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Capitain O, Seegers V, Metges JP, Faroux R, Stampfli C, Ferec M, Budnik TM, Senellart H, Rossi V, Blouin N, Dauvé J, Campone M. Comparison of 4 Screening Methods for Detecting Fluoropyrimidine Toxicity Risk: Identification of the Most Effective, Cost-Efficient Method to Save Lives. Dose Response 2020; 18:1559325820951367. [PMID: 32973417 PMCID: PMC7493257 DOI: 10.1177/1559325820951367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 01/07/2023] Open
Abstract
Background Fluoropyrimidines (FPs) carry around 20% risk of G3-5 toxicity and 0.2-1% risk of death, due to dihydropyrimidine dehydrogenase (DPD) deficiency. Several screening approaches exist for predicting toxicity, however there is ongoing debate over which method is best. This study compares 4 screening approaches. Method 472 patients treated for colorectal, head-and-neck, breast, or pancreatic cancers, who had not been tested pre-treatment for FP toxicity risk, were screened using: DPYD genotyping (G); phenotyping via plasma Uracil (U); phenotyping via plasma-dihydrouracil/uracil ratio (UH2/U); and a Multi-Parametric Method (MPM) using genotype, phenotype, and epigenetic data. Performance was compared, particularly the inability to detect at-risk patients (false negatives). Results False negative rates for detecting G5 toxicity risk were 51.2%, 19.5%, 9.8% and 2.4%, for G, U, UH2/U and MPM, respectively. False negative rates for detecting G4-5 toxicity risk were 59.8%, 36.1%, 21.3% and 4.7%, respectively. MPM demonstrated significantly (p < 0.001) better prediction performance. Conclusion MPM is the most effective method for limiting G4-5 toxicity. Its systematic implementation is cost-effective and significantly improves the risk-benefit ratio of FP-treatment. The use of MPM, rather than G or U testing, would avoid nearly 8,000 FP-related deaths per year globally (500 in France), and spare hundreds of thousands from G4 toxicity.
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Affiliation(s)
| | | | | | - Roger Faroux
- CH Départemental Vendée La Roche sur Yon, France
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Del Re M, Cinieri S, Michelucci A, Salvadori S, Loupakis F, Schirripa M, Cremolini C, Crucitta S, Barbara C, Di Leo A, Latiano TP, Pietrantonio F, Di Donato S, Simi P, Passardi A, De Braud F, Altavilla G, Zamagni C, Bordonaro R, Butera A, Maiello E, Pinto C, Falcone A, Mazzotti V, Morganti R, Danesi R. DPYD*6 plays an important role in fluoropyrimidine toxicity in addition to DPYD*2A and c.2846A>T: a comprehensive analysis in 1254 patients. THE PHARMACOGENOMICS JOURNAL 2019; 19:556-563. [PMID: 30723313 PMCID: PMC6867961 DOI: 10.1038/s41397-019-0077-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/30/2018] [Accepted: 12/21/2018] [Indexed: 12/11/2022]
Abstract
Dihydropyrimidine dehydrogenase (DPYD) is a highly polymorphic gene and classic deficient variants (i.e., c.1236G>A/HapB3, c.1679T>G, c.1905+1G>A and c.2846A>T) are characterized by impaired enzyme activity and risk of severe adverse drug reactions (ADRs) in patients treated with fluoropyrimidines. The identification of poor metabolizers by pre-emptive DPYD screening may reduce the rate of ADRs but many patients with wild-type genotype for classic variants may still display ADRs. Therefore, the search for additional DPYD polymorphisms associated with ADRs may improve the safety of treatment with fluoropyrimidines. This study included 1254 patients treated with fluoropyrimidine-containing regimens and divided into cohort 1, which included 982 subjects suffering from gastrointestinal G≥2 and/or hematological G≥3 ADRs, and cohort 2 (control group), which comprised 272 subjects not requiring dose reduction, delay or discontinuation of treatment. Both groups were screened for DPYD variants c.496A>G, c.1236G>A/HapB3, c.1601G>A (DPYD*4), c.1627A>G (DPYD*5), c.1679T>G (DPYD*13), c.1896T>C, c.1905 + 1G>A (DPYD*2A), c.2194G>A (DPYD*6), and c.2846A>T to assess their association with toxicity. Genetic analysis in the two cohorts were done by Real-Time PCR of DNA extracted from 3 ml of whole blood. DPYD c.496A>G, c.1601G>A, c.1627A>G, c.1896T>C, and c.2194G>A variants were found in both cohort 1 and 2, while c.1905+1G>A and c.2846A>T were present only in cohort 1. DPYD c.1679T>G and c.1236G>A/HapB3 were not found. Univariate analysis allowed the selection of c.1905+1G>A, c.2194G>A and c.2846A>T alleles as significantly associated with gastrointestinal and hematological ADRs (p < 0.05), while the c.496A>G variant showed a positive trend of association with neutropenia (p = 0.06). In conclusion, c.2194G>A is associated with clinically-relevant ADRs in addition to the already known c.1905+1G>A and c.2846A>T variants and should be evaluated pre-emptively to reduce the risk of fluoropyrimidine-associated ADRs.
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Affiliation(s)
- Marzia Del Re
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Saverio Cinieri
- Medical Oncology Division and Breast Unit, Civil Hospital, Brindisi, Italy
| | - Angela Michelucci
- Medical Genetics Unit, Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Stefano Salvadori
- Epidemiology and Health Services Research Department, Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Fotios Loupakis
- Medical Oncology Unit, Istituto Oncologico del Veneto IRCCS, Padova, Italy
| | - Marta Schirripa
- Medical Oncology Unit, Istituto Oncologico del Veneto IRCCS, Padova, Italy
| | - Chiara Cremolini
- Medical Oncology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Stefania Crucitta
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | | | - Tiziana Pia Latiano
- Medical Oncology Unit, Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Filippo Pietrantonio
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Paolo Simi
- Medical Genetics Unit, Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Alessandro Passardi
- Medical Oncology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Filippo De Braud
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Giuseppe Altavilla
- Medical Oncology Unit, Department of Human Pathology, University of Messina, Messina, Italy
| | - Claudio Zamagni
- Medical Oncology Unit, Addarii Institute of Oncology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto Bordonaro
- Medical Oncology Unit, Department of Oncology, ARNAS Garibaldi, Catania, Italy
| | - Alfredo Butera
- Medical Oncology Unit, Department of Oncology, Civil Hospital, Agrigento, Italy
| | - Evaristo Maiello
- Medical Oncology Unit, Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | - Alfredo Falcone
- Medical Oncology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Valentina Mazzotti
- Statistics Applied to Clinical Trials Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Riccardo Morganti
- Statistics Applied to Clinical Trials Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Romano Danesi
- Clinical Pharmacology and Pharmacogenetics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
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