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Houvenaeghel G, Cohen M, Gonçalves A, Berthelot A, Chauvet MP, Faure C, Classe JM, Jouve E, Sabiani L, Bannier M, Tassy L, Martino M, Tallet A, de Nonneville A. Triple-negative and Her2-positive breast cancer in women aged 70 and over: prognostic impact of age according to treatment. Front Oncol 2023; 13:1287253. [PMID: 38162480 PMCID: PMC10757327 DOI: 10.3389/fonc.2023.1287253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Background Elderly breast cancer (BC) patients have been underrepresented in clinical trials whereas ~60% of deaths from BC occur in women aged 70 years and older. Only limited data are available on the prognostic impact of age according to treatment, especially in the triple-negative (TN) and Her2-positive because of the lower frequency of these subtypes in elderly patients. We report herein the results of a multicenter retrospective study analyzing the prognostic impact of age according to treatment delivered in TN and Her2-positive BC patients of 70 years or older, including comparison by age groups. Methods The medical records of 31,473 patients treated from January 1991 to December 2018 were retrieved from 13 French cancer centers for retrospective analysis. Our study population included all ≥70 patients with TN or Her2-positive BC treated by upfront surgery. Three age categories were determined: 70-74, 75-80, and > 80 years. Results Of 528 patients included, 243 patients were 70-74 years old (46%), 172 were 75-80 years (32.6%) and 113 were >80 years (21.4%). Half the population (51.9%, 274 patients) were TN, 30.1% (159) Her2-positive/hormone receptors (HR)-positive, and, 18% (95) Her2-positive/endocrine receptors (ER)-negative BC. Advanced tumor stage was associated with older age but no other prognostic factors (tumor subtype, tumor grade, LVI). Adjuvant chemotherapy delivery was inversely proportional to age. With 49 months median follow-up, all patient outcomes (overall survival (OS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and recurrence-free survival (RFS)) significantly decreased as age increased. In multivariate analysis, age >80, pT2-3 sizes, axillary macrometastases, lymphovascular involvement, and HR-negativity tumor negatively affected DFS and OS. Comparison between age >80 and <=80 years old showed worse RFS in patients aged > 80 (HR=1.771, p=0.031). Conclusion TN and Her2-positive subtypes occur at similar frequency in elderly patients. Older age is associated with more advanced tumor stage presentation. Chemotherapy use decreases with older age without worse other pejorative prognostic factors. Age >80, but not ≤80, independently affected DFS and OS.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Anthony Gonçalves
- Department of Medical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Axel Berthelot
- Department of Medical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | | | | | - Jean Marc Classe
- Institut René Gauducheau, Site hospitalier Nord, St Herblain, France
| | - Eva Jouve
- Surgical Oncology Department, Centre Claudius Regaud, Toulouse, France
| | - Laura Sabiani
- Department of Surgical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Marie Bannier
- Department of Surgical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Louis Tassy
- Department of Medical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Marc Martino
- Department of Surgical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Agnès Tallet
- Department of Radiotherapy, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
| | - Alexandre de Nonneville
- Department of Medical Oncology, Cancer Research Center of Marseille (CRCM), Institut Paoli−Calmettes, Aix-Marseille Univ, CNRS, INSERM, Marseille, France
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Vuger AT, Tiscoski K, Apolinario T, Cardoso F. Anthracyclines in the treatment of early breast cancer friend or foe? Breast 2022; 65:67-76. [PMID: 35839583 PMCID: PMC9289865 DOI: 10.1016/j.breast.2022.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022] Open
Abstract
Standard chemotherapy for early breast cancer consists generally of an anthracycline – taxane - based regimen, preferably in sequence. Anthracyclines are among the most active cytotoxic drugs against breast cancer. Nevertheless, benefits attained by the use of the more potent anthracycline schedules must be balanced against increased short – and long – term toxicity, and treatment options must be individualized for each patient. Authors review available data regarding anthracycline efficacy and toxicity in the early breast cancer setting and the potential directions for future research. Anthracyclines are one of the most effective drugs against breast cancer. Anthracyclines and taxanes for early breast cancer reduce mortality. Anthracyclines raise some concerns about cardiotoxicity and secondary leukemia. Controversy remains regarding risk/benefit for the use of adjuvant anthracyclines.
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Affiliation(s)
- Ana Tecic Vuger
- Breast Cancer Department, Division for Medical Oncology, University Hospital for Tumors, Sestre Milosrdnice UCC, Zagreb, Croatia
| | - Katsuki Tiscoski
- Department of Clinical Oncology, Santa Casa Misericordia Porto Alegre, Porto Alegre, Brazil; Post-Graduation Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil
| | - Thiago Apolinario
- Department of Clinical Oncology, Institute of Integral Medicine Professor Fernando Figueira, Recife, Brazil
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal.
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3
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Battisti NML, De Glas N, Soto-Perez-de-Celis E, Liposits G, Bringuier M, Walko C, Lichtman SM, Aapro M, Cheung KL, Biganzoli L, Ring A, Portielje J, Wildiers H, Brain E. Chemotherapy and gene expression profiling in older early luminal breast cancer patients: An International Society of Geriatric Oncology systematic review. Eur J Cancer 2022; 172:158-170. [PMID: 35777273 PMCID: PMC10861271 DOI: 10.1016/j.ejca.2022.05.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/14/2022] [Accepted: 05/24/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The benefit of chemotherapy for older patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer (EBC) is a key area of debate. Gene expression profiling (GEP) may identify patients deriving benefit, but their predictive role has not been established for older adults. We summarise evidence on efficacy, safety, and quality-of-life impacts of chemotherapy and on GEP use and impact in older HR-positive, HER2-negative EBC patients. METHODS We conducted a literature search of PubMed and Embase on publications describing prospective studies evaluating chemotherapy in older adults with HR-positive, HER2-negative EBC and on publications describing retrospective and prospective studies evaluating GEP in older adults. RESULTS Eight publications on chemotherapy use, including 2,035 older patients with EBC were selected. Only one trial evaluated chemotherapy survival benefits in older adults, showing no benefit. Of four studies comparing different regimens, only one showed the superiority of taxanes versus anthracyclines alone. Those investigating alternative regimens did not show improvements over standard regimens despite significant limitations. Five publications on GEP, including 445,323 older patients, were included and investigated Oncotype DX. Limited evidence shows that GEP aids treatment decisions in this population. GEP was offered less frequently to older versus younger patients. Higher Recurrence Score was prognostic for distant recurrence, but chemotherapy did not improve prognosis. CONCLUSIONS In older patients with HR-positive, HER2-negative, chemotherapy survival benefits EBC are unclear and GEP is less used. Although its prognostic role is well established, its predictive role remains unknown.
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Affiliation(s)
- Nicolò Matteo Luca Battisti
- Breast Unit - Department of Medicine, The Royal Marsden NHS Foundation Trust, London, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, London, United Kingdom.
| | - Nienke De Glas
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Gabor Liposits
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense, Denmark.
| | - Michael Bringuier
- Interdisciplinary Supportive Care Department for Cancer Patients and Medical Oncology Department, Institut Curie/Saint-Cloud, Paris, France.
| | - Christine Walko
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL, USA.
| | - Stuart M Lichtman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Matti Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland.
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK.
| | - Laura Biganzoli
- "Sandro Pitigliani" Department of Medical Oncology, Nuovo Ospedale di Prato, Prato, Italy.
| | - Alistair Ring
- Breast Unit - Department of Medicine, The Royal Marsden NHS Foundation Trust, London, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, London, United Kingdom.
| | - Johanneke Portielje
- Department of Internal Medicine and Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Hans Wildiers
- Department of General Medical Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, Leuven, Belgium.
| | - Etienne Brain
- Department of Medical Oncology, Institut Curie/Saint-Cloud, Paris, France.
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4
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Li Z, Zheng J, Ji Z, Chen L, Wu J, Zou J, Liu Y, Lin W, Cai J, Chen Y, Chen Y, Lu H. Addition of Capecitabine to Adjuvant Chemotherapy May be the Most Effective Strategy for Patients With Early-Stage Triple-Negative Breast Cancer: A Network Meta-Analysis of 9 Randomized Controlled Trials. Front Endocrinol (Lausanne) 2022; 13:939048. [PMID: 35957836 PMCID: PMC9358934 DOI: 10.3389/fendo.2022.939048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/03/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Previous studies determined the therapeutic effects of capecitabine-based chemotherapy regimens on early-stage triple-negative breast cancer (TNBC). However, the optimal strategy of capecitabine-based chemotherapy remains uncertain. We conducted this network meta-analysis to address this issue. METHODS We systematically searched PubMed, Embase, and the Cochrane Registry of Controlled Trials (CENTRAL) to retrieve eligible studies published before September 2021. Two independent reviewers extracted information from eligible studies using a pre-designed data extraction sheet. The primary outcome included disease-free survival, and the second outcome showed overall survival and adverse events. Direct meta-analysis was performed using RevMan 5.4, and Bayesian network analysis was performed using R version 3.6.1 with the "gemtc" and "rjags" packages. RESULTS Nine studies involving 3661 TNBC patients met the selection criteria. The network meta-analysis suggested that the addition of capecitabine to adjuvant chemotherapy achieved a significantly longer disease-free (HR = 0.66, 95% CrI = 0.49 to 0.86) and overall survival time (HR = 0.60, 95% CrI = 0.43 to 0.83) than standard chemotherapy. All comparisons did not achieve statistical significance. The addition of capecitabine to adjuvant chemotherapy was the most effective treatment for improving disease-free (81.24%) and overall survival (78.46%) times, and the replacement of capecitabine to adjuvant chemotherapy was the safest regime. CONCLUSIONS Based on available evidence, capecitabine-based chemotherapy benefits TNBC patients, and the addition of capecitabine with adjuvant chemotherapy was the most effective regime. In contrast, the replacement of capecitabine to adjuvant chemotherapy was the safest regime. More studies of high quality and large scale are needed to confirm our findings.
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Affiliation(s)
- Zhiyang Li
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jiehua Zheng
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Zeqi Ji
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Lingzhi Chen
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jinyao Wu
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Juan Zou
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Yiyuan Liu
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Weixun Lin
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jiehui Cai
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Yaokun Chen
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Yexi Chen
- Department of Thyroid, Breast and Hernia Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Hai Lu
- Department of Breast, The First People's Hospital of Shao Guan, Shaoguan, China
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5
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Xiu M, Zhang P, Li Q, Yuan P, Wang J, Luo Y, Ma F, Cai R, Fan Y, Li Q, Xu B. Chemotherapy Decision-Making and Survival Outcomes in Older Women With Early Triple-Negative Breast Cancer: Evidence From Real-World Practice. Front Oncol 2022; 12:867583. [PMID: 35574419 PMCID: PMC9097590 DOI: 10.3389/fonc.2022.867583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/30/2022] [Indexed: 11/22/2022] Open
Abstract
Data regarding chemotherapy options and benefits in older women with early triple-negative breast cancer (TNBC) are limited. Our study aimed to assess the effects of adjuvant chemotherapy on recurrence-free survival (RFS), breast cancer-specific survival (BCSS), and overall survival (OS) rates in elderly TNBC patients. Patients aged ≥65 years diagnosed with stage I-III TNBC (except T1aN0) between 2010 and 2016 were retrospectively included. Multivariate Cox regression was performed to minimize bias. A total of 177 patients were included with a median age of 69 years (range, 65-86), almost all had a Charlson Comorbidity Index of 0-2, and 127 (71.8%) received chemotherapy. Patients who received chemotherapy were younger, had more advanced-stage disease and had better ECOG performance status (P<0.05). Among the 127 patients who were administered chemotherapy, 45 (35%) received taxane plus carboplatin, 36 (28%) received anthracycline-and-taxane-based regimens, and 23 (18%) received taxane-based regimens. The regimen options differed based on patient age and tumour stage (P<0.05). Nearly 80% of the patients completed ≥6 cycles of chemotherapy, and half had their dosage decreased. After adjustment for confounding factors, patients who received ≥6 cycles of chemotherapy were found to have improved RFS rates (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.09-0.87; P=0.027), and receipt of chemotherapy (≥1 cycle) was associated with better BCSS (HR, 0.19; 95% CI, 0.04-0.97; P=0.046) and OS (HR, 0.26; 95% CI, 0.08-0.87; P=0.029) rates. These results support the considering the risk for recurrence and performing individualized assessments when determining the appropriate chemotherapy approach for older women with early TNBC.
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Affiliation(s)
| | - Pin Zhang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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6
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Joensuu H, Kellokumpu-Lehtinen PL, Huovinen R, Jukkola A, Tanner M, Ahlgren J, Auvinen P, Lahdenperä O, Villman K, Nyandoto P, Nilsson G, Poikonen-Saksela P, Kataja V, Bono P, Junnila J, Lindman H. Adjuvant Capecitabine for Early Breast Cancer: 15-Year Overall Survival Results From a Randomized Trial. J Clin Oncol 2022; 40:1051-1058. [PMID: 35020465 PMCID: PMC8966968 DOI: 10.1200/jco.21.02054] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Few data are available regarding the influence of adjuvant capecitabine on long-term survival of patients with early breast cancer. METHODS The Finland Capecitabine Trial (FinXX) is a randomized, open-label, multicenter trial that evaluates integration of capecitabine to an adjuvant chemotherapy regimen containing a taxane and an anthracycline for the treatment of early breast cancer. Between January 27, 2004, and May 29, 2007, 1,500 patients with axillary node-positive or high-risk node-negative early breast cancer were accrued. The patients were randomly allocated to either TX-CEX, consisting of three cycles of docetaxel (T) plus capecitabine (X) followed by three cycles of cyclophosphamide, epirubicin, and capecitabine (CEX, 753 patients), or to T-CEF, consisting of three cycles of docetaxel followed by three cycles of cyclophosphamide, epirubicin, and fluorouracil (CEF, 747 patients). We performed a protocol-scheduled analysis of overall survival on the basis of approximately 15-year follow-up of the patients. RESULTS The data collection was locked on December 31, 2020. By this date, the median follow-up time of the patients alive was 15.3 years (interquartile range, 14.5-16.1 years) in the TX-CEX group and 15.4 years (interquartile range, 14.8-16.0 years) in the T-CEF group. Patients assigned to TX-CEX survived longer than those assigned to T-CEF (hazard ratio 0.81; 95% CI, 0.66 to 0.99; P = .037). The 15-year survival rate was 77.6% in the TX-CEX group and 73.3% in the T-CEF group. In exploratory subgroup analyses, patients with estrogen receptor-negative cancer and those with triple-negative cancer treated with TX-CEX tended to live longer than those treated with T-CEF. CONCLUSION Addition of capecitabine to a chemotherapy regimen that contained docetaxel, epirubicin, and cyclophosphamide prolonged the survival of patients with early breast cancer.
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Affiliation(s)
- Heikki Joensuu
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Riikka Huovinen
- Department of Oncology, Turku University Hospital, Turku, Finland
| | - Arja Jukkola
- Department of Oncology, Tampere University Hospital and Tampere University, Tampere, Finland.,Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland
| | - Minna Tanner
- Department of Oncology, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Johan Ahlgren
- Gävle Hospital, Gävle, Sweden.,Regional Cancer Centre of Mid-Sweden, Academic Hospital, Uppsala, Sweden
| | - Päivi Auvinen
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Outi Lahdenperä
- Department of Oncology, Turku University Hospital, Turku, Finland
| | | | | | - Greger Nilsson
- Department of Oncology, Gävle Hospital and Visby Hospital, and Uppsala University, Uppsala, Sweden
| | - Paula Poikonen-Saksela
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vesa Kataja
- Central Finland Central Hospital, Jyväskylä, Finland
| | - Petri Bono
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Henrik Lindman
- Department of Immunology, Genetics and Pathology, Uppsala University Hospital, Uppsala, Sweden
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7
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van Mackelenbergh MT, Seither F, Möbus V, O'Shaughnessy J, Martin M, Joensuu H, Untch M, Nitz U, Steger GG, Miralles JJ, Barrios CH, Toi M, Bear HD, Muss H, Reimer T, Nekljudova V, Loibl S. Effects of capecitabine as part of neo-/adjuvant chemotherapy - A meta-analysis of individual breast cancer patient data from 13 randomised trials including 15,993 patients. Eur J Cancer 2022; 166:185-201. [PMID: 35305453 DOI: 10.1016/j.ejca.2022.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/28/2022] [Accepted: 02/04/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite the large number of patients with early breast cancer (EBC) who have been treated with capecitabine in randomised trials, no individual patient data meta-analysis has been conducted. The primary objective was to examine the effect of capecitabine on disease-free survival (DFS), and the secondary objectives were to analyse distant DFS (DDFS), overall survival (OS), pathological complete response (for neoadjuvant studies) and the interaction between capecitabine-related toxicity and treatment effect. METHODS www. CLINICALTRIALS gov and www.pubmed.ncbi.nlm.nih.gov were searched using the following criteria: use of capecitabine for EBC as adjuvant or neoadjuvant therapy; multicentre randomised trial with >100 patients; recruitment completed, and outcomes available. Required data were available for 13 trials. RESULTS Individual data from 15,993 patients were collected. Cox regression analyses of all included patients revealed that the addition of capecitabine did not alter DFS significantly compared with treatment without capecitabine (hazard ratio [HR] 0.952; 95% CI 0.895-1.012; P value = 0.115). There was also no effect on DFS in the subset of studies where capecitabine was given instead of another drug (HR 1.035; 95% CI 0.945-1.134; P = 0.455). However, capecitabine administered in addition to the standard systemic treatment improved DFS (HR 0.888; 95% CI 0.817-0.965; P = 0.005). An OS improvement was observed in the entire cohort (HR 0.892; 95% CI 0.824-0.965, P = 0.005) and in the subset of capecitabine addition (HR 0.837; 95% CI 0.751, 0.933, P = 0.001). Subgroup analyses revealed that triple-negative breast cancer (TNBC) patients benefitted from treatment with capecitabine overall and in addition to other systemic treatments in terms of DFS and OS. CONCLUSION Capecitabine was able to improve DFS and OS in patients with TNBC and in all patients with EBC when administered in addition to systemic treatment.
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Affiliation(s)
- Marion T van Mackelenbergh
- German Breast Group, Neu-Isenburg, Germany; Department of Gynecology and Obstetrics, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.
| | | | - Volker Möbus
- University Hospital Frankfurt, Frankfurt, Germany
| | - Joyce O'Shaughnessy
- US Oncology Research, Inc., The Woodlands, TX, USA; Texas Oncology/Baylor University Medical Center, Dallas, TX, USA
| | - Miguel Martin
- Instituto de Investigacion Sanitaria Gregorio Marañon, CIBERONC, Universidad Complutense, Madrid, Spain; Spanish Breast Cancer Group, GEICAM, Madrid, Spain
| | - Heikki Joensuu
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Ulrike Nitz
- Breast Center Niederrhein, Evangelical Hospital Johanniter Bethesda, Mönchengladbach, Germany
| | - Guenther G Steger
- Department of Internal Medicine I and Gaston H. Glock Research Centre, Medical University of Vienna, Vienna, Austria
| | | | - Carlos H Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Grupo Oncoclinicas, Porto Alegre, Brazil
| | - Masakazu Toi
- Breast Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Harry D Bear
- NRG Oncology and Division of Surgical Oncology, Massey Cancer Center, Virginia Commonwealth University, VCU Health, Richmond, VA, USA
| | - Hyman Muss
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Toralf Reimer
- Breast Center, University of Rostock, Rostock, Germany
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8
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Marinopoulos S, Dimitrakakis C, Kalampalikis A, Zagouri F, Andrikopoulou A, Rodolakis A. Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure. Breast Care (Basel) 2022; 17:71-80. [PMID: 35355693 PMCID: PMC8914240 DOI: 10.1159/000513708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 12/11/2020] [Indexed: 02/03/2023] Open
Abstract
Background Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach. Summary In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly. Key Messages The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.
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Affiliation(s)
- Spyridon Marinopoulos
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece,*Spyridon Marinopoulos, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, 80 V. Sofias Ave., GR–11528 Athens (Greece),
| | - Constantine Dimitrakakis
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Andreas Kalampalikis
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Flora Zagouri
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Angeliki Andrikopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Alexandros Rodolakis
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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9
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Schreiber AR, Kagihara J, Eguchi M, Kabos P, Fisher CM, Meyer E, Molina E, Kondapalli L, Bradley CJ, Diamond JR. Evaluating anthracycline + taxane versus taxane-based chemotherapy in older women with node-negative triple-negative breast cancer: a SEER-Medicare study. Breast Cancer Res Treat 2021; 191:389-399. [PMID: 34705147 PMCID: PMC8763743 DOI: 10.1007/s10549-021-06424-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/14/2021] [Indexed: 11/22/2022]
Abstract
Purpose Adjuvant chemotherapy reduces recurrence in early-stage triple-negative breast cancer (TNBC). However, data are lacking evaluating anthracycline + taxane (ATAX) versus taxane-based (TAX) chemotherapy in older women with node-negative TNBC, as they are often excluded from trials. The purpose of this study was to evaluate the effect of adjuvant ATAX versus TAX on cancer-specific (CSS) and overall survival (OS) in older patients with node-negative TNBC. Patients and methods Using the SEER-Medicare database, we selected patients aged ≥ 66 years diagnosed with Stage T1-4N0M0 TNBC between 2010 and 2015 (N = 3348). Kaplan–Meier survival curves and adjusted Cox proportional hazards models were used to estimate 3-year OS and CSS. Multivariant Cox regression analysis was used to identify independent factors associated with use of ATAX compared to TAX. Results Approximately half (N = 1679) of patients identified received chemotherapy and of these, 58.6% (N = 984) received TAX, 25.0% (N = 420) received ATAX, and 16.4% (N = 275) received another regimen. Three-year CSS and OS was improved with any adjuvant chemotherapy from 88.9 to 92.2% (p = 0.0018) for CSS and 77.2% to 88.6% for OS (p < 0.0001). In contrast, treatment with ATAX compared to TAX was associated with inferior 3-year CSS and OS. Three-year CSS was 93.7% with TAX compared to 89.8% (p = 0.048) for ATAX and OS was 91.0% for TAX and 86.4% for ATAX (p = 0.032). Conclusion While adjuvant chemotherapy was associated with improved clinical outcomes, the administration of ATAX compared to TAX was associated with inferior 3-year OS and CSS in older women with node-negative TNBC. The use of adjuvant ATAX should be considered carefully in this patient population. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06424-z.
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Affiliation(s)
- Anna R Schreiber
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Jodi Kagihara
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, 12801 East 17th Ave, Mailstop 8117, Aurora, CO, 80045, USA
| | - Megan Eguchi
- School of Public Health, Department of Health Systems, Management, and Policy, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Peter Kabos
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, 12801 East 17th Ave, Mailstop 8117, Aurora, CO, 80045, USA
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Elisabeth Meyer
- School of Public Health, Department of Health Systems, Management, and Policy, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Elizabeth Molina
- School of Public Health, Department of Health Systems, Management, and Policy, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Lavanya Kondapalli
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Cathy J Bradley
- School of Public Health, Department of Health Systems, Management, and Policy, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Jennifer R Diamond
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, 12801 East 17th Ave, Mailstop 8117, Aurora, CO, 80045, USA.
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10
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Zhou W, Cao Y, Gou P, Zeng X, Hu X, Lin Z, Ye C, Chen L, Yao G. Additional adjuvant capecitabine in early breast cancer patients: a meta-analysis of randomized controlled trials. Future Oncol 2021; 17:4993-5002. [PMID: 34689590 DOI: 10.2217/fon-2020-1131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: To assess the efficacy and safety of adjuvant capecitabine in early breast cancer patients. Methods: A literature search of databases was conducted to identify randomized controlled trials reporting the efficacy and toxicity of capecitabine as adjuvant therapy in early breast cancer patients. Results: Six studies were eligible and included a total of 6941 patients. Disease-free survival (hazard ratio = 0.79; 95% CI = 0.71-0.88; p < 0.0001) was significantly improved with additional capecitabine, whereas improvement in overall survival (OS) was not significant. The more pronounced benefits in both disease-free survival and OS were observed among triple-negative breast cancer patients. Conclusion: Additional capecitabine in the adjuvant setting conferred substantial disease-free survival benefit and a tendency toward improved OS. Triple-negative breast cancer patients can benefit from capecitabine irrespective of the administration sequence. Capecitabine may be considered a preferred additional treatment for early-stage triple-negative breast cancer patients, and sequential capecitabine can serve as an alternative choice for patients with poor tolerance.
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Affiliation(s)
- Wenqi Zhou
- Breast Center, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, PR China
| | - Yong Cao
- Breast Center, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, PR China
| | - Ping Gou
- Department of Ultrasonography, Nanfang Hospital, Southern Medical University, Guangzhou 510515, PR China
| | - Xiaohua Zeng
- Breast Center, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, PR China
| | - Xiaolei Hu
- Department of General Surgery, Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, PR China
| | - Zhousheng Lin
- Department of General Surgery, Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, PR China
| | - Changsheng Ye
- Department of General Surgery, Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, PR China
| | - Lujia Chen
- Department of General Surgery, Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, PR China
| | - Guangyu Yao
- Department of General Surgery, Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, PR China
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11
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Hoon SN, Lau PK, White AM, Bulsara MK, Banks PD, Redfern AD. Capecitabine for hormone receptor-positive versus hormone receptor-negative breast cancer. Cochrane Database Syst Rev 2021; 5:CD011220. [PMID: 34037241 PMCID: PMC8150746 DOI: 10.1002/14651858.cd011220.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Retrospective analyses suggest that capecitabine may carry superior activity in hormone receptor-positive relative to hormone receptor-negative metastatic breast cancer. This review examined the veracity of that finding and explored whether this differential activity extends to early breast cancer. OBJECTIVES To assess effects of chemotherapy regimens containing capecitabine compared with regimens not containing capecitabine for women with hormone receptor-positive versus hormone receptor-negative breast cancer across the three major treatment scenarios: neoadjuvant, adjuvant, metastatic. SEARCH METHODS On 4 June 2019, we searched the Cochrane Breast Cancer Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) in the Cochrane Library; MEDLINE; Embase; the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials looking at chemotherapy regimens containing capecitabine alone or in combination with other agents versus a control or similar regimen without capecitabine for treatment of breast cancer at any stage. The primary outcome measure for metastatic and adjuvant trials was overall survival (OS), and for neoadjuvant studies pathological complete response (pCR). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias and certainty of evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and odds ratios (ORs) for dichotomous outcomes, and meta-analysis was performed using a fixed-effect model. MAIN RESULTS We included 26 studies with outcome data by hormone receptor: 12 metastatic studies (n = 4325), 6 neoadjuvant trials (n = 3152), and 8 adjuvant studies (n = 13,457). Capecitabine treatment was added in several different ways across studies. These could be classified as capecitabine alone compared to another treatment, capecitabine substituted for part of the control chemotherapy, and capecitabine added to control chemotherapy. In the metastatic setting, the effect of capecitabine was heterogenous between hormone receptor-positive and -negative tumours. For OS, no difference between capecitabine-containing and non-capecitabine-containing regimens was observed for all participants taken together (HR 1.01, 95% confidence interval (CI) 0.98 to 1.05; 12 studies, 4325 participants; high-certainty evidence), for those with hormone receptor-positive disease (HR 0.93, 95% CI 0.84 to 1.04; 7 studies, 1834 participants; high-certainty evidence), and for those with hormone receptor-negative disease (HR 1.00, 95% CI 0.88 to 1.13; 8 studies, 1577 participants; high-certainty evidence). For progression-free survival (PFS), a small improvement was seen for all people (HR 0.89, 95% CI 0.82 to 0.96; 12 studies, 4325 participants; moderate-certainty evidence). This was largely accounted for by a moderate improvement in PFS for inclusion of capecitabine in hormone receptor-positive cancers (HR 0.82, 95% CI 0.73 to 0.91; 7 studies, 1594 participants; moderate-certainty evidence) compared to no difference in PFS for hormone receptor-negative cancers (HR 0.96, 95% CI 0.83 to 1.10; 7 studies, 1122 participants; moderate-certainty evidence). Quality of life was assessed in five studies; in general there did not seem to be differences in global health scores between the two treatment groups at around two years' follow-up. Neoadjuvant studies were highly variable in design, having been undertaken to test various experimental regimens using pathological complete response (pCR) as a surrogate for disease-free survival (DFS) and OS. Across all patients, capecitabine-containing regimens resulted in little difference in pCR in comparison to non-capecitabine-containing regimens (odds ratio (OR) 1.12, 95% CI 0.94 to 1.33; 6 studies, 3152 participants; high-certainty evidence). By subtype, no difference in pCR was observed for either hormone receptor-positive (OR 1.22, 95% CI 0.76 to 1.95; 4 studies, 964 participants; moderate-certainty evidence) or hormone receptor-negative tumours (OR 1.28, 95% CI 0.61 to 2.66; 4 studies, 646 participants; moderate-certainty evidence). Four studies with 2460 people reported longer-term outcomes: these investigators detected no difference in either DFS (HR 1.02, 95% CI 0.86 to 1.21; high-certainty evidence) or OS (HR 0.97, 95% CI 0.77 to 1.23; high-certainty evidence). In the adjuvant setting, a modest improvement in OS was observed across all participants (HR 0.89, 95% CI 0.81 to 0.98; 8 studies, 13,547 participants; moderate-certainty evidence), and no difference in OS was seen in hormone receptor-positive cancers (HR 0.86, 95% CI 0.68 to 1.09; 3 studies, 3683 participants), whereas OS improved in hormone receptor-negative cancers (HR 0.72, 95% CI 0.59 to 0.89; 5 studies, 3432 participants). No difference in DFS or relapse-free survival (RFS) was observed across all participants (HR 0.93, 95% CI 0.86 to 1.01; 8 studies, 13,457 participants; moderate-certainty evidence). As was observed for OS, no difference in DFS/RFS was seen in hormone receptor-positive cancers (HR 1.03, 95% CI 0.91 to 1.17; 5 studies, 5604 participants; moderate-certainty evidence), and improvements in DFS/RFS with inclusion of capecitabine were observed for hormone receptor-negative cancers (HR 0.74, 95% CI 0.64 to 0.86; 7 studies, 3307 participants; moderate-certainty evidence). Adverse effects were reported across all three scenarios. When grade 3 or 4 febrile neutropenia was considered, no difference was seen for capecitabine compared to non-capecitabine regimens in neoadjuvant studies (OR 1.31, 95% CI 0.97 to 1.77; 4 studies, 2890 participants; moderate-certainty evidence), and a marked reduction was seen for capecitabine in adjuvant studies (OR 0.55, 95% CI 0.47 to 0.64; 5 studies, 8086 participants; moderate-certainty evidence). There was an increase in diarrhoea and hand-foot syndrome in neoadjuvant (diarrhoea: OR 1.95, 95% CI 1.32 to 2.89; 3 studies, 2686 participants; hand-foot syndrome: OR 6.77, 95% CI 4.89 to 9.38; 5 studies, 3021 participants; both moderate-certainty evidence) and adjuvant trials (diarrhoea: OR 2.46, 95% CI 2.01 to 3.01; hand-foot syndrome: OR 13.60, 95% CI 10.65 to 17.37; 8 studies, 11,207 participants; moderate-certainty evidence for both outcomes). AUTHORS' CONCLUSIONS In summary, a moderate PFS benefit by including capecitabine was seen only in hormone receptor-positive cancers in metastatic studies. No benefit of capecitabine for pCR was noted overall or in hormone receptor subgroups when included in neoadjuvant therapy. In contrast, the addition of capecitabine in the adjuvant setting led to improved outcomes for OS and DFS in hormone receptor-negative cancer. Future studies should stratify by hormone receptor and triple-negative breast cancer (TNBC) status to clarify the differential effects of capecitabine in these subgroups across all treatment scenarios, to optimally guide capecitabine inclusion.
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Affiliation(s)
- Siao-Nge Hoon
- Medical Oncology Department, St John of God Midland, Perth, Australia
- Medical Oncology Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Peter Kh Lau
- Medical Oncology Department, Sir Charles Gairdner Hospital, Perth, Australia
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Alison M White
- Murdoch Community Hospice, St John of God Hospital Murdoch, Perth, Australia
- Palliative Care Department, Royal Perth Hospital, Perth, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame Australia, Fremantle, Australia
- School of Population and Global Health, The University of Western Australia, Perth, Australia
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Patricia D Banks
- Medical Oncology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Medical Oncology Department, University Hospital Geelong, Geelong, Australia
| | - Andrew D Redfern
- School of Medicine, University of Western Australia, Perth, Australia
- Medical Oncology Department, Fiona Stanley Hospital, Perth, Australia
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12
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Crozier JA, Pezzi TA, Hodge C, Janeva S, Lesnikoski BA, Samiian L, Devereaux A, Hammond W, Audisio RA, Pezzi CM. Addition of chemotherapy to local therapy in women aged 70 years or older with triple-negative breast cancer: a propensity-matched analysis. Lancet Oncol 2021; 21:1611-1619. [PMID: 33271091 DOI: 10.1016/s1470-2045(20)30538-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is a scarcity of data exploring the benefits of adjuvant or neoadjuvant chemotherapy in the treatment of breast cancer in older women. We aimed to explore the effect of adding chemotherapy to local therapy on overall survival in older women with triple-negative breast cancer. METHODS For this propensity-matched analysis, we used data from the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. We included data from women aged 70 years or older with surgically treated, American Joint Committee on Cancer (AJCC) Stage I-III invasive triple-negative breast cancer diagnosed from 2004 to 2014. Patients with T1aN0M0 disease and those with incomplete data on oestrogen receptor status, progesterone receptor status, or HER2 status were excluded. To reduce bias, patients were subdivided into three groups: those who were recommended chemotherapy but did not receive it; those who received chemotherapy; and those for whom chemotherapy was not recommended and not given. The primary outcome was overall survival. Multivariate Cox regression analysis and propensity score matching were done to minimise bias. FINDINGS Between Jan 1, 2004, and Dec, 31, 2014, 16 062 women with triple-negative breast cancer in the database met the inclusion criteria for this analysis. Median follow-up was 38·3 months (IQR 20·7-46·1, range 0-138·0; 95% CI 37·8-38·7). Collectively, the 5-year overall survival estimate of the 16 062 patients in the study cohort was 62·3% (95% CI 59·7-64·4). 5-year estimated overall survival was 68·5% (95% CI 66·4-70·6) for patients receiving chemotherapy, 61·1% (59·0-63·2) for patients recommended but not given chemotherapy, and 53·7% (51·8-55·8) for patients not recommended chemotherapy and not given chemotherapy (pooled log rank p<0·0001). Multivariate Cox regression analysis of a propensity score-matched sample comparing those who received chemotherapy with those who were recommended but not given chemotherapy (n=1884 matched pairs) identified improved overall survival with chemotherapy (hazard ratio [HR] 0·69 [95% CI 0·60-0·80]; p<0·0001). After stratifying the propensity score matching sample, this benefit persisted for node-negative women (HR 0·80 [95% CI 0·66-0·97]; p=0·007), node-positive women (0·76 [0·64-0·91]; p=0·006), and those with a comorbidity score greater than 0 (HR 0·74 [95% CI 0·59-0·94]; p=0·013). INTERPRETATION These data support consideration of chemotherapy in the treatment of women aged 70 years or older with triple-negative breast cancer. FUNDING None.
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Affiliation(s)
- Jennifer A Crozier
- Division of Cancer Medicine, Baptist MD Anderson Cancer Center, Jacksonville, FL, USA
| | - Todd A Pezzi
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caitlin Hodge
- Department of Surgery, Abington-Jefferson Health, Abington, PA, USA
| | - Slavica Janeva
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Beth-Ann Lesnikoski
- Division of Surgery, Baptist MD Anderson Cancer Center, Jacksonville, FL, USA
| | - Laila Samiian
- Division of Surgery, Baptist MD Anderson Cancer Center, Jacksonville, FL, USA
| | - Amanda Devereaux
- Division of Cancer Medicine, Baptist MD Anderson Cancer Center, Jacksonville, FL, USA
| | - William Hammond
- Division of Cancer Medicine, Baptist MD Anderson Cancer Center, Jacksonville, FL, USA
| | - Riccardo A Audisio
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher M Pezzi
- Division of Surgery, Baptist MD Anderson Cancer Center, Jacksonville, FL, USA.
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13
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Li J, Yu K, Pang D, Wang C, Jiang J, Yang S, Liu Y, Fu P, Sheng Y, Zhang G, Cao Y, He Q, Cui S, Wang X, Ren G, Li X, Yu S, Liu P, Qu X, Tang J, Wang O, Fan Z, Jiang G, Zhang J, Wang J, Zhang H, Wang S, Zhang J, Jin F, Rao N, Ma B, He P, Xu B, Zhuang Z, Wang J, Sun Q, Guo X, Mo M, Shao Z. Adjuvant Capecitabine With Docetaxel and Cyclophosphamide Plus Epirubicin for Triple-Negative Breast Cancer (CBCSG010): An Open-Label, Randomized, Multicenter, Phase III Trial. J Clin Oncol 2020; 38:1774-1784. [PMID: 32275467 PMCID: PMC7255982 DOI: 10.1200/jco.19.02474] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Standard adjuvant chemotherapy for triple-negative breast cancer (TNBC) includes a taxane and an anthracycline. Concomitant capecitabine may be beneficial, but robust data to support this are lacking. The efficacy and safety of the addition of capecitabine into the TNBC adjuvant treatment regimen was evaluated. PATIENTS AND METHODS This randomized, open-label, phase III trial was conducted in China. Eligible female patients with early TNBC after definitive surgery were randomly assigned (1:1) to either capecitabine (3 cycles of capecitabine and docetaxel followed by 3 cycles of capecitabine, epirubicin, and cyclophosphamide) or control treatment (3 cycles of docetaxel followed by 3 cycles of fluorouracil, epirubicin, and cyclophosphamide). Randomization was centralized without stratification. The primary end point was disease-free survival (DFS). RESULTS Between June 2012 and December 2013, 636 patients with TNBC were screened, and 585 were randomly assigned to treatment (control, 288; capecitabine, 297). Median follow-up was 67 months. The 5-year DFS rate was higher for capecitabine than for control treatment (86.3% v 80.4%; hazard ratio, 0.66; 95% CI, 0.44 to 0.99; P = .044). Five-year overall survival rates were numerically higher but not significantly improved (capecitabine, 93.3%; control, 90.7%). Overall, 39.1% of patients had capecitabine dose reductions, and 8.4% reported grade ≥ 3 hand-foot syndrome. The most common grade ≥ 3 hematologic toxicities were neutropenia (capecitabine, 136 [45.8%]; control, 118 [41.0%]) and febrile neutropenia (capecitabine, 50 [16.8%]; control, 46 [16.0%]). Safety data were similar to the known capecitabine safety profile and generally comparable between arms. CONCLUSION Capecitabine when added to 3 cycles of docetaxel followed by 3 cycles of a 3-drug anthracycline combination containing capecitabine instead of fluorouracil significantly improved DFS in TNBC without new safety concerns.
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Affiliation(s)
- Junjie Li
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Key Laboratory of Breast Cancer in Shanghai, Shanghai, People's Republic of China
| | - Keda Yu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Key Laboratory of Breast Cancer in Shanghai, Shanghai, People's Republic of China
| | - Da Pang
- Department of Breast Surgery, The Third Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Changqin Wang
- Department of Breast Surgery, Jilin Cancer Hospital and Institute, Changchun, Jilin, People's Republic of China
| | - Jun Jiang
- Department of Breast Surgery, Southwest Hospital, Chongqing, Chongqing, People's Republic of China
| | - Suisheng Yang
- Department of Breast Surgery, Gansu Cancer Hospital, Lanzhou, Gansu, People's Republic of China
| | - Yunjiang Liu
- Department of Breast Surgery, The Fourth Clinical Medical College of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Peifen Fu
- Department of Breast Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yuan Sheng
- Department of Breast Surgery, Changhai Hospital of Shanghai, Shanghai, People's Republic of China
| | - Guojun Zhang
- Department of Breast Surgery, Cancer Hospital of Shantou Medical College, Shantou, Guangdong, People's Republic of China
| | - Yali Cao
- Department of Breast Surgery, The Third Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qi He
- Department of Breast Surgery, The International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai, People's Republic of China
| | - Shude Cui
- Department of Breast Surgery, Henan Cancer Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Xijing Wang
- Department of Breast Surgery, Medical College, The Second Affiliated Hospital of Xi'An Jiaotong University, Xi'an, Shanxi, People's Republic of China
| | - Guosheng Ren
- Department of Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, Chongqing, People's Republic of China
| | - Xinzheng Li
- Department of Breast Surgery, Shanxi Cancer Hospital, Taiyuan, Shanxi, People's Republic of China
| | - Shiyou Yu
- Department of Oncology, Eastern Hospital of Suzhou Municipal Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Pengxi Liu
- Department of Breast Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Xiang Qu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jinhai Tang
- Department of Breast Surgery, Jiangsu Cancer Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Ouchen Wang
- Department of Oncology, The First Hospital of Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
| | - Zhimin Fan
- Department of Breast Surgery, The First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Guoqin Jiang
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Jin Zhang
- Department of Breast Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, People's Republic of China
| | - Jiandong Wang
- Department of General Surgery, The General Hospital of the People's Liberation Army, Beijing, People's Republic of China
| | - Hongwei Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Shui Wang
- Department of Breast Surgery, Jiangsu Province Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Jianguo Zhang
- Department of Breast Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Feng Jin
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Nanyan Rao
- Department of Breast Surgery, The Second Affiliated Hospital of Zhongshan University, Guangzhou, Guangdong, People's Republic of China
| | - Binlin Ma
- Department of Breast Surgery, Xinjiang Cancer Hospital, Wulumuqi, Xinjiang, People's Republic of China
| | - Pingqing He
- Department of Breast Surgery, Shanghai Sixth People's Hospital, Shanghai, People's Republic of China
| | - Binghe Xu
- Department of Medical Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zhigang Zhuang
- Department of Breast Surgery, Shanghai First Maternity and Infant Hospital Corporation, Shanghai, People's Republic of China
| | - Jianfeng Wang
- Department of General Surgery, Shanghai General Hospital, Shanghai, People's Republic of China
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Xiaofeng Guo
- Continuing Education and Technology Services Department, Chinese Anti-Cancer Association, Tianjin, People's Republic of China
| | - Miao Mo
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Key Laboratory of Breast Cancer in Shanghai, Shanghai, People's Republic of China
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14
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Li Y, Zhou Y, Mao F, Lin Y, Zhang X, Shen S, Sun Q. Adjuvant addition of capecitabine to early-stage triple-negative breast cancer patients receiving standard chemotherapy: a meta-analysis. Breast Cancer Res Treat 2019; 179:533-542. [PMID: 31865475 DOI: 10.1007/s10549-019-05513-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Triple-negative breast cancer (TNBC) pertains to a breast cancer subtype that has the highest metastatic and recurrence rates. The effectiveness of capecitabine as adjuvant chemotherapy for TNBC has remained unclear. This study conducted a meta-analysis of the efficacy of capecitabine as adjuvant chemotherapy for early-stage TNBC treated with taxane-/anthracycline-based chemotherapy. METHODS We identified relevant research reports in online databases until May 2019. We finally included seven randomized clinical trials to perform this meta-analysis. Altogether, the seven trials enrolled 3151 early-stage TNBC patients, with 1552 receiving standard (neo)adjuvant chemotherapy regimens and 1599 receiving addition of capecitabine in the adjuvant settings besides standard regimens. RESULTS A meta-analysis of the seven trials revealed a significant increase in disease-free survival (DFS) with the addition of capecitabine (Hazard ratio (HR) = 0.77, 95% CI 0.66-0.90). This improvement in DFS was significant both in trials conducted in America-Europe and in Asia. In trials involving six to eight cycles of capecitabine addition, we observed a significant improvement in DFS. Furthermore, in the meta-analysis of six trials, we detected a significant increase in overall survival (OS) favoring capecitabine (HR = 0.69, 95% CI 0.56-0.85). CONCLUSIONS Adjuvant addition of capecitabine to early-stage TNBC patients receiving standard chemotherapy showed significant DFS and OS improvement. Future studies involving the selection of patients that may have the highest survival benefit from adding capecitabine are warranted.
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Affiliation(s)
- Yan Li
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Yidong Zhou
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Feng Mao
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Yan Lin
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xiaohui Zhang
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Songjie Shen
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
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Varshavsky-Yanovsky AN, Goldstein LJ. Role of Capecitabine in Early Breast Cancer. J Clin Oncol 2019; 38:179-182. [PMID: 31804861 DOI: 10.1200/jco.19.02946] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Willson ML, Burke L, Ferguson T, Ghersi D, Nowak AK, Wilcken N. Taxanes for adjuvant treatment of early breast cancer. Cochrane Database Syst Rev 2019; 9:CD004421. [PMID: 31476253 PMCID: PMC6718224 DOI: 10.1002/14651858.cd004421.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Adjuvant chemotherapy improves survival in premenopausal and postmenopausal women with early breast cancer. Taxanes are highly active chemotherapy agents used in metastatic breast cancer. Review authors examined their role in early breast cancer. This review is an update of a Cochrane Review first published in 2007. OBJECTIVES To assess the effects of taxane-containing adjuvant chemotherapy regimens for treatment of women with operable early breast cancer. SEARCH METHODS For this review update, we searched the Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, Embase, CENTRAL (2018, Issue 6), the WHO International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov on 16 July 2018, using key words such as 'early breast cancer' and 'taxanes'. We screened reference lists of other related literature reviews and articles, contacted trial authors, and applied no language restrictions. SELECTION CRITERIA Randomised trials comparing taxane-containing regimens versus non-taxane-containing regimens in women with operable breast cancer were included. Studies of women receiving neoadjuvant chemotherapy were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias and quality of the evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and meta-analysis was performed using a fixed-effect model. The primary outcome measure was overall survival (OS); disease-free survival (DFS) was a secondary outcome measure. Toxicity was represented as odds ratios (ORs), and quality of life (QoL) data were extracted when present. MAIN RESULTS This review included 29 studies (27 full-text publications and 2 abstracts or online theses). The updated analysis included 41,911 randomised women; the original review included 21,191 women. Taxane-containing regimens improved OS (HR 0.87, 95% confidence interval (CI) 0.83 to 0.92; high-certainty evidence; 27 studies; 39,180 women; 6501 deaths) and DFS (HR, 0.88, 95% CI 0.85 to 0.92; high-certainty evidence; 29 studies; 41,909 women; 10,271 reported events) compared to chemotherapy without a taxane. There was moderate to substantial heterogeneity across studies for OS and DFS (respectively).When a taxane-containing regimen was compared with the same regimen without a taxane, the beneficial effects of taxanes persisted for OS (HR 0.84, 95% CI 0.77 to 0.92; P < 0.001; 7 studies; 10,842 women) and for DFS (HR 0.84, 95% CI 0.78 to 0.90; P < 0.001; 7 studies; 10,842 women). When a taxane-containing regimen was compared with the same regimen with another drug or drugs that were substituted for the taxane, a beneficial effect was observed for OS and DFS with the taxane-containing regimen (OS: HR 0.80, 95% CI 0.74 to 0.86; P < 0.001; 13 studies; 16,196 women; DFS: HR 0.83, 95% CI 0.78 to 0.88; P < 0.001; 14 studies; 16,823 women). Preliminary subgroup analysis by lymph node status showed a survival benefit with taxane-containing regimens in studies of women with lymph node-positive disease only (HR 0.83, 95% CI 0.78 to 0.88; P < 0.001; 17 studies; 22,055 women) but less benefit in studies of women both with and without lymph node metastases or with no lymph node metastases. Taxane-containing regimens also improved DFS in women with lymph node-positive disease (HR 0.84, 95% CI 0.80 to 0.88; P < 0.001; 17 studies; 22,055 women), although the benefit was marginal in studies of women both with and without lymph node-positive disease (HR 0.95, 95% CI 0.88 to 1.02; 9 studies; 12,998 women) and was not apparent in studies of women with lymph node-negative disease (HR 0.99, 95% CI 0.86 to 1.14; 3 studies; 6856 women).Taxanes probably result in a small increase in risk of febrile neutropenia (odds ratio (OR) 1.55, 95% CI 0.96 to 2.49; moderate-certainty evidence; 24 studies; 33,763 women) and likely lead to a large increase in grade 3/4 neuropathy (OR 6.89, 95% CI 3.23 to 14.71; P < 0.001; moderate-certainty evidence; 22 studies; 31,033 women). Taxanes probably cause little or no difference in cardiotoxicity compared to regimens without a taxane (OR 0.87, 95% CI 0.56 to 1.33; moderate-certainty evidence; 23 studies; 32,894 women). Seven studies reported low-quality evidence for QoL; overall, taxanes may make little or no difference in QoL compared to chemotherapy without a taxane during the follow-up period; however, the duration of follow-up differed across studies. Only one study, which was conducted in Europe, provided cost-effectiveness data. AUTHORS' CONCLUSIONS This review of studies supports the use of taxane-containing adjuvant chemotherapy regimens, with improvement in overall survival and disease-free survival for women with operable early breast cancer. This benefit persisted when analyses strictly compared a taxane-containing regimen versus the same regimen without a taxane or the same regimen with another drug that was substituted for the taxane. Preliminary evidence suggests that taxanes are more effective for women with lymph node-positive disease than for those with lymph node-negative disease. Considerable heterogeneity across studies probably reflects the varying efficacy of the chemotherapy backbones of the comparator regimens used in these studies. This review update reports results that are remarkably consistent with those of the original review, and it is highly unlikely that this review will be updated, as new trials are assessing treatments based on more detailed breast cancer biology.
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Affiliation(s)
- Melina L Willson
- NHMRC Clinical Trials Centre, The University of SydneySystematic Reviews and Health Technology AssessmentsLocked Bag 77SydneyNSWAustralia1450
| | - Lucinda Burke
- Chris O'Brien LifehouseDepartment of Radiation OncologySydneyAustralia
| | - Thomas Ferguson
- Royal Perth HospitalDepartment of Medical OncologyWellington StPerthWAAustralia6010
| | - Davina Ghersi
- National Health and Medical Research CouncilResearch Policy and Translation16 Marcus Clarke StreetCanberraACTAustralia2601
- The University of SydneySydney Medical SchoolSydneyAustralia
| | - Anna K Nowak
- Sir Charles Gairdiner Hospital and University of Western AustraliaDepartment of Medical OncologyB Block, Hospital AvenueNedlandsPerthWAAustralia6099
| | - Nicholas Wilcken
- The University of SydneySydney Medical SchoolSydneyAustralia
- Crown Princess Mary Cancer CentreMedical OncologyWestmeadNSWAustralia2145
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Muss HB, Polley MYC, Berry DA, Liu H, Cirrincione CT, Theodoulou M, Mauer AM, Kornblith AB, Partridge AH, Dressler LG, Cohen HJ, Kartcheske PA, Perez EA, Wolff AC, Gralow JR, Burstein HJ, Mahmood AA, Sutton LM, Magrinat G, Parker BA, Hart RD, Grenier D, Hurria A, Jatoi A, Norton L, Hudis CA, Winer EP, Carey L. Randomized Trial of Standard Adjuvant Chemotherapy Regimens Versus Capecitabine in Older Women With Early Breast Cancer: 10-Year Update of the CALGB 49907 Trial. J Clin Oncol 2019; 37:2338-2348. [PMID: 31339827 DOI: 10.1200/jco.19.00647] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Older women with breast cancer remain under-represented in clinical trials. The Cancer and Leukemia Group B 49907 trial focused on women age 65 years and older. We previously reported the primary analysis after a median follow-up of 2.4 years. Standard adjuvant chemotherapy showed significant improvements in recurrence-free survival (RFS) and overall survival compared with capecitabine. We now update results at a median follow-up of 11.4 years. PATIENTS AND METHODS Patients age 65 years or older with early breast cancer were randomly assigned to either standard adjuvant chemotherapy (physician's choice of either cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide and doxorubicin) or capecitabine. An adaptive Bayesian design was used to determine sample size and test noninferiority of capecitabine. The primary end point was RFS. RESULTS The design stopped accrual with 633 patients at its first sample size assessment. RFS remains significantly longer for patients treated with standard chemotherapy. At 10 years, in patients treated with standard chemotherapy versus capecitabine, the RFS rates were 56% and 50%, respectively (hazard ratio [HR], 0.80; P = .03); breast cancer-specific survival rates were 88% and 82%, respectively (HR, 0.62; P = .03); and overall survival rates were 62% and 56%, respectively (HR, 0.84; P = .16). With longer follow-up, standard chemotherapy remains superior to capecitabine among hormone receptor-negative patients (HR, 0.66; P = .02), but not among hormone receptor-positive patients (HR, 0.89; P = .43). Overall, 43.9% of patients have died (13.1% from breast cancer, 16.4% from causes other than breast cancer, and 14.1% from unknown causes). Second nonbreast cancers occurred in 14.1% of patients. CONCLUSION With longer follow-up, RFS remains superior for standard adjuvant chemotherapy versus capecitabine, especially in patients with hormone receptor-negative disease. Competing risks in this older population dilute overall survival benefits.
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Affiliation(s)
- Hyman B Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | - Donald A Berry
- Alliance Statistics and Data Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heshan Liu
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | | | | | - Ann M Mauer
- Advocate Illinois Masonic Medical Center, Chicago, IL
| | | | | | - Lynn G Dressler
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | - Antonio C Wolff
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Julie R Gralow
- University of Washington Seattle Cancer Alliance, Seattle, WA
| | | | | | | | | | - Barbara A Parker
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | | | | | - Arti Hurria
- City of Hope Comprehensive Cancer Center, Duarte, CA.,Deceased
| | | | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Lisa Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Fatal events during clinical trials: an evaluation of deaths during breast cancer studies. Breast Cancer 2019; 26:826-834. [PMID: 31254201 DOI: 10.1007/s12282-019-00990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Information on deaths occurring during oncological clinical trials has never been systematically assessed. Here, we examine the incidence of death and the profile of patients who died during randomized clinical breast cancer (BC) trials. METHODS Information on fatal events during German Breast Group (GBG) led BC trials was prospectively captured. Data were derived from the trial databases and death narratives. All deaths were evaluated for possible causes, underlying conditions, treatment relatedness, time point and rate of autopsies. RESULTS From 12/1996 to 01/2017, 23,387 patients were treated within 32 trials. Of those 88 (0.4%) died on therapy within 17 trials. Median age was 64 [range 35-84] years, 63.2% of patients had a body mass index (BMI) ≥ 25 kg/m2; 65.9% 1-3 and 22.7% ≥ 4 comorbidities; 61.4% 1-2 cardiovascular risk factors (CRFs); 26.4% took > 3 drugs; 81.7% had ECOG 0; 50.0% stage III, 76.7% luminal BC. The main causes of death were infection (38.6%; of those, 82.3% sepsis, 17.6% pneumonia), heart failure (14.8%), and pulmonary embolism (13.6%). Fatal events mainly occurred within the first 4 therapy cycles (55.7%), in the investigational arm (66.7%) and under anthracycline-taxane-based chemotherapy (51.1%). A relationship with the treatment was declared in 27.3% of the cases. An autopsy was performed in 13.6% of patients. CONCLUSIONS Death during study treatment was mainly related to infections, and patients with advanced disease, high BMI, underlying comorbidities, CRFs and concomitant medications. If considered for study participation these patients need careful monitoring due to their higher risk for death on study.
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19
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Leinert E, Schwentner L, Blettner M, Wöckel A, Felberbaum R, Flock F, Kühn T, Denkinger MD, Janni W, Kreienberg R, Singer S. Association between cognitive impairment and guideline adherence for application of chemotherapy in older patients with breast cancer: Results from the prospective multicenter BRENDA II study. Breast J 2019; 25:386-392. [PMID: 30945393 DOI: 10.1111/tbj.13231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 06/03/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study examined the association between cognitive impairment and guideline adherence for application of chemotherapy in older patients with breast cancer. PATIENTS AND METHODS In the prospective multicenter cohort study BRENDA II, patients aged ≥65 years with primary breast cancer were sampled over a period of 4 years (2009-2012). A multiprofessional team (tumor board) discussed recommendation for adjuvant chemotherapy according to the German S3 guideline. Cognitive impairment was screened by the clock-drawing test (CDT) prior to adjuvant treatment. RESULTS Two hundred and sixty-three patients were included in the study and CDT data were available for 193 patients. Thirty-one percent of the patients had cognitive impairment with different degree of severity. In high-risk patients (n = 61) tumor board recommendation in favor of chemotherapy was 90% and in intermediate-risk patients (n = 170) 27%. Not receiving recommendation for chemotherapy in spite of guideline recommendation was more frequent in patients with cognitive impairment (67%) vs patients without cognitive impairment (46%) with P = 0.02 (OR 2.4, 95% confidence interval (CI) 1.2-4.9). Age, education, migration background and comorbidities were not associated with chemotherapy recommendation by the tumor board among cognitively impaired patients. Once the tumor board had recommended chemotherapy, application of chemotherapy was similar in both groups of patients with or without cognitive impairment. CONCLUSION Almost one third of older patients with breast cancer are affected by cognitive impairment prior to adjuvant treatment. In these patients, cognitive impairment was associated with tumor board decision against chemotherapy in spite of a positive guideline recommendation.
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Affiliation(s)
- Elena Leinert
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Lukas Schwentner
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Achim Wöckel
- Department of Gynecology and Obstetrics, University of Würzburg, Würzburg, Germany
| | - Ricardo Felberbaum
- Department of Gynecology and Obstetrics, Hospital Kempten, Kempten, Germany
| | - Felix Flock
- Department of Gynecology and Obstetrics, Hospital Memmingen, Memmingen, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Hospital Esslingen, Esslingen, Germany
| | - Michael Dieter Denkinger
- Geriatric Research Unit, Agaplesion Bethesda Hospital, Ulm University and Geriatric Center Ulm, Ulm, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Rolf Kreienberg
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Susanne Singer
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
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van Abbema DL, van den Akker M, Janssen-Heijnen ML, van den Berkmortel F, Hoeben A, de Vos-Geelen J, Buntinx F, Kleijnen J, Tjan-Heijnen VC. Patient- and tumor-related predictors of chemotherapy intolerance in older patients with cancer: A systematic review. J Geriatr Oncol 2019; 10:31-41. [DOI: 10.1016/j.jgo.2018.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/22/2018] [Accepted: 04/03/2018] [Indexed: 12/19/2022]
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Ding W, Li Z, Wang C, Dai J, Ruan G, Tu C. Anthracycline versus nonanthracycline adjuvant therapy for early breast cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12908. [PMID: 30335021 PMCID: PMC6211907 DOI: 10.1097/md.0000000000012908] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE The clinical benefits provided by using anthracycline-contained regimens in patients with early breast cancer (EBC) remain uncertain. This meta-analysis used data from all relevant trials to compare treatment outcomes for patients with EBC receiving adjuvant chemotherapy with non-anthracycline-contained regimens or anthracycline-contained regimens. PATIENTS AND METHODS Individual patient data were collected on 7 randomized trials comparing non-anthracycline-contained regimens with anthracycline-contained regimens, a total of 14,451 women were analyzed. The hazard ratios (HR) of disease-free survival (DFS) and overall survival (OS), and the risk ratios for grades 3 to 4 toxicities were extracted from the retrieved studies and analyzed using various statistical methods. A pooled analysis was accomplished and HR with 95% confidence intervals (95% CIs) was derived. The significant differences in DFS and OS were explored. A heterogeneity test was applied as well. RESULTS Among 7 eligible trials, significant differences in favor of anthracycline-contained regimens were seen in DFS (HR: 0.86; 95% CI: 0.78-0.95; P = .003) and in OS (HR: 0.85; 95% CI: 0.75-0.97; P = .01). Subgroup analyses of DFS showed similar treatment effects by hormone-receptor status and nodal status, but differential effects by human epidermal growth factor receptor 2 status, menopausal status, and malignancy grade. Sensitive analysis showed that the DFS of taxanes and cyclophosphamide (TC) was noninferior to anthracycline-contained regiments. CONCLUSION Despite failing to show noninferior to the anthracycline-contained regimens in patients with EBC, it provides evidence that both regimens significantly improved the DFS and OS, and TC regimen may be noninferior to anthracycline-contained regimens.
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Affiliation(s)
- Wu Ding
- Department of Oncological Surgery
| | - Zhian Li
- Department of Oncological Surgery
| | - Caiyun Wang
- Department of Nephrology, Shaoxing Second Hospital
| | | | | | - Chuanjian Tu
- Department of Oncological Surgery
- Department of surgery, Shaoxing Keqiao Women and Children's Hospital, Shaoxing, China
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22
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Pharmacotherapeutic Management of Breast Cancer in Elderly Patients: The Promise of Novel Agents. Drugs Aging 2018; 35:93-115. [PMID: 29388072 DOI: 10.1007/s40266-018-0519-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
As its incidence increases with age, breast cancer in elderly patients takes on a growing importance in clinical oncology practice. Management decisions are challenging because there is a lack of high-quality evidence in this heterogeneous population. Epidemiological studies have shown that breast cancer mortality does not decrease substantially in the older population compared with younger adults. Recent data suggest a phenotype somewhat different from that of younger patients, also confirmed at the molecular level. Breast cancer biology has been incompletely deciphered in this age group. New therapeutic agents continue to expand the available treatment options at every stage, and for each subtype of breast cancer. In the estrogen receptor-positive subtype, agents to overcome endocrine resistance have been introduced; CDK 4/6 and mTOR inhibitors have already been approved in this setting. In addition, more potent agents targeting the HER2 pathway are actively being trialed. Besides trastuzumab, pertuzumab, or lapatinib, new agents like neratinib or PI3K inhibitors are currently being tested in clinical trials. Finally, even though chemotherapy remains the cornerstone of the treatment of triple negative tumors, alternative promising approaches such as immunotherapy, notably antibodies against PD-1/PD-L1 or targeted therapies (PARP or androgen inhibitors), are currently being investigated in this specific subtype.
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23
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MESH Headings
- Aftercare
- Antineoplastic Agents, Hormonal/adverse effects
- Antineoplastic Agents, Hormonal/therapeutic use
- Aromatase Inhibitors/therapeutic use
- Breast Neoplasms, Male/diagnosis
- Breast Neoplasms, Male/drug therapy
- Breast Neoplasms, Male/genetics
- Breast Neoplasms, Male/surgery
- Chemotherapy, Adjuvant
- Diagnosis, Differential
- Genes, BRCA1
- Genes, BRCA2
- Humans
- Male
- Mutation
- Prognosis
- Risk Factors
- Tamoxifen/adverse effects
- Tamoxifen/therapeutic use
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Affiliation(s)
- Sharon H Giordano
- From the Departments of Health Services Research and Breast Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston
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24
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Individualizing Local-Regional Therapy of Breast Cancer in the Elderly. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Exman P, Burstein HJ. How Old is Too Old? Breast Cancer Treatment in Octogenarians. Ann Surg Oncol 2018; 25:1458-1460. [DOI: 10.1245/s10434-018-6457-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 11/18/2022]
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Mamtani A, Gonzalez JJ, Neo DT, Friedman RS, Recht A, Hacker MR, Sharma R. Treatment Strategies in Octogenarians with Early-Stage, High-Risk Breast Cancer. Ann Surg Oncol 2018; 25:1495-1501. [PMID: 29427213 DOI: 10.1245/s10434-018-6350-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Octogenarians with early-stage breast cancer often have low-risk tumor biology. However, optimal treatment strategies for those with high-risk biology remain unclear. METHODS We reviewed the records of women ages 80-89 years with biopsy-proven, Stage I-II invasive breast cancer who were referred for surgical evaluation from January 2001 through December 2010. High-risk was defined as human epidermal growth factor receptor-positive (HER2+), triple-negative (TN), or histologic grade 3 disease. RESULTS Among 178 patients, 40 (22%) were high-risk: 12 were grade 1-2 (10 HER2 + , 2 TN); 28 were grade 3 (7 HER2+, 6 TN, 15 estrogen receptor-positive (ER+)/HER2-). The high-risk group had larger tumors and more often had ductal histology and lymphovascular invasion than the low-risk group and was more likely to undergo mastectomy (18 vs. 5%, p = 0.02), radiotherapy (55 vs. 36%, p = 0.03), and chemotherapy (10 vs. 0%, p = 0.002). Endocrine therapy use was similar among ER+ patients in both groups. The four patients in the high-risk group given chemotherapy were HER2+ and received trastuzumab-based regimens, without any reported toxicities. At median follow-up of 67 months, 10% of the high-risk group had a recurrence (3 distant-only, 1 simultaneous locoregional and distant in a patient treated with mastectomy without radiotherapy). CONCLUSIONS Tailored locoregional and systemic therapy resulted in low incidence of failure in these octogenarians with high-risk cancers with low morbidity. Modern adjuvant therapies should be considered for elderly women with high-risk cancers in the absence of significant comorbidities.
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Affiliation(s)
- Anita Mamtani
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Julie J Gonzalez
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dayna T Neo
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robb S Friedman
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ranjna Sharma
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Joensuu H, Kellokumpu-Lehtinen PL, Huovinen R, Jukkola-Vuorinen A, Tanner M, Kokko R, Ahlgren J, Auvinen P, Lahdenperä O, Kosonen S, Villman K, Nyandoto P, Nilsson G, Poikonen-Saksela P, Kataja V, Junnila J, Bono P, Lindman H. Adjuvant Capecitabine in Combination With Docetaxel, Epirubicin, and Cyclophosphamide for Early Breast Cancer: The Randomized Clinical FinXX Trial. JAMA Oncol 2017; 3:793-800. [PMID: 28253390 DOI: 10.1001/jamaoncol.2016.6120] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Capecitabine is not considered a standard agent in the adjuvant treatment of early breast cancer. The results of this study suggest that addition of adjuvant capecitabine to a regimen that contains docetaxel, epirubicin, and cyclophosphamide improves survival outcomes of patients with triple-negative breast cancer (TNBC). Objective To investigate the effect of capecitabine on long-term survival outcomes of patients with early breast cancer, particularly in subgroups defined by cancer estrogen receptor (ER) and progesterone receptor (PR) content, and HER2 content (human epidermal growth factor receptor 2). Design, Setting, and Participants This is an exploratory analysis of the multicenter FinXX randomized clinical trial that accrued 1500 women in Finland and Sweden between January 27, 2004, and May 29, 2007. About half received 3 cycles of docetaxel followed by 3 cycles of cyclophosphamide, epirubicin, and fluorouracil (T+CEF), while the other half received 3 cycles of docetaxel plus capecitabine followed by 3 cycles of cyclophosphamide, epirubicin, and capecitabine (TX+CEX). Data analysis took place between January 27, 2004, and December 31, 2015. Main Outcomes and Measures Recurrence-free survival (RFS). Results Following random allocation, 747 women received T+CEF, and 753 women received TX+CEX. Five patients were excluded from the intention-to-treat population (3 had overt distant metastases at the time of randomization; 2 withdrew consent). The median age of the remaining 1495 patients was 53 years at the time of study entry; 157 (11%) had axillary node-negative disease; 1142 (76%) had ER-positive cancer; and 282 (19%) had HER2-positive cancer. The median follow-up time after random allocation was 10.3 years. There was no significant difference in RFS or overall survival between the groups (hazard ratio [HR], 0.88; 95% CI, 0.71-1.08; P = .23; and HR, 0.84, 95% CI, 0.66-1.07; P = .15; respectively). Breast cancer-specific survival tended to favor the capecitabine group (HR, 0.79; 95% CI, 0.60-1.04; P = .10). When RFS and survival of the patients were compared within the subgroups defined by cancer steroid hormone receptor status (ER and/or PR positive vs ER and PR negative) and HER2 status (positive vs negative), TX+CEX was more effective than T+CEF in the subset of patients with TNBC (HR, 0.53; 95% CI, 0.31-0.92; P = .02; and HR, 0.55, 95% CI, 0.31-0.96; P = .03; respectively). Conclusions and Relevance Capecitabine administration with docetaxel, epirubicin, and cyclophosphamide did not prolong RFS or survival compared with a regimen that contained only standard agents. Patients with TNBC had favorable survival outcomes when treated with the capecitabine-containing regimen in an exploratory subgroup analysis. Trial Registration clinicaltrials.gov Identifier: NCT00114816.
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Affiliation(s)
- Heikki Joensuu
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Riikka Huovinen
- Department of Oncology, Turku University Central Hospital, Turku, Finland
| | | | - Minna Tanner
- Department of Oncology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Riitta Kokko
- Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | | | - Päivi Auvinen
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Outi Lahdenperä
- Department of Oncology, Turku University Central Hospital, Turku, Finland
| | | | | | | | | | - Paula Poikonen-Saksela
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vesa Kataja
- Cancer Center, Kuopio University Hospital, Kuopio, Finland12Vaasa Central Hospital, Vaasa, Finland
| | | | - Petri Bono
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Influence of comorbidity on chemotherapy use for early breast cancer: systematic review and meta-analysis. Breast Cancer Res Treat 2017; 165:17-39. [DOI: 10.1007/s10549-017-4295-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 05/13/2017] [Indexed: 10/19/2022]
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Natori A, Ethier JL, Amir E, Cescon DW. Capecitabine in early breast cancer: A meta-analysis of randomised controlled trials. Eur J Cancer 2017; 77:40-47. [PMID: 28355581 DOI: 10.1016/j.ejca.2017.02.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 12/07/2016] [Accepted: 02/20/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Capecitabine is an effective therapy for metastatic breast cancer. Its role in early breast cancer is uncertain due to conflicting data from randomised controlled trials (RCTs). METHODS PubMed and major conference proceedings were searched to identify RCTs comparing standard chemotherapy with or without capecitabine in the neoadjuvant or adjuvant setting. Hazard ratios (HRs) for disease-free survival (DFS) and overall survival (OS), as well as odds ratios (ORs) for toxicities were extracted or calculated and pooled in a meta-analysis. Subgroup analysis compared triple-negative breast cancer (TNBC) to non-TNBC and whether capecitabine was given in addition to or in place of standard chemotherapy. Meta-regression was used to explore the influence of TNBC on OS. RESULTS Eight studies comprising 9302 patients were included. In unselected patients, capecitabine did not influence DFS (hazard ratio [HR] 0.99, p = 0.93) or OS (HR 0.90, p = 0.36). There was a significant difference in DFS when capecitabine was given in addition to standard treatment compared with in place of standard treatment (HR 0.92 versus 1.62, interaction p = 0.002). Addition of capecitabine to standard chemotherapy was associated with significantly improved DFS in TNBC versus non-TNBC (HR 0.72 versus 1.01, interaction p = 0.02). Meta-regression showed that adding capecitabine to standard chemotherapy was associated with improved OS in studies with higher proportions of patients with TNBC (R = -0.967, p = 0.007). Capecitabine increased grade 3/4 diarrhoea (odds ratio [OR] 2.33, p < 0.001) and hand-foot syndrome (OR 8.08, p < 0.001), and resulted in more frequent treatment discontinuation (OR 3.80, p < 0.001). CONCLUSION Adding capecitabine to standard chemotherapy appears to improve DFS and OS in TNBC, but increases adverse events in keeping with its known toxicity profile.
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Affiliation(s)
- Akina Natori
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada; Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, 200 Elizabeth Street, Suite RFE3-805, Toronto, Ontario, M5G 2C4, Canada.
| | - Josee-Lyne Ethier
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada; Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, 200 Elizabeth Street, Suite RFE3-805, Toronto, Ontario, M5G 2C4, Canada.
| | - Eitan Amir
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada; Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, 200 Elizabeth Street, Suite RFE3-805, Toronto, Ontario, M5G 2C4, Canada.
| | - David W Cescon
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada; Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, 200 Elizabeth Street, Suite RFE3-805, Toronto, Ontario, M5G 2C4, Canada.
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Chen G, Guo Z, Liu M, Yao G, Dong J, Guo J, Ye C. Clinical Value of Capecitabine-Based Combination Adjuvant Chemotherapy in Early Breast Cancer: A Meta-Analysis of Randomized Controlled Trials. Oncol Res 2017; 25:1567-1578. [PMID: 28337954 PMCID: PMC7841120 DOI: 10.3727/096504017x14897173032733] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Capecitabine has consistently demonstrated high efficacy and acceptable tolerability in salvage chemotherapy for advanced breast cancer. However, there remains no consensus on its role in adjuvant chemotherapy for early breast cancer (EBC). To estimate the value of capecitabine-based combination adjuvant treatment in EBC, eight randomized controlled trials with 14,072 participants were analyzed. The efficacy and safety outcomes included disease-free survival (DFS), overall survival (OS), relapse, breast cancer-specific survival (BCSS), and grades 3-5 adverse events. Capecitabine-based combination adjuvant chemotherapy demonstrated a 16% increase in BCSS (HR = 0.84, 95% CI = 0.71-0.98, p = 0.03) in the overall analysis and a 22% improvement in DFS (HR = 0.78, 95% CI = 0.64-0.96, p = 0.02) in the hormone receptor-negative (HR-) subgroup. However, there were no significant differences in DFS (HR = 0.96, 95% CI = 0.89-1.05, p = 0.38), OS (HR = 0.91, 95% CI = 0.82-1.00, p = 0.06), or relapse between capecitabine-based and capecitabine-free combination adjuvant chemotherapy. Analogous results were observed in the subgroup analyses of HR+, HER2-, HER2+, and triple-negative EBC. Regarding safety, reduced myelosuppression and hand-foot syndrome development were observed in capecitabine-treated patients. Capecitabine-based combination adjuvant chemotherapy might provide some BCSS benefit compared with capecitabine-free regimens in EBC, but the absolute survival gain is small, and the survival benefit appears to be restricted to patients with HR- EBC, which may indicate a target population for capecitabine-based combination adjuvant chemotherapy.
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Brufsky A. nab-Paclitaxel for the treatment of breast cancer: an update across treatment settings. Exp Hematol Oncol 2017; 6:7. [PMID: 28344858 PMCID: PMC5361712 DOI: 10.1186/s40164-017-0066-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/02/2017] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The purpose of this systematic review is to discuss recent studies and ongoing trials of nab-paclitaxel in breast cancer and to examine the potential role of nab-paclitaxel as a backbone for immuno-oncology therapies. METHODS PubMed and selected congress proceedings were searched for studies of nab-paclitaxel in breast cancer published between 2013 and 2015. All phase II and III clinical trials, retrospective analyses, and institutional studies were included. Active, ongoing, phase II or III trials on nab-paclitaxel that were listed on ClinicalTrials.gov were also included. RESULTS Sixty-three studies, including 23 in early-stage and 30 in metastatic breast cancer (some studies not classifiable by setting), were included in this analysis. Trials of neoadjuvant nab-paclitaxel-containing regimens have reported pathological complete response rates ranging from 5.7 to 53%. Median overall survival in metastatic breast cancer studies ranged from 10.8 to 23.5 months, depending on dose and regimen. Adverse event profiles of nab-paclitaxel were generally similar to those reported from previous studies. Several ongoing trials are evaluating nab-paclitaxel in the early-stage and metastatic settings, including in combination with immuno-oncology agents. CONCLUSIONS nab-Paclitaxel continues to demonstrate promising efficacy in breast cancer. Recent studies demonstrate high pathological complete response rates in early-stage breast cancer, particularly in triple-negative breast cancer, an area of high unmet need, and encouraging overall survival in metastatic breast cancer across doses and schedules. Ongoing trials will provide further insights into the role of nab-paclitaxel in breast cancer including use as a potential backbone chemotherapy agent for immuno-oncology therapies such as checkpoint inhibitors.
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Affiliation(s)
- Adam Brufsky
- Division of Hematology/Oncology, University of Pittsburgh, 300 Halket Street, Suite 4628, Pittsburgh, PA 15213 USA
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Bachet JB, Hammel P, Desramé J, Meurisse A, Chibaudel B, André T, Debourdeau P, Dauba J, Lecomte T, Seitz JF, Tournigand C, Aparicio T, Meyer VG, Taieb J, Volet J, Monier A, Bonnetain F, Louvet C. Nab-paclitaxel plus either gemcitabine or simplified leucovorin and fluorouracil as first-line therapy for metastatic pancreatic adenocarcinoma (AFUGEM GERCOR): a non-comparative, multicentre, open-label, randomised phase 2 trial. Lancet Gastroenterol Hepatol 2017; 2:337-346. [PMID: 28397697 DOI: 10.1016/s2468-1253(17)30046-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nab-paclitaxel plus gemcitabine has become a standard treatment regimen in patients with metastatic pancreatic adenocarcinoma; however, retrospective data suggest that gemcitabine might be inefficient in 50-60% of patients and thus not an optimum regimen in combination with nab-paclitaxel. We did a phase 2 trial to assess the activity and safety of a new regimen of nab-paclitaxel plus simplified leucovorin and fluorouracil. METHODS We did a non-comparative, multicentre, open-label, randomised phase 2 trial in 15 hospitals and institutions in France. Eligible participants were previously untreated patients with metastatic pancreatic adenocarcinoma (previous adjuvant chemotherapy after curative intent resection was allowed if the interval between the end of chemotherapy and relapse was more than 12 months). Patients had to have at least one measurable lesion assessed by CT scan or MRI and an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less. We randomly assigned participants (1:2) centrally to 28-day cycles of either gemcitabine plus nab-paclitaxel or simplified leucovorin and fluorouracil plus nab-paclitaxel. The randomisation was by minimisation, stratified by centre and ECOG performance status. Drugs were administered in each cycle as follows: nab-paclitaxel (125 mg/m2) and gemcitabine (1000 mg/m2) as 30-min intravenous infusions on days 1, 8, and 15; leucovorin (400 mg/m2) as a 120-min intravenous infusion on days 1 and 15; and fluorouracil (400 mg/m2) as a 5-min bolus intravenous infusion followed by a 46-h continuous intravenous infusion of 2400 mg/m2 on days 1 and 15. Patients continued treatment until unacceptable toxicity, disease progression, or patient withdrawal. The primary endpoint was progression-free survival at 4 months in the first 72 assessable patients in the leucovorin and fluorouracil group, with a target of 50% for the regimen to be deemed sufficiently active to warrant further study. We did the primary analysis on the modified intention-to-treat (ITT) population, defined as all randomly assigned and assessable patients regardless of their eligibility and received treatments. This trial is registered at ClinicalTrials.gov, number NCT01964534. The trial has ended and we report the final analysis here. FINDINGS Between Dec 12, 2013, and Oct 31, 2014, we randomly assigned 114 patients to treatment: 75 patients to the leucovorin and fluorouracil group and 39 to the gemcitabine group. One patient in the leucovorin and fluorouracil group did not have a 4-month assessment, and was thus excluded from the modified ITT analysis. Median follow-up was 13·1 months (95% CI 12·5-14·1). At 4 months, 40 (56%, 90% CI 45-66) of 72 patients in the leucovorin and fluorouracil group were alive and free from disease progression (21 [54%, 40-68] of 39 patients in the gemcitabine group were also alive and progression-free at 4 months). Grade 3-4 adverse events occurred in 33 (87%) of 38 patients in the gemcitabine group and in 56 (77%) of 73 patients in the leucovorin and fluorouracil group, with different toxicity profiles. The most common grade 3-4 adverse events in the leucovorin and fluorouracil group were neutropenia without fever (17 [23%]), fatigue (16 [22%]), paraesthesia (14 [19%]), diarrhoea (nine [12%]), and mucositis (seven [10%]); in the gemcitabine group they were neutropenia without fever (12 [32%]), thrombocytopenia (seven [18%]), fatigue (eight [21%]), anaemia (five [13%]), increased alanine aminotransferase and aspartate aminotransferase concentrations (five [13%] for both), and paraesthesia (four [11%]). Two participants died; one in the leucovorin and fluorouracil group from septic shock, and one in the gemcitabine group from diabetes compensation with acidosis; these deaths were deemed to be not related to treatment. Treatment-related serious adverse events occurred in 28 (38%) of 73 patients in the leucovorin and fluorouracil group and in 14 (37%) of 38 in the gemcitabine group. INTERPRETATION Nab-paclitaxel plus simplified leucovorin and fluorouracil fulfilled the primary endpoint in that more than the required 50% of our study population were progression-free at 4 months, with a tolerable toxicity profile. This regimen thus deserves further assessment in a phase 3 trial. FUNDING GERCOR (Groupe Coopérateur Multidisciplinaire en Oncologie) and Celgene through grants to GERCOR.
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Affiliation(s)
- Jean-Baptiste Bachet
- Sorbonne Universités, UPMC Univ Paris 06, Paris, France; Department of Hepato-Gastroenterology, Groupe hospitalier Pitié Salpêtrière, Paris, France.
| | - Pascal Hammel
- Department of Digestive Oncology, Hôpital Beaujon, Paris, France
| | - Jérôme Desramé
- Department of Hepato-Gastroenterology, Hôpital Privé Jean Mermoz, Lyon, France
| | - Aurélia Meurisse
- Department of Methodology and Quality of Life in Oncology, INSERM UMR 1098, Hôpital Universitaire de Besancon, Paris, France
| | - Benoist Chibaudel
- Department of Oncology, Institut Franco-Britannique, Levallois-Perret, Paris, France
| | - Thierry André
- Department of Oncology, Hôpital Saint Antoine, Paris, France
| | | | - Jérome Dauba
- Department of Oncology, Hôpital Layne Mont de Marsan, Mont de Marsan, France
| | - Thierry Lecomte
- Department of Hepato-Gastroenterology, Hôpital Trousseau, Tours, France
| | | | | | - Thomas Aparicio
- Department of Hepato-Gastroenterology, CHU Avicenne, Bobigny, France
| | | | - Julien Taieb
- Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France
| | - Julien Volet
- Department of Hepato-Gastroenterology, CHU Robert Debré, Reims, France
| | - Amandine Monier
- GERCOR (Groupe Coopérateur Multidisciplinaire en Oncologie), Paris, France
| | - Franck Bonnetain
- Department of Methodology and Quality of Life in Oncology, INSERM UMR 1098, Hôpital Universitaire de Besancon, Paris, France
| | - Christophe Louvet
- Department of Oncology, Institut Mutualiste Montsouris, Paris, France
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Sun J, Chia S. Adjuvant chemotherapy and HER-2-directed therapy for early-stage breast cancer in the elderly. Br J Cancer 2016; 116:4-9. [PMID: 27875517 PMCID: PMC5220141 DOI: 10.1038/bjc.2016.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 02/01/2023] Open
Abstract
There is a lack of sufficient evidence-based data defining the optimal adjuvant systemic therapies in older women. Recommendations are mainly based on retrospective studies, subgroup analyses within larger randomised trials and expert opinion. Treatment decisions should consider the functional fitness of the patient, co-morbidities, in addition to chronological age with the aim to balance risks and potential benefits from treatment(s). In this review, we discuss assessment tools to aid clinicians to select elderly patients who are ‘fit' for chemotherapy, and review the literature on the use of chemotherapy and of the anti-HER 2 antibody trastuzumab in this population. We will also review two commonly used prediction models to assess their accuracy in predicting survival outcomes in elderly patients. Ongoing clinical trials specifically focusing on older patients may help to clarify the absolute benefits and risks of adjuvant systemic therapy in this age group.
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Affiliation(s)
- J Sun
- Department of Medical Oncology, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
| | - S Chia
- Department of Medical Oncology, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6, Canada
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Leinert E, Singer S, Janni W, Harbeck N, Weissenbacher T, Rack B, Augustin D, Wischnik A, Kiechle M, Ettl J, Fink V, Schwentner L, Eichler M. The Impact of Age on Quality of Life in Breast Cancer Patients Receiving Adjuvant Chemotherapy: A Comparative Analysis From the Prospective Multicenter Randomized ADEBAR trial. Clin Breast Cancer 2016; 17:100-106. [PMID: 27884722 DOI: 10.1016/j.clbc.2016.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/13/2016] [Accepted: 10/12/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Elderly breast cancer patients are affected by poorer quality of life (QoL) compared to younger patients. Because QoL has a relevant impact on guideline-adherent treatment, elderly breast cancer patients are often undertreated, especially with regard to adjuvant chemotherapy, and overall survival is decreased. Thus, understanding the impact of chemotherapy on QoL in elderly patients is crucial. This study compared QoL in patients aged < 65 years and 65 to 70 years receiving adjuvant chemotherapy as a secondary outcome in the prospective randomized multicenter ADEBAR trial. PATIENTS AND METHODS Patients with lymph node-positive breast cancer were prospectively randomized for either sequential anthracycline-taxane or epirubicin/fluorouracil/cyclophosphamid chemotherapy (FEC) therapy. QoL was assessed at baseline (t1), before cycle 4 FEC, and cycle 5 epirubicin/cyclophosphamid-docetaxel (EC-DOC) (t2), 4 weeks after chemotherapy (t3), and 6 weeks after radiation (t4) using the European Organization for Research and Treatment for Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) and the Breast Cancer-Specific Module (QLQ-BR23). We compared patients aged < 65 years and 65 to 70 years with respect to QoL and discontinuation of chemotherapy. RESULTS A total of 1363 patients were enrolled onto the ADEBAR trial, with 16.7% of the patients aged 65 to 70 years. In elderly patients, Eastern Cooperative Oncology Group performance status was higher and global health status and physical functioning were lower at baseline. Global health status decreased between t1 and t3 by 7 points in patients < 65 years and by 11 points in patients 65 to 70 years, and physical functioning decreased in the same period by 13.4 points in patients aged < 65 years and by 15.9 points in patients 65 to 70 years. In both groups, at t4 global health status exceeded baseline by 6 points, and physical functioning was 1.3 points under baseline in patients < 65 years old and 3 points under baseline in patients 65 to 70 years. There was a trend to more fatigue in elderly patients and to more nausea and vomiting while receiving chemotherapy in younger patients at t3. There was a higher dropout rate in patients aged 65 to 70 years (25.7%) than in patients aged < 65 years (16.2%). CONCLUSION There were only small or trivial differences in QoL in patients aged < 65 years versus 65 to 70 years who were receiving adjuvant chemotherapy, although the dropout rate from chemotherapy was notably higher in elderly breast cancer patients.
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Affiliation(s)
- Elena Leinert
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany.
| | - Susanne Singer
- Insitute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre Mainz, Mainz, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Nadia Harbeck
- Breast Cancer Center, University of Munich, Munich, Germany
| | - Tobias Weissenbacher
- Department of Gynecology and Obstetrics, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Brigitte Rack
- Department of Gynecology and Obstetrics, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Doris Augustin
- Breast Center of Eastern Bavaria, DONAUISAR Hospital, Deggendorf, Germany
| | | | - Marion Kiechle
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Johannes Ettl
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Visnja Fink
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Lukas Schwentner
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | - Martin Eichler
- Insitute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre Mainz, Mainz, Germany
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Jerzak KJ, Desautels DN, Pritchard KI. An update on adjuvant systemic therapy for elderly patients with early breast cancer. Expert Opin Pharmacother 2016; 17:1881-8. [PMID: 27539883 DOI: 10.1080/14656566.2016.1219339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Elderly women with early breast cancer require an individualized approach to risk assessment and treatment. Unfortunately, there are limited data to inform optimal adjuvant therapy decisions in this population. Cytotoxic chemotherapy, biologic treatments and endocrine agents, while important in reducing breast cancer recurrence and mortality, are associated with the potential for adverse effects that may be of particular significance to elderly patients. AREAS COVERED In this review, we summarize the evidence for geriatric assessment in elderly patients with early breast cancer, outline special considerations for the use of chemotherapy and trastuzumab in older adults, and describe the age-specific risks of endocrine therapy in the adjuvant breast cancer setting. EXPERT OPINION The treatment of elderly women with early breast cancer should take into account cancer risk, life expectancy, comorbidities, functional status, physiologic changes, and patient values. Formal geriatric assessment may better inform treatment recommendations for individual patients. In general, there is no strong evidence to suggest that older women benefit less from standard adjuvant therapies than do their younger counterparts. When choosing between endocrine therapies, the differential risks associated with each agent should be considered and particular attention to the fracture risk on aromatase inhibitors (AIs) is warranted. Enrolment of women over 70 years of age into breast cancer clinical trials should be encouraged to better inform treatment guidelines.
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Leone J, Leone BA, Leone JP. Adjuvant systemic therapy in older women with breast cancer. BREAST CANCER-TARGETS AND THERAPY 2016; 8:141-7. [PMID: 27524919 PMCID: PMC4966695 DOI: 10.2147/bctt.s110765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Breast cancer in the elderly is an increasing clinical problem. In addition, ~60% of deaths from breast cancer occur in women aged 65 years and older. Despite this, older women with breast cancer have been underrepresented in clinical trials, and this has led to less than optimal evidence to guide their therapy. The management of elderly women with early breast cancer is a complex process that requires careful evaluation of life expectancy, comorbidities, patient values, and risks and benefits of available treatment options. This review will focus on current adjuvant systemic therapy options for older women with breast cancer, discuss the principles in the decision-making process, and define the role of endocrine therapy, chemotherapy, and targeted agents.
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Affiliation(s)
- Julieta Leone
- Department of Medical Oncology, Grupo Oncológico Cooperativo del Sur (GOCS), Neuquén, Argentina
| | - Bernardo Amadeo Leone
- Department of Medical Oncology, Grupo Oncológico Cooperativo del Sur (GOCS), Neuquén, Argentina
| | - José Pablo Leone
- Department of Internal Medicine, Division of Hematology-Oncology and Blood & Marrow Transplantation, University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA
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Pondé N, Dal Lago L, Azim HA. Adjuvant chemotherapy in elderly patients with breast cancer: key challenges. Expert Rev Anticancer Ther 2016; 16:661-71. [PMID: 27010772 DOI: 10.1586/14737140.2016.1170595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Elderly women with early breast cancer (BC) form a heterogeneous and large subgroup (41.8% of women with BC are over 65). Decision making in this subgroup is made more difficult by lack of familiarity with their physical, cognitive and social issues. Adequate management depends on biological factors and accurate clinical evaluation through comprehensive geriatric assessment (CGA). CGA can help to better select and determine potential risks factors for patients who are candidates for adjuvant chemotherapy. It is still recently introduced in geriatric oncology and there is a lack of awareness of its importance. Available data on adjuvant chemotherapy for BC is limited but suggests it can be of benefit for well selected patients, though the risk of short and long-term toxicity is significant. Here we provide a discussion of the key practical issues in decision making in the setting of adjuvant chemotherapy for elderly BC patients.
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Affiliation(s)
- Noam Pondé
- a BrEAST Data Centre, Department of Medicine, Institut Jules Bordet , Université Libre de Bruxelles , Brussels , Belgium
| | - Lissandra Dal Lago
- b Medicine Department, Institut Jules Bordet , Université Libre de Bruxelles , Brussels , Belgium
| | - Hatem A Azim
- a BrEAST Data Centre, Department of Medicine, Institut Jules Bordet , Université Libre de Bruxelles , Brussels , Belgium
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Zhang ZC, Xu QN, Lin SL, Li XY. Capecitabine in Combination with Standard (Neo)Adjuvant Regimens in Early Breast Cancer: Survival Outcome from a Meta-Analysis of Randomized Controlled Trials. PLoS One 2016; 11:e0164663. [PMID: 27741288 PMCID: PMC5065157 DOI: 10.1371/journal.pone.0164663] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/28/2016] [Indexed: 02/05/2023] Open
Abstract
Capecitabine has been investigated in early breast cancer in several studies, but it was undefined that whether it could improve survival. To investigate whether the addition of capecitabine affected survival in patients with early breast cancer, a meta-analysis was conducted and overall survival (OS), disease-free survival (DFS), and toxicity were assessed. The PubMed, Embase databases and the Cochrane Central Register of Controlled Trials were searched for studies between January 2006 and April 2016. Hazard ratios (HRs) with their 95% confidence intervals (CIs), or data for calculating HRs with 95% CI were derived. Seven trials with 9097 patients, consisted of 4 adjuvant and 3 neoadjuvant studies, were included in this meta-analysis. Adding capecitabine showed no improvement in DFS (HR = 0.93; 95% CI, 0.85-1.02; P = 0.12), whereas a significant improvement in OS was observed (HR = 0.85; 95% CI, 0.75-0.96; P = 0.008). A sub-analysis of DFS showed that benefit of capecitabine derived from patients with triple negative subtype and with extensive axillary involvement. Safety profiles were consistent with the known side-effects of capecitabine, but more patients discontinued scheduled treatment in the capecitabine group. Combining capecitabine with standard (neo)adjuvant regimens in early breast cancer demonstrated a significantly superior OS, and indicated DFS improvement in some subtypes with high risk of recurrence. Selection of subtypes was a key to identify patients who might gain survival benefit from capecitabine.
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Affiliation(s)
- Ze-Chun Zhang
- Department of Diagnosis and Treatment Center of Breast Diseases, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, Guangdong, China
| | - Qi-Ni Xu
- Department of Respiratory Medical Oncology, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Sui-Ling Lin
- Department of Prevention and Health Care, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xu-Yuan Li
- Department of Medical Oncology, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, Guangdong, China
- * E-mail:
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