Evaluation of physician knowledge and referral practices for colorectal cancer (CRC) genetic risk assessment: The experience at the Hospital of University of Pennsylvania (HUP)

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Background: 3-5% of CRCs are due to inherited genetic mutations. We surveyed knowledge and practices of academic physicians for identification and care of individuals at risk for inherited CRC.

Methods: 264 physicians (oncologists (ON), gastroenterologists (GA), surgeons, internists, gynecologists, and radiation oncologists) at HUP were invited to participate in a web-based 9-min survey. The ability to obtain appropriate medical history and to make referral to genetic services was evaluated. Knowledge of hereditary CRC syndromes was examined both pre and post viewing of an educational web-page on inherited CRCs. Mantel-Haenszel, Fisher exact, and McNemar statistical tests were applied.

Results: Response rate was 33.3%; and of those, 97.4% accessed the educational webpage. In the cohort, 98.9 % obtained a medical history very frequently (VF), 88.6% obtained cancer history in 1st and 45.5% in the 2nd degree relatives VF, and 63.9% asked about the relatives' age at time of cancer diagnosis VF. Of those most likely to care for patients with CRC, the GA more frequently asked about relatives' age at cancer diagnosis (p=0.014) and family history of polyps (p< 0.001) than ON. GA were more likely than ON to refer patients for genetic counseling (73.9% vs. 36.8%, p=0.008). GA had superior knowledge of the availability of genetic testing for Lynch syndrome (LS) (95.6% GA vs. 63.2% ON, p=0.005) and for familial adenomatous polyposis (FAP) (100.0% GA vs. 65.8% ON, p<0.001). For the entire cohort, the educational intervention raised awareness of genetic testing for LS (64.5% pre vs. 94.7% post, p<0.001), FAP (69.7% pre vs. 97.4% post, p<0.001), and Peutz-Jeghers Syndrome (31.6% pre vs. 84.2% post, p<0.001); and it significantly improved recognition of LS family pedigrees and selection of appropriate surveillance.

Conclusions: Of the respondents, GA are more likely to obtain a detailed family history, utilize genetic services, and have a greater awareness of the availability of genetic testing, than ON. A simple educational intervention improves physician knowledge on inherited CRC risk recognition and surveillance recommendations.

No significant financial relationships to disclose.

Increased oesophageal acid exposure at the beginning of the recumbent period is primarily a recumbent-awake phenomenon

BACKGROUND

A significant increase in oesophageal acid exposure during early recumbent period has been demonstrated.

AIM

To determine if acid reflux during the early recumbent period occurs in the recumbent-asleep or recumbent-awake period using a novel integrative actigraphy and pH programme.

METHOD

Thirty-nine subjects with heartburn at least three times a week were included. Subjects underwent pH testing concomitantly with actigraphy. Simultaneously recorded actigraphy and pH data were incorporated using a novel integrative technique to determine sleep and awake periods. Characteristics of acid reflux were compared between the recumbent-awake and recumbent-asleep periods.

RESULTS

Seventeen (44.7%) subjects had acid reflux events during recumbent-awake period as compared to seven (18.4%) in the corresponding recumbent-asleep period (P = 0.046). The mean number of acid reflux events in recumbent-awake period was significantly higher than in the corresponding recumbent-asleep period (8.1 +/- 4.4 vs. 3.2 +/- 1.5, P < 0.001). In the recumbent-awake period, 38.4% of acid reflux events were associated with GERD-related symptoms as compared with 3.7% of acid reflux events during the corresponding recumbent-asleep period (P = 0.01).

CONCLUSION

Increased acid reflux in the early recumbent period occurs primarily during the recumbent-awake and not during the recumbent-asleep period.

Riser's reflux--an eye-opening experience

BACKGROUND

Patients with gastro-oesophageal reflux disease (GORD) commonly report waking up in the morning with a sour or bitter taste in their mouth. The aim of the study was to compare the prevalence and frequency of acid reflux events prior to and immediately after awakening from sleep in the morning between GORD patients and normal subjects.

METHODS

Thirty-nine patients with heartburn at least three times a week and abnormal pH test and nine healthy controls were included. All subjects were evaluated by demographic and GORD Symptom Checklist questionnaires. Subjects underwent pH testing concomitantly with actigraphy. A novel technology that simultaneously integrates raw actigraphy and pH monitoring data was utilized to determine the presence, frequency, and characteristics of acid reflux events prior to (up to 1 h) and immediately after (10 and 20 min) awakening from sleep in the morning.

KEY RESULTS

Nineteen (48.7%) of the GORD patients had an acid reflux event within the first 20 min after awakening from sleep in the morning as compared to only seven (17.9%) during the hour prior to awakening. Within the first 10 and 20 min after awakening, patients had a total of 32 and 60 acid reflux events, respectively, as compared to 14 during the 1 h prior to awakening (P < 0.05). None of the healthy control patients demonstrated any reflux events during these three studied periods (P < 0.001).

CONCLUSIONS & INFERENCES

Riser's reflux is very common among GORD patients and possibly may explain reports of early-morning GORD symptoms.

The effect of esomeprazole 20 mg twice daily on acoustic and perception parameters of the voice in laryngopharyngeal reflux

BACKGROUND

Randomized, placebo-controlled studies have failed to demonstrate a significant treatment effect for laryngopharyngeal reflux (LPR) using traditional clinical endpoints. We compared the effect of esomeprazole 20 mg twice daily (b.i.d.) vs placebo on voice and acoustic-related measures in patients with LPR.

METHODS

Patients with LPR underwent endoscopy and pH testing. Subsequently, patients underwent videostroboscopic recordings of the larynx, acoustic voice and speech analysis. A voice use and quality diary and oesophageal symptom diary were completed at baseline. Thereafter, patients were randomized to esomeprazole 20 mg twice daily vs placebo for 3 months. The voice use and quality diary and oesophageal symptom dairy were repeated during the last week of treatment. Videostroboscopy and acoustic voice and speech analysis were also performed at the end of treatment.

KEY RESULTS

Twenty-four patients were randomized to the esomeprazole group and 17 to the placebo group. There was no significant difference in videostroboscopic reflux finding scores from baseline to post-treatment. Acoustic measures also failed to demonstrate significant differences within the same or between groups, even when a sub-group analysis of patients with endoscopically documented oesophageal inflammation at baseline was performed. Additionally, no significant differences were found between groups when using voice use and quality diary.

CONCLUSIONS & INFERENCES

Use of more specific laryngeal functional parameters such as voice-related acoustic measures of pitch range, fundamental frequency and intensity also failed to demonstrate a significant response to proton pump inhibitor treatment as compared to placebo in patients with suspected LPR.

Mature results of a randomized phase II study of OGX-011 in combination with docetaxel/prednisone versus docetaxel/prednisone in patients with metastatic castration-resistant prostate cancer

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Background: Clusterin is a cytoprotective chaperone protein associated with CRPC progression. OGX is a 2'-methoxyethyl antisense that potentiates chemotherapy in xenografts and inhibits clusterin expression at doses of <640 mg. Methods: Pts with CRPC and chemo-naive received docetaxel (DOC) 75mg/m2 q3w + OGX 640mg IV weekly + prednisone (Arm A) or DOC + prednisone (Arm B) in a single stage randomized phase II design. Primary endpoint was PSA response rate (RR). Progression-free survival (PFS) and overall survival (OS) were secondary endpoints. Planned sample size was 40/arm: Arm A the hypotheses (PSA RR<40% vs. >60%) could be tested at 10% β and 10% α, Arm B the true PSA RR could be estimated with half-width of the 90% CI<13% if PSA RR=40%. Results: 82 pts (41 Arm A, 41 Arm B) were randomized from 09/05–12/06. At this analysis time, all pts are off therapy and 49 have died. One pt was ineligible but included in ITT survival analysis. Baseline characteristics were similar: median age 69 (49–87), PSA >100 μg/L in 51%, Hgb ≥100 g/L in 98%, alk phos >ULN in 44%, LDH >ULN in 36%, ECOG performance status (PS) 0:1 in 51%:49%, bone/lymph node/visceral metastases in 69%/50%/28%. Median cycles for Arm A and B was 9 and 7. Adverse events associated with OGX included fatigue, fever, rigors, diarrhea and rash. Mean serum clusterin change on day 1 cycle 2 was -18% in Arm A and +8% in Arm B (p = 0.0005). PSA RR was 58% (Arm A) and 54% (Arm B). PSA declines at 12 weeks of any/>30%/>50% was observed in 87%/65%/45% (Arm A) and 68%/58%/34% (Arm B). PSA/objective disease progression as best response occurred in 0%/4% (Arm A), and 3%/17% (Arm B). PFS for Arms A and B was 7.3 (5.3–8.8) and 6.1 months (3.7–8.6). Median OS for Arms A and B was 27.5 (19.2-∞) and 16.9 months (12.7–26.0) (unadjusted HR = 0.60 [0.34–1.06], p = 0.07). Variables predictive of OS on multivariate analysis: PS 0 vs 1 (p = 0.0002), presence of visceral metastasis (p = 0.006) and treatment assignment (HR = 0.54 [0.29–0.97], p = 0.04). Conclusions: The PSA RR in both arms met criterion for further study. OGX reduced serum clusterin and OS appears superior with DOC/OGX. This combination warrants further evaluation. Supported by a grant from the NCI-Canada/Canadian Cancer Society.

[Table: see text]

Breast cancer risks in individuals testing negative for known family mutations in BRCA1 or BRCA2

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Background: Genetic testing for BRCA1 and BRCA2 mutations in individuals from families with known deleterious mutations can identify both those at high risk of disease and those who are not. Recent studies have raised concern that women who test negative for mutations previously identified in their families (“true negatives,” TN), may nonetheless have a higher incidence of breast cancer than women in the general population. To evaluate this question, we have examined a prospectively followed cohort of TN to assess their risk of breast cancer. Methods: The women included were first and second degree relatives of known BRCA1 and BRCA2 mutation carriers, had undergone genetic testing and were negative for the known familial mutation, and were unaffected at the time of genetic testing. Standardized incidence ratios (SIR) and 95% confidence intervals (CI) were calculated using SEER incidence rates from 1992–2005. Results: Among 375 TN women followed for a mean of 4.9 years (total 1,962 person-years), 2 invasive and 2 in situ breast cancers were diagnosed. Four invasive breast cancers were expected, whereas 2 were observed, for an age-adjusted SIR of 0.52 (95% confidence interval 0.13–2.09). One case of in situ breast cancer was expected, whereas 2 were observed (SIR=2.30; 95% CI 0.57–9.19). There were no cases of ovarian cancer observed, whereas 0.4 cases were expected. Conclusions: In this prospective study of women who were unaffected at the time of genetic testing and who were negative for a known familial mutation in BRCA1 or BRCA2, no excess risk of invasive breast cancer was observed. Although we cannot exclude a modest increase in risk (RR<2), our data suggest that such women should adhere to population based guidelines for breast cancer screening.

No significant financial relationships to disclose.

Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain

BACKGROUND

Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians.

AIM

To determine the efficacy of Johrei as compared to wait-list in improving symptoms of FCP patients.

METHODS

Patients with chest pain of noncardiac origin for at least 3 months were enrolled into the study. All patients had to have negative upper endoscopy, pH testing and oesophageal manometry prior to randomization. Subsequently, patients were randomized to either Johrei or wait-list control. Patients received 18 Johrei sessions from a Johrei practitioner for 6 weeks.

RESULTS

A total of 21 FCP patients enrolled into the Johrei group and 18 into the wait-list group. There was no difference in symptom intensity score between Johrei group and wait-list group at baseline (20.28 vs. 23.06, P = N.S.). However, there was a significant pre- and post-treatment reduction in symptom intensity in the Johrei group (20.28 vs. 7.0, P = 0.0023). There was no significant reduction in symptom intensity score between baseline and at the end of the study in the wait-list group (23.06 vs. 20.69, P = N.S.).

CONCLUSION

This pilot study shows that Johrei may have a role in improving FCP symptoms; however, future studies are needed to compare Johrei treatment with sham Johrei or supportive care.

Human leucocyte elastase and cathepsin G: structural and functional characteristics

Two of the major enzymes present in an released from neutrophil granulocytes are the endoproteinases elastase and cathepsin G. While the former is believed to be one of the major causative agents responsible for tissue destruction in emphysema and rheumatoid arthritis, little is known about the function of cathepsin G. We have recently developed simple procedures for isolating the isoenzymes of each type of proteinase as well as for their specific controlling plasma inhibitors. We have also prepared synthetic substrates and inhibitor analogues. Some sequence studies have been initiated and the results indicate homology of these enzymes not only with each other and with the pancreatic proteinases but also between cathepsin G and proteolytic enzymes present in muscle and mast cell tissue. Significantly, both types of enzyme can degrade the structural protein myosin, as well as elastin and proteoglycan. However, their relative importance in muscle protein turnover or muscle disease has not yet been clarified.

Double-negative regulatory T cells induce allotolerance when expanded after allogeneic haematopoietic stem cell transplantation

Double-negative (DN) regulatory T cells (Tregs) are specialized T lymphocytes involved in the down-modulation of immune responses, resulting in allotolerance after allogeneic haematopoietic stem cell transplantation (HSCT). Most of the properties of DN Tregs were identified in murine models, including the unique ability to suppress alloreactive syngeneic effector T cells in an antigen-specific manner via Fas/Fas-ligand interactions. We investigated the behaviour of DN Tregs following human allogeneic HSCT with regard to occurrence of graft-versus-host disease (GvHD) and restoration of T-cell receptor repertoire in a cohort of 40 patients. The frequency of DN Tregs and CD4/CD8 TCR repertoire was measured serially and at the time of diagnosis of GvHD by flow cytometry. Analysis demonstrated a positive correlation between degree of alloreactivity, as measured by grade of GvHD, and the number of variable beta chain (Vbeta) family expansions in both T-cell populations. We also found that a deficiency of DN Tregs was associated with an increased number of Vbeta family expansions, and most importantly, with the occurrence of GvHD. All individuals who demonstrated more than 1% DN Tregs did not develop GvHD, providing evidence that DN Tregs participate in peripheral tolerance to prevent GvHD when expanded after allogeneic HSCT.

Assessment of 24-h oesophageal pH monitoring should be divided to awake and asleep rather than upright and supine time periods

Oesophageal acid exposure analysis is divided to upright and supine, based on the assumption that the supine-awake period is similar to the supine-asleep period. To determine if the principal acid-reflux characteristics of supine-awake are closer to supine-asleep or upright period. Patients with heartburn underwent an upper endoscopy and pH testing. The patients were instructed to carefully document their upright, supine-awake and supine-asleep periods. A total of 64 patients were enrolled into this study (M/F 35/29; mean age 52.4 +/- 13.3). The mean percentage total time pH <4, frequency of acid-reflux events (per h) and number of sensed reflux events was not different between upright and the supine-awake period (P = ns). In contrast, the mean percentage total time pH <4, frequency of acid-reflux events and number of sensed reflux events was significantly higher in both upright and supine-awake periods vs supine-asleep (4.3 +/- 6.9, 1.86 +/- 2.7 and 0.01 +/- 0.05, P < 0.0001, respectively). The principal characteristics of the acid-reflux events in the supine-awake period are closer to the upright period than to the supine-asleep period.

Comparisons of the distribution of oesophageal acid exposure throughout the sleep period among the different gastro-oesophageal reflux disease groups

BACKGROUND

Nocturnal gastro-oesophageal reflux diseases (GERD) can lead to oesophageal mucosal injury and extra-oesophageal complications.

AIM

To compare distribution of oesophageal acid exposure during sleep time among patients with non-erosive reflux disease and abnormal pH test (NERD-positive), erosive oesophagitis (EO) and Barrett's oesophagus (BO).

METHODS

Patients underwent endoscopy followed by 24-h oesophageal pH testing. Oesophageal acid exposure was assessed every 2 h of the sleep period (0-2, 2-4, 4-6 and 6-8 h). Each period of 2 h was evaluated for acid reflux parameters. All groups were matched by age, time from last meal and duration of sleep time.

RESULTS

Thirty-eight patients were enrolled (NERD-positive, 16; EO, 1.4; and BO, 8). All GERD groups demonstrated higher oesophageal acid exposure in the first vs. second half of the sleep period as determined by percent time pH <4 (BO: 34.7 vs.11.6, EO: 13.5 vs. 6.9, NERD-positive: 8.8 vs. 2.5, all P < 0.01). In general, patients with BO had a significantly higher distribution of oesophageal acid exposure than those with NERD-positive and EO.

CONCLUSIONS

Oesophageal acid exposure generally declines throughout the sleep period regardless of GERD group, but BO patients demonstrated the greatest decline during the sleep period.

A randomized phase II study of OGX-011 in combination with docetaxel and prednisone or docetaxel and prednisone alone in patients with metastatic hormone refractory prostate cancer (HRPC)

5069

Background: Clusterin, a cytoprotective chaperone protein that promotes cell survival, is associated with androgen independent progression and overexpressed in HRPC. OGX-011 (OGX, developed by OncoGenex Technologies/Isis Pharmaceuticals) is a 2’- methoxyethyl modified phosphorothioate antisense that inhibits clusterin expression in humans at doses of ≤640 mg and potentiates chemotherapy activity in prostate xenografts. The objective of this study was to determine the anti-tumor activity of OGX in combination with docetaxel (DOC) in patients (pts) with HRPC. Methods: Chemo-naive pts with metastatic HRPC were randomized to receive DOC 75mg/m2 q3 weeks + OGX 640mg weekly as a 2-hour IV infusion (Arm A) + prednisone or DOC + prednisone (Arm B). Serum levels of clusterin were assessed serially. A single stage randomized phase II design was employed with PSA response rate (RR) as the primary endpoint (Bubley et al, J Clin Oncol 1999;17:3461). Planned sample size was 40 per arm: Arm A the hypotheses (H0:PSA RR<40% vs. H1:PSA RR>60%) could be tested at 10% β and 10% a, Arm B the true PSA RR could be estimated with half-width of the 90% confidence interval <13% if observed PSA RR was 40%. Results: 82 pts (41/arm) were enrolled from September 2005 to December 2006 at 12 centers. Baseline characteristics are similar in both arms (available to date for 63 pts): median age 67 (range: 49–84), PSA 110 μg/L (5.6–1261), hemoglobin 128 g/L (96–158), alkaline phosphatase 133 U/L (47–1294), LDH 193 U/L (120–741). ECOG performance status was 0 in 49% and 1 in 51%; 67% had bone/nodal disease only and 33% had other metastatic sites. To date, 56 pts have received ≥2 cycles. Toxicity due to OGX included grade 1/2 fevers and rigors in 37% and 67% pts respectively, but other adverse events were similar in both arms. PSA response has occurred in 43%, progression in 9%, and 48% have not yet met criteria for response or progression. Conclusions: Combined docetaxel and OGX is well tolerated in pts with metastatic HRPC and PSA responses have been observed. Pt treatment, follow-up and analysis of serum clusterin levels continue. Results by arm will be available by June 2007. Supported by a grant from the NCI-Canada/Canadian Cancer Society.

No significant financial relationships to disclose.

IND.175: Phase I study of daily oral AZD2171, a vascular endothelial growth factor receptor inhibitor (VEGFRI), in combination with gemcitabine and cisplatin (G/C) in patients with advanced non-small cell lung cancer (ANSCLC): A study of the NCIC Clinical Trials Group

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Background: AZD2171 is an oral an inhibitor of the tyrosine kinase activity of all VEGFR subtypes. Objectives: To determine recommended phase II dose (RPTD), dose limiting toxicity (DLT), toxicity, pharmacokinetics and efficacy of AZD2171 with G/C, in pts with untreated ANSCLC. Methods: Eligibility: stage IIIB/IV NSCLC; PS 0–2; no prior chemotherapy (CT) for advanced disease; adequate hematological, biochemical and end-organ function; no significant hemoptysis or bleeding. Treated stable brain metastases were permitted. G 1,250 mg/m2 day 1 & 8 and C 80 mg/m2 day 1 was given q3 weekly with AZD2171 starting day 2 cycle 1. Planned dose levels (DL) of AZD2171 were 30 and 45 mg once daily PK assayed in cycle 1&2, response (RECIST) every 2nd cycle. Results: 14 pts enrolled. 30 mg (5 pts) and 45 mg (9 pts). Pt characteristics (n=13) median age 56; 11 PS 0–1; 9 males. No DLTs seen in initial 3 pts at 30 mg dose; nor in 9 pts at 45 mg dose. Actual median dose intensity for AZD2171 in cycle 1 (C1) was similar to planned in C1 for both DL (200 mg and 300 mg)), but was higher for 30 mg vs 45 mg for subsequent cycles (150 mg vs 134 mg). At the 45 mg DL 13 dose reductions occurred in 9 pts. Grade 3 adverse events occurred in 2 of 3 30 mg pts (1 hypertension (HT), 1 fatigue); at 45 mg 6 pts of 9 pts had grade 3 events (HT, fatigue, diarrhea, voice changes); 2 pts had grade 4 toxicity (1 reversible CNS ischemia, 1 fatigue). PK: no effect of AZD2171 on gemcitabine PK Objective response: 9 pts are evaluable (4 too early At 30 mg-PR 2, SD 1; at 45 mg-PR 3, SD 3. 2 additional patients were accrued at the 30 mg DL. Conclusions: Toxicities of this combination are manageable and predictable. HT was easily controlled with a standardized treatment algorithm. MTD was not reached at the 30 or 45mg dose level, but 30mg of AZD2171 appears better tolerated in combination with G/C and is suggested as the RPTD. Encouraging anti-tumor activity has been observed which does not appear dose dependent at the doses tested.

No significant financial relationships to disclose.

A phase II study of bortezomib in mantle cell lymphoma: the National Cancer Institute of Canada Clinical Trials Group trial IND.150

BACKGROUND

We evaluated the activity and toxic effects of bortezomib in patients with mantle cell lymphoma.

PATIENTS AND METHODS

Thirty patients, including 29 eligible patients, were enrolled; 13 had received no prior chemotherapy. The dose of bortezomib was 1.3 mg/m2 given on days 1, 4, 8 and 11 every 21 days. Response was assessed according to the International Workshop Criteria for non-Hodgkin's lymphoma and toxicity graded using the National Cancer Institute Common Toxicity Criteria version 2.0.

RESULTS

There were 13 responding patients (46.4%; 95% confidence interval=27.5% to 66.1%), including one unconfirmed complete remission. The median response duration was 10 months. Response rates were similar in previously untreated (46.2%) and treated (46.7%) patients. Neurological toxicity and myalgia led to treatment discontinuation in 10 patients after two to seven treatment cycles. Five serious adverse events (including two deaths) associated with fluid retention were observed in the first 12 patients. We subsequently excluded patients with baseline effusions, dyspnea or edema; no further events were seen.

CONCLUSIONS

Bortezomib is active in treating patients with mantle cell lymphoma. While cumulative neuromuscular toxic effects limited therapy duration and specific issues related to fluid retention require further evaluation, continued study of this drug in combination regimens is warranted.

Bortezomib is active in Waldenstrom’s Macroglobulinemia (WM)—Results of a National Cancer Institute of Canada (NCIC) phase II study in previously untreated or treated WM

7543

Background: WM is a B cell lymphoma characterized by a serum monoclonal IgM and marrow infiltration by lymphoplasmacytoid cells. Bortezomib is a proteasome inhibitor active in myeloma and other hematologic malignancies. In this 2-stage study, 27 WM pts received single agent bortezomib with RR as primary endpoint. Methods: Eligibility: symptomatic WM (Hb <110 g/L; lymphadenopathy; organomegaly; or hyperviscosity); ≤2 prior chemo regimens (± rituximab). Bortezomib 1.3 mg/m2 IV given d1, 4, 8, 11 on a 21d cycle until PD or 2 cycles beyond CR/SD. Nodal disease was included in response criteria (2nd International WM Workshop). Results: Median age 65 (46–87), M:F 14:13, no prior therapy 11 (44%). At entry, median IgM 38 g/L (11.2–83.3); median Hb 108 g/L (63–142); 18 (66%) with nodal disease on CT. At a median of 6 cycles (2–35), 11/27 (41%) patients had ≥50% decrease in IgM alone plus 10 (37%) minor responses (25–49% decrease). Using IgM + nodal criteria: 1 CR, 5 PR (≥50% decrease in IgM and bidimensional disease), 20 SD, 1 PD = overall RR 22% (95% CI 8.6–42.2%). IgM responses were prompt (median 2 cycles; range 1–8) with nodal responses lagging (median 4 cycles). Hb increased by ≥10g/L in 18 pts (66%). Bortezomib was well-tolerated with most non-hematologic toxicities Gr 1–2: fatigue (74%), nausea (63%), myalgias (51%), non-neutropenic infections (48%), diarrhea (44%), constipation (44%). 18 pts (66%) developed neuropathy (sensory): typical onset 2–4 cycles; Gr 3 in 5 pts; 15/18 (83%) improving ≥1 grade (11 complete) in 2–13 mo. Gr 3 myalgias in 2 pts resolved in <1 mo. Gr 3–4 thrombocytopenia (30%) and neutropenia (18%) led to 12 missed doses, 1 dose reduction. Conclusions: Bortezomib is active in WM with 78% pts with ≥25% fall in IgM, 41% with IgM response criteria of ≥50% decrease, 22% with composite nodal/IgM responses. Despite prompt IgM and hematologic improvement, decrease in nodal disease is slow, reflected in overall responses lower than IgM alone. Although bortezomib is generally well-tolerated, neuropathy is common but reversible. Bortezomib combinations with conventional cytotoxic or targeted agents warrant further study in WM. This is a NCIC CTG study with a grant from NCIC and funds from Canadian Cancer Society.

[Table: see text]

Screening for unmet psycho-social needs in cancer care

8633

Background: Persons receiving cancer care are at risk for undiagnosed depression, but the burden of anxiety symptoms and social work needs is not well described. The objectives of the clinical intervention were: 1) to describe the burden of depression, anxiety and social distress; and 2) to determine whether an unmet need for psycho-social services existed in a sample of cancer patients at a university cancer center with an active psycho-social referral program. Methods: We developed a survey composed of the Memorial Distress Thermometer (MDT), specific social work needs, and the depression and anxiety modules from the Patient Health Questionnaire (PHQ). The clinical survey was administered to a convenience sample presenting for either referral visits or ongoing cancer treatment at the Indiana University Cancer Center for a four month period. Patient request for services, indicated need, and standardized threshold scores were used to determine need for referral (MDT ≥ 4; PHQ depression ≥ 10; PHQ anxiety ≥ 10). Descriptive statistics were calculated. Results: 184 patients (70% male) completed the survey. One-third of those screened met criteria for social work referral. 78% reported at least some distress (mean score 3.6) on the MDT, with 46% (n=81) scoring 4 or above. Social work needs included helping children cope with parental illness (11%), pharmaceutical expenses (11%), insurance assistance (6%), discussing illness with spouse (6%), and lodging during treatment (5%). Mental health distress was common. 34% met criteria for referral to psychological or psychiatric services. The mean PHQ depression score was 4.7, with moderate to severe depression (score ≥ 10) in 13%. Symptoms of generalized anxiety were also common, with a mean score of (5.0) and 11% scoring ≥ 10. Conclusions: In persons receiving cancer care, previously unknown distress, social work needs, depression, and anxiety were common. The burden of symptoms resulted in a markedly increased need for psycho-social services. These data reflect upon the significant need for regular screening and integration of psycho-social services with cancer treatment.

No significant financial relationships to disclose.

A phase I, first in man study of OSI-7836 in patients with advanced refractory solid tumors: IND.147, a study of the Investigational New Drug Program of the National Cancer Institute of Canada Clinical Trials Group

PURPOSE

To determine the maximum tolerated dose (MTD), recommended phase II dose (RP2D), safety, tolerability, toxicity profile, dose-limiting toxicities (DLTs), anti-tumor activity and pharmacokinetics of OSI-7836 given IV on day 1 and day 8 every 3 weeks in patients with advanced incurable cancer.

METHODS

Twenty-seven previously treated patients with advanced or metastatic solid tumors were enrolled in this phase I study conducted by the National Cancer Institute of Canada Clinical Trial Group (NCIC CTG). OSI-7836 was administered IV on day 1 and day 8 every 3 weeks. The dose was initially escalated from 100 to 600 mg/m2 and finally de-escalated to 200 mg/m2 in seven cohorts of patients. Patients were evaluated every other cycle of treatment for radiological response. Pharmacokinetics were performed on day 1 and day 8 of cycle 1 for all patients.

RESULTS

Twenty-six patients were evaluable for toxicity. All patients experienced reversible Grade 3 lymphopenia beginning at cycle 1. The maximal delivered dose was 600 mg/m2. MTD was reached at 400 mg/m2. DLTs included fever, fatigue, rash, herpes simplex infection, nausea and vomiting. The RP2D was 200 mg/m2. No objective responses were seen in 21 evaluable patients. Pharmacokinetics were dose proportional, with a mean half-life of 46.0 min and a clearance of 34 l/(h.m2).

CONCLUSION

OSI-7836 given at 200 mg/m2 on day 1 and day 8 every 3 weekly is associated with manageable toxicity and is recommended for further study. While no objective responses were seen, the significant treatment related lymphopenia suggests that hematologic malignancies may warrant further investigation.

The activity of letrozole in patients with advanced or recurrent endometrial cancer and correlation with biological markers--a study of the National Cancer Institute of Canada Clinical Trials Group

A multicenter phase II trial was conducted to define the activity of letrozole in postmenopausal women with recurrent or advanced endometrial carcinoma, who had no more than one prior line of progestins and never had chemotherapy (except adjuvant). Archival paraffin-embedded tumor samples were retrieved to determine the expression level of estrogen (ER) and progesterone receptor (PgR), p53, HER-2, bcl-2 and PTEN protein, and phosphorylation status of protein kinase B (PKB/Akt). Thirty-two eligible patients were treated with letrozole at 2.5 mg daily continuously, of whom 10 (31%) had prior progestins. Of the 28 patients evaluated for response, one complete and two partial responses were noted; overall response was 9.4% (95% confidence interval 2-25%). Eleven patients had stable disease for a median duration of 6.7 months (range 3.7-19.3 months). Amongst 22 patients who had tumor blocks available, the proportion showing positive expression of the following markers includes: PgR (86%), ER (86%), PTEN (82%), phosphorylated PKB/Akt (59%), bcl-2 (45%), p53 (32%), and HER-2 (0%). None of these markers correlated with response to letrozole or disease progression. In conclusion, letrozole is well tolerated but has little overall activity in this cohort of women with endometrial cancer.