Pegfilgrastim +/- ciprofloxacin for primary prophylaxis with TAC (docetaxel/doxorubicin/cyclophosphamide) chemotherapy for breast cancer. Results from the GEPARTRIO study

BACKGROUND

TAC (docetaxel/doxorubicin/cyclophosphamide) is associated with high incidences of grade 4 neutropenia and febrile neutropenia (FN). This analysis compared the efficacies of four regimens for primary prophylaxis of FN and related toxic effects in breast cancer patients receiving neoadjuvant TAC.

PATIENTS AND METHODS

Patients with stage T2-T4 primary breast cancer were scheduled to receive 6-8 cycles of TAC. Primary prophylaxis was: ciprofloxacin 500 mg orally twice daily on days 5-14 (n = 253 patients; 1478 cycles), daily granulocyte colony-stimulating factor (G-CSF) (filgrastim 5 microg/kg/day or lenograstim 150 microg/m(2)/day) on days 5-10 (n = 377; 2400 cycles), pegfilgrastim 6 mg on day 2 (n = 305; 1930 cycles), or pegfilgrastim plus ciprofloxacin (n = 321; 1890 cycles).

RESULTS

Pegfilgrastim with/without ciprofloxacin was significantly more effective than daily G-CSF or ciprofloxacin in preventing FN (5% and 7% versus 18% and 22% of patients; all P < 0.001), grade 4 neutropenia, and leukopenia. Pegfilgrastim plus ciprofloxacin completely prevented first cycle FN (P < 0.01 versus pegfilgrastim alone) and fatal neutropenic events.

CONCLUSION

Ciprofloxacin alone, or daily G-CSF from day 5-10 (as in common practice), provided suboptimal protection against FN and related toxic effects in patients receiving TAC. Pegfilgrastim was significantly more effective in this setting, especially if given with ciprofloxacin.

Inflammatory and locally advanced breast cancer respond similar to operable breast cancer to neoadjuvant chemotherapy: Results from 278 patients with cT4a-d tumors of the GeparTRIO trial

542

Background: Neoadjuvant chemotherapy is the treatment of choice in patients with T4a-c and inflammatory (T4d) breast cancer. However, data on large-scale, multicentre, prospective trials are missing. In the GeparTRIO study (SABCS 2006, abstr. 42) 278 of 2,090 patients with cT4a-c or T4d tumors were included as a separate stratum for inoperable disease for a prospectively planned analysis. Methods: Patients were treated with 2 cycles TAC (docetaxel 75 mg/m2, doxorubicin 50 mg/m2, cyclophosphamide 500 mg/m2, q d 21). If tumor reduction was >50%, patients were randomized to receive 4 or 6 additional TAC cycles. If tumor reduction was less, patients were randomized to 4 additional TAC cycles or to 4 NX cycles (vinorelbine 25 mg/m2 day 1 + 8, capecitabine 2,000 mg/m2 day 1 14, q21). Efficacy endpoints were pCR-rate (no invasive and no non-invasive residuals in breast and lymph nodes) (primary), clinical response before surgery and breast conserving therapy (BCT) rate (secondary). Results: 95 (4.6%) T4d, 183 (8.9%) cT4a-c, and 1,767 (86.4%) T1–3 tumors were registered in GeparTRIO within 36 months. Patients with inoperable/operable tumors had a median age of 53.9/49.0 years, median cT size: 7.0/4.0cm, cN+: 75.6/52.0%, ductal: 76.3/78.4%, lobular: 14.0/13.5%, multiple lesions: 28.5/19.5%, grade 3: 34.8/39.9%, hormone receptor (HR) neg: 24.7/36.6%, HER-2 pos: 41.0/35.5%. Response rates for T4d, T4a-c, T1–3 were 8.4, 10.9, 17.5% (pCR, p=0.007), 36.7, 59.4, 72.6% (palpation after 2 cycles TAC, p<0.0001), 64.2, 62.3, 77.8% (palpation before surgery, p<0.0001), 52.6, 51.9, 67.4% (ultrasound before surgery, p<0.0001). BCT was performed in 12.6, 31.7, 69.5% (p<0.0001). Response after two cycles, negative HR content, young age, high grade, ductal type, but not tumor stage or size, were independent predictors for pCR in the total population. Conclusions: Inflammatory and cT4a-c breast carcinomas, compared to cT1–3 tumors, show less favorable tumor characteristics but a comparable pattern of response to TAC/NX. These patients do not need separate neoadjuvant trials.

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A randomized multicenter phase II study on neoadjuvant chemotherapy with carboplatin and docetaxel in advanced ovarian carcinomas (PRIMOVAR)

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Background: In the past years the concept of neoadjuvant chemotherapy and interval laparotomy has emerged for patients with advanced ovarian cancer and unfavorable prognosis (e.g. diffuse peritoneal carcinosis). In a recent study on neoadjuvant chemotherapy higher tumor resection rates and longer median survival were demonstrated in patients with advanced ovarian carcinoma and ascites >500ml. Most studies use three cycles of preoperative chemotherapy. However, chemoresistant tumorclones may be induced by increasing number of preoperative chemotherapy cycles. The purpose of this study is to evaluate the optimal number of cycles prior to interval laparotomy. Methods: 67/73 patients with advanced serous ovarian carcinoma (FIGO IIIc n = 48, FIGO IV n = 19) and ascites >500ml were randomized into two arms, receiving either 2 (n = 33) or 3 (n = 34) cycles of Carboplatin (AUC5) and Docetaxel (75mg/m2) before interval laparotomy. Postoperatively, they received either 4 or 3 additional cycles. Response rate and postoperative residual tumor were evaluated. Results: Surgical response was assessed during interval laparotomy. At present 32 patients underwent tumordebulking. Partial remission was observed in 28/32 patients irrespective of the number of preoperative chemotherapy cycles. Two patients in each arm showed stable disease. Optimal cytoreduction was achieved in 25/32 patients. No severe adverse events were reported. Six of 73 patients were not eligible. Two patients were excluded due to therapy-unrelated events. In 4 patients ovarian cancer was excluded by laparoscopy prior to neoadjuvant chemotherapy. Conclusions: Neoadjuvant chemotherapy followed by interval laparotomy was safe and well tolerated. Diagnostic laparoscopy prior to neoadjuvant chemotherapy allowed differentiation of primary ovarian cancers from tumors of other origin. In these cases laparotomy could be circumvented. Optimal tumor reduction was achieved in a significant number of patients. Response rate and postoperative residual tumor were essentially the same in both arms. Our data indicate that two cycles of preoperative chemotherapy may be the preferential choice of therapy for future studies.

No significant financial relationships to disclose.

Survival benefit of switching to anastrozole after 2 years’ treatment with tamoxifen versus continued tamoxifen therapy: The ARNO 95 study

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Background: Initial adjuvant treatment with anastrozole has significant efficacy and tolerability advantages over tamoxifen in postmenopausal women with hormone-sensitive early breast cancer (EBC) (ATAC Trialists’ Group. Lancet 2005; 365: 60–62). The ARNO 95 study evaluated prospectively switching to anastrozole from tamoxifen after 2 years, compared with continuing tamoxifen therapy. Here, we present an interim efficacy and safety analysis. Methods: This was a prospective, randomized, open-label study conducted in 54 centers in Germany. Postmenopausal women (≤75 years) with hormone receptor-positive, invasive EBC, who had received 2 years of adjuvant tamoxifen without recurrence, were randomized to switch to anastrozole (1 mg/day) or continue on tamoxifen (20 or 30 mg/day) for a further 3 years. No adjuvant chemotherapy was given. The primary end point was disease-free survival (DFS; time to earliest occurrence of local or distant recurrence, new primary breast cancer, or death from any cause); secondary end points included overall survival (OS), safety, and tolerability. Data were analyzed using a log-rank test; a second analysis used a Cox proportional hazards model with covariates of age, tumor size, nodal status, grade, and type of surgery. Results: Overall, 979 patients (mean age 60 years; 74% node-negative; 97% hormone receptor-positive) were enrolled, 489 were randomized to switch to anastrozole, with 490 continuing on tamoxifen. Median follow-up was 30.1 months. Switching to anastrozole significantly improved DFS and OS compared with continuing on tamoxifen ( Table ). Fewer patients who switched to anastrozole reported serious adverse events (22.7%) compared with those who remained on tamoxifen (30.8%). Conclusions: Switching endocrine treatment improved DFS and OS in this well-defined population. Postmenopausal women with hormone-sensitive EBC who have already received 2 years’ adjuvant tamoxifen therapy should be switched to anastrozole.

[Table: see text]

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Comparison of neoadjuvant 6 vs 8 cycles of docetaxel/doxorubicin/cyclophosphamide (TAC) in patients early responding to TACx2-the GEPARTRIO Study

576

Background: Primary breast cancer (BC) patients (P) with early response to neoadjuvant TACx2 (75mg/m, 50 mg/m, 500 mg/m, day 1, q21, supported with (pegylated) G-CSF and epoetin) experience a high pathologic complete remission (pCR) rate after further TACx4 (von Minckwitz et al, Ann Oncol 2005) compared to patients without early response (SABCS 2005, Abst 38). We compared prolongation to 8 cycles of TAC with conventional 6 cycles TAC in the chemosensitive subgroup. Methods: P with operable (T 2 cm by palpation) or locally advanced (T4 or N3, M0) BC were treated with TACx2. If tumor reduction was exceeding 50% according to breast ultrasound, P were randomized to receive either 4 or 6 additional cycles. Endpoints were pCR-rate (no invasive and no non-invasive residuals) (primary), sonographic response before surgery, breast conservation rate, safety and compliance (secondary). To detect an increase in pCR-rate from 20 to 26%, 606 evaluable patients were requested for each arm (α=0.05, β=0.2, one-sided). Results: 2106 P were recruited into the multi-centre, prospective, open-label, randomized GEPARTRIO-trial within 36 months. 1400 P with an early response to TACx2 were randomized with the last patient having surgery in Dec 05. Median clinical tumor size was 4.0 (1.0 - 30.0) cm at study entry. A planned safety and blinded efficacy interim analysis was performed on the first 600 patients (306 TACx6, 294 TACx8). Main toxicities (grade I-IV %TACx6 vs %TACx8) were: anemia (91 vs 93), thrombopenia (39 vs 49), neutropenia (65 vs 75), febrile neutropenia (10 vs 16), infection (29 vs 30), vomiting (42 vs 44), diarrhea (59 vs 52), stomatitis (66 vs 67), conjunctivitis (51 vs 57), allergic reactions (20 vs 14), edema (40 vs 47), asthenia (90 vs 93), hand-foot-syndrome (25 vs 28), nail (43 vs 50), dyspnea (33 vs 37), sensory neuropathy (51 vs 61). Treatment was discontinued early in 165 P (31.0%), 53 (19.8%) P during TACx6 and 112 (42.3%) P during TACx8. Overall pCR was reported in 102 (17.0%) of these patients. Conclusions: TACx8 is associated with moderate increase in toxicity and treatment discontinuations compared to TACx6. Final results on the primary and secondary endpoints will be presented.

[Table: see text]

In vivo chemosensitivity-adapted preoperative chemotherapy in patients with early-stage breast cancer: the GEPARTRIO pilot study

BACKGROUND

Response to the first two cycles of preoperative chemotherapy might differentiate subgroups of breast cancer patients with high or minimal chances for a pathologic complete response (pCR) and may be used as an in vivo chemosensitivity test.

METHODS

Breast cancer patients were treated with two cycles of TAC (docetaxel 75 mg/m(2), doxorubicin 50 mg/m(2), cyclophosphamide 500 mg/m(2) every 21 days). Patients whose tumors showed a response received four more cycles. Patients whose tumors did not respond were randomized to four additional cycles TAC or NX (vinorelbine 25 mg/m(2) days 1 and 8, capecitabine 2000 mg/m(2) days 1-14, every 21 days). The primary end point was pCR at surgery.

RESULTS

Two hundred and eighty-five patients showed a clinical response, in 73.0% after two cycles, in 88.4% at surgery, and a pCR was seen in 17.9%. Breast conservation was possible in 72.2%. Responding patients obtained a pCR in 22.6% whereas non-responding patients reached a pCR in 7.3% and 3.1% with TAC or NX, respectively. Grade III/IV neutropenia and febrile neutropenia were observed during TAC in 70.2% and 13.5%, respectively. Significantly less toxicity were observed with NX.

CONCLUSION

Early response to TAC can reliably identify patients with a high chance of achieving a pCR. New effective treatments need to be explored for patients without an early response.

Towards in-vitro prediction of an in-vivo cytostatic response of human tumor cells with a fast chemosensitivity assay

The objective of this study is to evaluate a novel approach to chemosensitivity testing with respect to its predictive value in the selection of clinically effective cytostatic drugs to optimize the therapeutic treatment of cancer. The chemosensitivity assay, which we used in this study, has its roots in pharmaceutical drug screening and the surrounding intellectual property is protected by various patent applications and trademarks. Therefore, we will refer to this test in the following pages as ChemoSelect. ChemoSelect is a sensor-chip based diagnostic test, which permits the functional and continuous real-time measurement of induced tumor cell cytotoxicity following the administration of chemotherapeutic drugs. Chemosensitivity is measured through the reduction of the excretion of lactic and carbonic acids--by-products of the metabolic processes of glycolysis and respiration and a parameter for cell vitality--generated specifically by ATP hydrolysis and lactic acid production. We used this test to study the applicability of this assay for tumor cells based on the analysis of tumor cell lines and tumor specimens. In this preliminary study, this test was studied in predicting chemoresistance and chemosensitivity in cell lines and tumor specimens for which the result was already predetermined by the properties of the cell line or the tumor specimen used in the experiment. The applicability in a clinical setting was studied by confirming the trends on selected drug sensitivity and drug resistance with an interim analysis of an ongoing clinical study in selected patients with breast cancer undergoing neoadjuvant chemotherapy. The minimum detection limit of cells and biologic cell responses, an important variable determining the applicability of the test in routine clinical use, was also assessed. ChemoSelect avoids many of the limitations of existing chemoresistance assays and provides more comprehensive information and output, as it has a 24-h turnaround time, is applicable to the majority of solid tumors and available cytostatic drugs, does not need more than 10(5) cells in total, cultivated tumor cells, provides dynamic monitoring of cellular responses through on-line data read-out during the perfusion with drugs and can be extended to the analysis of novel therapeutic modalities such as biologics.

[Preoperative chemotherapy in primary operable breast cancer with a dose-dense combination of doxorubicin and docetaxel (ADoc) - Experience of the GEPARDO-GABG study group]

OBJECTIVE

The German Adjuvant Breast Cancer Study Group (GABG) conducts trials of preoperative chemotherapy in patients with primary breast cancer using a combination of doxorubicin and docetaxel (ADoc). -

PATIENTS AND METHODS

We conducted a parallel-grouped phase IIa-study with 42 patients with a conventionally dosed and a dose-dense ADoc-schedule (4 cycles of Doxorubicin 50 mg/m(2), Docetaxel 75 mg/m(2) i. v. day 1, q day 15 or 22; G-CSF day 3-15 only for the dose-dense schedule) and a randomized phase IIb-study (GEPARDO-Study) with 250 patients with ADoc +/- Tamoxifen. Biological factors were determined immunohistochemically on 197 core biopsies before treatment. A comparison to a sequential AC-Doc regimen including 913 patients has been completed recently. -

RESULTS

ADoc can be applicated on schedule in 93 % of all patients. The dose-dense regimen shows a tendency to more toxicity but also to more efficacy. The rate of complete pathological remissions (pCR) was 9.7 %. No difference was found between chemo- and chemoendocrine treatment. Clinically negative lymphnodes and a negative estrogen receptor status is predictive for a higher pCR-rate. To date no differences in toxicity could be found between ADoc and AC-Doc. -

CONCLUSIONS

The dose-dense ADoc regimen is well tolerated and highly effective as preoperative therapy of breast cancer.

Dose-dense doxorubicin, docetaxel, and granulocyte colony-stimulating factor support with or without tamoxifen as preoperative therapy in patients with operable carcinoma of the breast: a randomized, controlled, open phase IIb study

PURPOSE

To investigate the effect of adding tamoxifen to a preoperative dose-dense doxorubicin and docetaxel regimen on the pathologic response of primary operable breast cancer.

PATIENTS AND METHODS

Patients (tumor size > or = 3 cm, N0 to 2, M0) were prospectively randomized to receive every 14 days a total of four cycles of doxorubicin 50 mg/m2 and docetaxel 75 mg/m(2), either with (ADocT) or without (ADoc) simultaneous tamoxifen. Granulocyte colony-stimulating factor (G-CSF) was routinely given on days 5 to 10. Surgery followed 8 to 10 weeks after the start of treatment.

RESULTS

Within 14 months, 250 patients were included in the study at 56 centers. Of 992 planned cycles, 97.9% were administered. Pathologically complete remission (pCR) with no detectable viable tumor cells was achieved in 9.7%. There was a nonsignificant difference of -1.2% in favor of ADoc, with a 95% confidence interval of -8.6% to 6.2%. A further 2.4% had only noninvasive tumor residues, and 13.8% had focal invasive residues. Complete and partial responses detected by palpation were observed in 28.9% and 52.4%, respectively. The response rates (complete and partial) by best appropriate imaging methods were 77.5% and 67.5% for ADocT and ADoc, respectively. Breast conservation was possible in 68.8% of the patients. A tendency toward more frequent toxic events was observed with ADocT treatment. Significant predictors of pCR to chemotherapy were negative lymph node and negative estrogen receptor status.

CONCLUSION

A dose-dense regimen of ADoc with G-CSF offers high compliance, moderate toxicity, and rapid efficacy as a form of preoperative chemotherapy in operable breast cancer. Concurrent treatment with tamoxifen for 8 weeks could not improve the pathologic response rate.