK-R from January 2012 till May 2017. Methods used for EGFR-M were Real time ARMS PCR and gene sequencing while Break Apart FISH and D5F3 immunohistochemistry(IHC) were used for ALK-R testing.

      Result:
      Of the 599 patients tested for EGFR-M, 541 (90.3%) had interpretable results with an overall prevalence of 21.4%(n=116). Real time ARMS-PCR and gene sequencing yielded 95.9% and 81.9% interpretable results respectively. ALK-R testing was done in 462 patients of whom 431 (93.3%) had interpretable results, of which 8.6%(n=37) were positive. D5F3 IHC and Break Apart FISH yielded 94.7% and 82% interpretable results respectively. Mean age was 59.2 and 54.0 years respectively for EGFR-M and ALK-R patients with 54.3% and 45.1% being females. Mutations in exon 19 were the most common (n=81, 69.8%) followed by exon 21 L858R (n=30, 25.9%). 87/116 (75%) and 19/37 (51.4%) of EGFR-M and ALK-R patients received EGFR-TKIs and crizotinib respectively. Table shows differences in prevalence of EGFR-M and ALK-R prevalence in relation to gender, smoking status, histology and testing method used.

      Table 1 Smoking, gender and histologic profile of the patients tested for EGFR mutations and ALK rearrangements
      EGFR-M positive (n=116) ALK-R positive (=37)
      Overall 21.4% 8.6%
      Adenocarcinoma only 23.8% 9.5%
      Females vs. males 37.1% vs. 14.3% 12.5% vs. 6.8%
      Non-smokers vs. smokers 34.6% vs. 11.9% 11.6% vs. 6.5%
      Female non smokers 39.9% 12.4%
      Male non-smokers 26.1% 10.5%
      Male smokers 11.1% 6.3%
      Females with adenocarcinoma 40.7% 13.3%
      Method used for testing 23.1% Real time ARMS PCR vs. 17.8% gene sequencing 9.0% D5F3 IHC vs. 4.9% Break Apart FISH


      Conclusion:
      Real time ARMS-PCR and D5F3 IHC are more sensitive methods for detecting EGFR-M and ALK-R respectively. Prevalence of a targetable driver in North Indian NSCLC patients ranges from 52.3% amongst female non-smokers to 17.4% of male smokers which are very encouraging results from both the patients and the treating oncologists perspectives. Higher percentage of EGFR-M patients receive targeted therapy as compared to ALK-R.