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Joy AA, Vos LJ, Pituskin E, Cook SF, Bies RR, Vlahadamis A, King K, Basi SK, Meza-Junco J, Mackey JR, Stanislaus A, Damaraju VL, Damaraju S, Sawyer MB. Uridine Glucuronosyltransferase 2B7 Polymorphism-Based Pharmacogenetic Dosing of Epirubicin in FEC Chemotherapy for Early-Stage Breast Cancer. Clin Breast Cancer 2021; 21:e584-e593. [PMID: 33832852 DOI: 10.1016/j.clbc.2021.03.001] [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: 10/13/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epirubicin is metabolized by uridine glucuronosyltransferase 2B7 (UGT2B7). Patients homozygous for the minor allele (CC) in the UGT2B7 -161 promoter polymorphism have lower clearance and significantly higher rates of leukopenia compared to wild-type homozygote (TT) or heterozygote (CT) patients. This study was designed to determine if TT and CT genotype patients could tolerate a higher epirubicin dose compared to CC genotype patients. PATIENTS AND METHODS We studied women with histologically confirmed non-metastatic, invasive breast cancer who were scheduled to receive at least three cycles of FE100C in the (neo)adjuvant setting. Patients received standard-dose FE100C during the first 21-day cycle. Based on genotype, the epirubicin dose was escalated in the second and third cycles to 115 and 130 mg/m2 or to 120 and 140 mg/m2 for CT and TT genotype patients, respectively. The main outcome measurements were myelosuppression and dose-limiting toxicity. These were analyzed for relationships with the three genotypes. RESULTS Forty-five patients were enrolled (10 CC, 21 CT, and 14 TT genotypes) and received 100 mg/m2 of epirubicin in the first cycle. Twelve and 10 TT patients were dose escalated at the second and third cycles, respectively; 16 CT patients were dose escalated at the second and third cycles. Leukopenia, but not febrile neutropenia, was genotype and dose dependent and increased in patients with CT and TT genotypes as their dose was increased. However, the third-cycle leukopenia rates were comparable to patients with the CC genotype receiving standard-dose epirubicin. CONCLUSION Pharmacogenetically guided epirubicin dosing is well tolerated and allowed dose escalation without increased toxicity.
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Affiliation(s)
- Anil A Joy
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Larissa J Vos
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Edith Pituskin
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sarah F Cook
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Robert R Bies
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Ann Vlahadamis
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Karen King
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sanraj K Basi
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Judith Meza-Junco
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John R Mackey
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Avalyn Stanislaus
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Vijaya L Damaraju
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sambasivarao Damaraju
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Michael B Sawyer
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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2
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Steenbruggen TG, Steggink LC, Seynaeve CM, van der Hoeven JJM, Hooning MJ, Jager A, Konings IR, Kroep JR, Smit WM, Tjan-Heijnen VCG, van der Wall E, Bins AD, Linn SC, Schaapveld M, Jacobse JN, van Leeuwen FE, Schröder CP, van Tinteren H, de Vries EGE, Sonke GS, Gietema JA. High-Dose Chemotherapy With Hematopoietic Stem Cell Transplant in Patients With High-Risk Breast Cancer and 4 or More Involved Axillary Lymph Nodes: 20-Year Follow-up of a Phase 3 Randomized Clinical Trial. JAMA Oncol 2020; 6:528-534. [PMID: 31999296 DOI: 10.1001/jamaoncol.2019.6276] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trials of adjuvant high-dose chemotherapy (HDCT) have failed to show a survival benefit in unselected patients with breast cancer, but long-term follow-up is lacking. Objective To determine 20-year efficacy and safety outcomes of a large trial of adjuvant HDCT vs conventional-dose chemotherapy (CDCT) for patients with stage III breast cancer. Design, Setting, and Participants This secondary analysis used data from a randomized phase 3 multicenter clinical trial of 885 women younger than 56 years with breast cancer and 4 or more involved axillary lymph nodes conducted from August 1, 1993, to July 31, 1999. Additional follow-up data were collected between June 1, 2016, and December 31, 2017, from medical records, general practitioners, the Dutch national statistical office, and nationwide cancer registries. Analysis was performed on an intention-to-treat basis. Statistical analysis was performed from February 1, 2018, to October 14, 2019. Interventions Participants were randomized 1:1 to receive 5 cycles of CDCT consisting of fluorouracil, 500 mg/m2, epirubicin, 90 mg/m2, and cyclophosphamide, 500 mg/m2, or HDCT in which the first 4 cycles were identical to CDCT and the fifth cycle was replaced by cyclophosphamide, 6000 mg/m2, thiotepa, 480 mg/m2, and carboplatin, 1600 mg/m2, followed by hematopoietic stem cell transplant. Main Outcomes and Measures Main end points were overall survival and safety and cumulative incidence risk of a second malignant neoplasm or cardiovascular events. Results Of the 885 women in the study (mean [SD] age, 44.5 [6.6] years), 442 were randomized to receive HDCT, and 443 were randomized to receive CDCT. With 20.4 years median follow-up (interquartile range, 19.2-22.0 years), the 20-year overall survival was 45.3% with HDCT and 41.5% with CDCT (hazard ratio, 0.89; 95% CI, 0.75-1.06). The absolute improvement in 20-year overall survival was 14.6% (hazard ratio, 0.72; 95% CI, 0.54-0.95) for patients with 10 or more invoved axillary lymph nodes and 15.4% (hazard ratio, 0.67; 95% CI, 0.42-1.05) for patients with triple-negative breast cancer. The cumulative incidence risk of a second malignant neoplasm at 20 years or major cardiovascular events was similar in both treatment groups (20-year cumulative incidence risk for second malignant neoplasm was 12.1% in the HDCT group vs 16.2% in the CDCT group, P = .10), although patients in the HDCT group more often had hypertension (21.7% vs 14.3%, P = .02), hypercholesterolemia (15.7% vs 10.6%, P = .04), and dysrhythmias (8.6% vs 4.6%, P = .005). Conclusions and Relevance High-dose chemotherapy provided no long-term survival benefit in unselected patients with stage III breast cancer but did provide improved overall survival in very high-risk patients (ie, with ≥10 involved axillary lymph nodes). High-dose chemotherapy did not affect long-term risk of a second malignant neoplasm or major cardiovascular events. Trial Registration ClinicalTrials.gov Identifier: NCT03087409.
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Affiliation(s)
- Tessa G Steenbruggen
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Lars C Steggink
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Caroline M Seynaeve
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Maartje J Hooning
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Inge R Konings
- Department of Medical Oncology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Wim M Smit
- Department of Internal Medicine/Medical Oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Adriaan D Bins
- Department of Medical Oncology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Michael Schaapveld
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Judy N Jacobse
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Flora E van Leeuwen
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Carolien P Schröder
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Harm van Tinteren
- Department of Biostatistics, the Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Jourik A Gietema
- Department of Medical Oncology, University Medical Center Groningen, Groningen, the Netherlands
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3
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Electronic Patient-reported Outcomes During Breast Cancer Adjuvant Radiotherapy. Clin Breast Cancer 2020; 21:e252-e270. [PMID: 33229222 DOI: 10.1016/j.clbc.2020.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/21/2020] [Accepted: 10/14/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Patient-reported outcomes (PROs) have become extremely important in following patients' health-related quality of life during cancer treatments. The aim of this study was to assess the usefulness of electronic PROs (ePROs) during adjuvant radiotherapy (RT) in patients with early breast cancer. MATERIALS AND METHODS A registry trial was conducted with a total of 253 patients with breast cancer receiving RT. Adverse event data were collected from 9 items on the ePRO questionnaires that were administered before RT (N = 253), at the end of RT (± 3 days; N = 234), 1 month after RT (N = 230), and 3 months (N = 225) after RT. The patient characteristics and treatment details were collected from the medical records. RESULTS The patients have started actively using the ePRO system, and the response rates were high (82.6%). During RT, 39.3% of the ePRO responses were about symptoms, and 60.7% were about treatment-related questions or advice. Patients treated with hypofractionated RT reported fewer local adverse events such as skin symptoms (P = .001) and pain (P = .002) than those who received conventional RT. One of the main findings of this study was that tiredness, fatigue, and anxiety were commonly reported on the patients' ePRO questionnaires, but they were rarely recorded in the medical records. CONCLUSION Patients were motivated to use the ePRO system, and the response rates were high. Additionally, patients seemed to find that the ePRO system was an easy way to contact their own health care professionals. More attention should be paid to mental well-being during visits to the clinic.
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4
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Martin JH, Dimmitt S. The rationale of dose-response curves in selecting cancer drug dosing. Br J Clin Pharmacol 2019; 85:2198-2204. [PMID: 31077412 PMCID: PMC6783605 DOI: 10.1111/bcp.13979] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 12/21/2022] Open
Abstract
Drug development for cancer chemotherapy has an interesting history. A mix of serendipity, animal, cell line, and standard pharmacological principles of dose, dose-response, dose-concentration, dose intensity and combination therapies have been used to develop optimal dosing schedules. However in practice, significant gaps in the translation of preclinical to clinical dosing schedules persist, and clinical development has instead moved to new drug development. A older chemotherapies are still the backbone of most solid tumour schedules, therapeutic drug monitoring has emerged as a method for optimising the dose for individual patients.
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Affiliation(s)
| | - Simon Dimmitt
- University of Newcastle. New South WalesAustralia
- University of Western AustraliaCrawleyPerthAustralia
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5
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Lindman H, Andersson M, Ahlgren J, Balslev E, Sverrisdottir A, Holmberg S, Bengtsson N, Jacobsen E, Jensen A, Hansen J, Tuxen M, Malmberg L, Villman K, Anderson H, Ejlertsen B, Bergh J, Blomqvist C. A randomised study of tailored toxicity-based dosage of fluorouracil-epirubicin-cyclophosphamide chemotherapy for early breast cancer (SBG 2000-1). Eur J Cancer 2018; 94:79-86. [DOI: 10.1016/j.ejca.2018.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 01/24/2023]
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6
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Matikas A, Margolin S, Hellström M, Johansson H, Bengtsson NO, Karlsson L, Edlund P, Karlsson P, Lidbrink E, Linderholm B, Lindman H, Malmstrom P, Villman K, Foukakis T, Bergh J. Long-term safety and survival outcomes from the Scandinavian Breast Group 2004-1 randomized phase II trial of tailored dose-dense adjuvant chemotherapy for early breast cancer. Breast Cancer Res Treat 2017; 168:349-355. [PMID: 29190004 PMCID: PMC5838137 DOI: 10.1007/s10549-017-4599-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 11/24/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Although adjuvant polychemotherapy improves outcomes for early breast cancer, the significant variability in terms of pharmacokinetics results in differences in efficacy and both short and long-term toxicities. Retrospective studies support the use of dose tailoring according to the hematologic nadirs. METHODS The SBG 2004-1 trial was a randomized feasibility phase II study which assessed tailored dose-dense epirubicin and cyclophosphamide (EC) followed by docetaxel (T) (group A), the same regimen with fixed doses (group B) and the TAC regimen (group C). Women aged 18-65 years, ECOG PS 0-1 with at least one positive axillary lymph node were randomized 1:1:1. The primary endpoint of the study was the safety and feasibility of the treatment. Toxicity was graded according to CTC-AE version 3.0. The design and short-term toxicity have been previously published. Here, we report safety and efficacy data after 10 years of follow-up. RESULTS A total of 124 patients were included in the study. After a median follow-up of 10.3 years, the probability for 10-year survival was 78.5, 75.1, and 63.4% and for relapse free survival 64.1, 71.0, and 59.5% for groups A, B, and C, respectively. There were no cases of clinically diagnosed cardiotoxicity or hematologic malignancies. No patient was lost to follow-up. CONCLUSIONS In this randomized phase II trial, tailored dose adjuvant chemotherapy was feasible, without an increased risk for long-term adverse events after a median follow-up of 10 years.
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Affiliation(s)
- Alexios Matikas
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden.
| | - Sara Margolin
- Department of Oncology, Stockholm South General Hospital, Stockholm, Sweden
| | - Mats Hellström
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Elisabet Lidbrink
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Barbro Linderholm
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Lindman
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Per Malmstrom
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | - Theodoros Foukakis
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Bergh
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
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Gallo S, Sangiolo D, Carnevale Schianca F, Aglietta M, Montemurro F. Treating breast cancer with cell-based approaches: an overview. Expert Opin Biol Ther 2017; 17:1255-1264. [PMID: 28728493 DOI: 10.1080/14712598.2017.1356816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Breast cancer is the most common malignancy in women. Despite there being considerable progress in the treatment of this disease, metastatic dissemination is still considered an incurable condition at the present time, causing 500,000 deaths worldwide every year. Although most of the research efforts have been focused on pharmacological approaches, over the last three decades, the use of bone marrow and peripheral blood-derived cell therapy approaches have been attempted and developed. Areas covered: This review will briefly address cell therapy for breast cancer, including autologous stem cell transplantations for overcoming the myelosuppressive effects of high-dose chemotherapy, allogeneic stem cell transplants and adoptive immunotherapy using bone-marrow derived T-cells. Expert opinion: The treatment of breast cancer using bone marrow or peripheral-blood derived cells has evolved from a supportive care approach to allow dose escalation of conventional chemotherapy to a therapeutic strategy aimed at eliciting immune cell mediated anticancer immunity. This latter principle has led to the development of adoptive immunotherapies, either with 'natural' or genetically engineered effectors, which are being intensively investigated for their great potential against several solid tumors, including breast cancer.
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Affiliation(s)
- Susanna Gallo
- a Medical Oncology , Candiolo Cancer Institute-FPO (IRCCS) , Candiolo , Italy
| | - Dario Sangiolo
- a Medical Oncology , Candiolo Cancer Institute-FPO (IRCCS) , Candiolo , Italy.,b Department of Oncology , University of Turin , Turin , Italy
| | | | - Massimo Aglietta
- a Medical Oncology , Candiolo Cancer Institute-FPO (IRCCS) , Candiolo , Italy.,b Department of Oncology , University of Turin , Turin , Italy
| | - Filippo Montemurro
- c Investigative Clinical Oncology , Candiolo Cancer Institute-FPO (IRCCS) , Candiolo , Italy
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8
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Cheng YC, Shi Y, Zhang MJ, Brazauskas R, Hemmer MT, Bishop MR, Nieto Y, Stadtmauer E, Ayash L, Gale RP, Lazarus H, Holmberg L, Lill M, Olsson RF, Wirk BM, Arora M, Hari P, Ueno N. Long-Term Outcome of Inflammatory Breast Cancer Compared to Non-Inflammatory Breast Cancer in the Setting of High-Dose Chemotherapy with Autologous Hematopoietic Cell Transplantation. J Cancer 2017; 8:1009-1017. [PMID: 28529613 PMCID: PMC5436253 DOI: 10.7150/jca.16870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 12/03/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction: Inflammatory breast cancer (IBC) is a rare aggressive form of breast cancer. It is well known that the long-term survival and progression-free survival of IBC are worse than that of non-IBC. We report the long term outcomes of patients with IBC and non-IBC who had undergone high-dose chemotherapy (HDC) with autologous hematopoietic cell transplantation (AHCT). Methods: All 3387 patients with IBC or non-IBC who underwent HDC with AHCT between1990-2002 and registered with CIBMTR were included in this analysis. Transplant-related mortality (TRM), disease relapse/progression, progression-free survival (PFS) and overall survival (OS) were compared between the two cohorts. Multivariate Cox regression model was used to determine the independent impact of stage on outcomes. Results: 527 patients with IBC and 2,860 patients with non-IBC were included; the median age at transplantation (47 vs 46 years old) and median follow-up period in the 2 groups (167 vs 168 months) were similar. The most common conditioning regimen was cyclophosphamide and carboplatin based in both groups (54% in IBC and 50% in non-IBC). AHCT was well tolerated in both groups. TRM was similar in both groups (one year TRM was 2% for IBC and 3% for non-IBC, p=0.16). The most common cause of death was disease progression or relapse (81% in IBC and 75% in non-IBC). The median survival for both IBC and non-IBC was the same at 40 months. The PFS at 10 years was 27% (95% CI: 23-31%) for IBC and 24% (95% CI: 22-26%) for non-IBC (p=0.21), and the OS at 10 years was 31% (95% CI: 27-35%) for IBC and 28% (95% CI: 26-30%) for non-IBC (p=0.16). In univariate analysis, patients with stage III IBC and no active diseases at transplantation had lower PFS and OS than that in non-IBC. In multivariate analysis, controlling for age, disease status at AHCT, hormonal receptor status, time from diagnosis to AHCT, and performance status at AHCT, patients with stage III IBC had higher mortality (HR 1.16, 95% CI: 1-1.34, p= 0.0459), worse PFS (HR: 1.17, 95% CI: 1.01-1.36, p= 0.0339) and higher risk of disease relapse/progression (HR: 1.24, 95% CI: 1.06-1.45, p= 0.0082) as compared to stage III non-IBC. Amongst all patients a higher stage disease was associated with worse PFS, OS and disease relapse/progression. Conclusions: Long-term outcomes of stage III IBC patients who underwent AHCT were poorer than that in non-IBC patients confirming that the poor prognosis of IBC even in the setting of HDC with AHCT.
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Affiliation(s)
| | - Yushu Shi
- Medical College of Wisconsin, Milwaukee, WI
| | - Mei-Jie Zhang
- CIBMTR(Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Ruta Brazauskas
- CIBMTR(Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Hemmer
- CIBMTR(Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Edward Stadtmauer
- Abramson Cancer Center University of Pennsylvania Medical Center, Philadelphia, PA
| | - Lois Ayash
- Karmanos Cancer Institute, Detroit, MI; Division of Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Hillard Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH
| | | | | | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Baldeep Mona Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | - Mukta Arora
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Parameswaran Hari
- CIBMTR(Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Naoto Ueno
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX
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9
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Farquhar C, Marjoribanks J, Lethaby A, Azhar M. High-dose chemotherapy and autologous bone marrow or stem cell transplantation versus conventional chemotherapy for women with early poor prognosis breast cancer. Cochrane Database Syst Rev 2016; 2016:CD003139. [PMID: 27200512 PMCID: PMC8078206 DOI: 10.1002/14651858.cd003139.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Overall survival rates are disappointing for women with early poor prognosis breast cancer. Autologous transplantation of bone marrow or peripheral stem cells (in which the woman is both donor and recipient) has been considered a promising technique because it permits use of much higher doses of chemotherapy. OBJECTIVES To compare the effectiveness and safety of high-dose chemotherapy and autograft (either autologous bone marrow or stem cell transplantation) with conventional chemotherapy for women with early poor prognosis breast cancer. SEARCH METHODS We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE (1966 to October 2015), EMBASE (1980 to October 2015), the World Health Organization's International Clinical Trials Registry Search Platform, and ClinicalTrials.gov on the 21 October 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing high-dose chemotherapy and autograft (bone marrow transplant or stem cell rescue) versus chemotherapy without autograft for women with early poor prognosis breast cancer. DATA COLLECTION AND ANALYSIS Two review authors selected RCTs, independently extracted data and assessed risks of bias. We combined data using a Mantel-Haenszel fixed-effect model to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). We assessed the quality of the evidence using GRADE methods. Outcomes were survival rates, toxicity and quality of life. MAIN RESULTS We included 14 RCTs of 5600 women randomised to receive high-dose chemotherapy and autograft (bone marrow transplant or stem cell rescue) versus chemotherapy without autograft for women with early poor prognosis breast cancer. The studies were at low risk of bias in most areas.There is high-quality evidence that high-dose chemotherapy does not increase the likelihood of overall survival at any stage of follow-up (at three years: RR 1.02, 95% CI 0.95 to 1.10, 3 RCTs, 795 women, I² = 56%; at five years: RR 1.00, 95% CI 0.96 to 1.04, 9 RCTs, 3948 women, I² = 0%; at six years: RR 0.94, 95% CI 0.81 to 1.08, 1 RCT, 511 women; at eight years: RR1.17, 95% CI 0.95 to 1.43, 1 RCT, 344 women; at 12 years: RR 1.18, 95% CI 0.99 to 1.42, 1 RCT, 382 women).There is high-quality evidence that high-dose chemotherapy improves the likelihood of event-free survival at three years (RR 1.19, 95% CI 1.06 to 1.34, 3 RCTs, 795 women, I² = 56%) but this effect was no longer apparent at longer duration of follow-up (at five years: RR 1.04, 95% CI 0.99 to 1.09, 9 RCTs, 3948 women, I² = 14%; at six years RR 1.04, 95% CI 0.87 to 1.24, 1 RCT, 511 women; at eight years: RR 1.27, 95% CI 0.99 to 1.64, 1 RCT, 344 women; at 12 years: RR 1.18, 95% CI 0.95 to 1.45, 1 RCT, 382 women).Treatment-related deaths were much more frequent in the high-dose arm (RR 7.97, 95% CI 3.99 to 15.92, 14 RCTs, 5600 women, I² = 12%, high-quality evidence) and non-fatal morbidity was also more common and more severe in the high-dose group. There was little or no difference between the groups in the incidence of second cancers at four to nine years' median follow-up (RR 1.25, 95% CI 0.90 to 1.73, 7 RCTs, 3423 women, I² = 0%, high-quality evidence). Women in the high-dose group reported significantly worse quality-of-life scores immediately after treatment, but there were few statistically significant differences between the groups by one year.The primary studies were at low risk of bias in most areas, and the evidence was assessed using GRADE methods and rated as high quality for all comparisons. AUTHORS' CONCLUSIONS There is high-quality evidence of increased treatment-related mortality and little or no increase in survival by using high-dose chemotherapy with autograft for women with early poor prognosis breast cancer.
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Affiliation(s)
- Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Jane Marjoribanks
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Anne Lethaby
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Maimoona Azhar
- Royal College of Surgeons in IrelandDepartment of Surgery123 St. Stephen's GreenDublin 2Ireland
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A Uridine Glucuronosyltransferase 2B7 Polymorphism Predicts Epirubicin Clearance and Outcomes in Early-Stage Breast Cancer. Clin Breast Cancer 2016; 16:139-44.e1-3. [DOI: 10.1016/j.clbc.2015.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/31/2015] [Accepted: 09/11/2015] [Indexed: 11/22/2022]
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11
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Eschrich SA, Fulp WJ, Pawitan Y, Foekens JA, Smid M, Martens JWM, Echevarria M, Kamath V, Lee JH, Harris EE, Bergh J, Torres-Roca JF. Validation of a radiosensitivity molecular signature in breast cancer. Clin Cancer Res 2012; 18:5134-43. [PMID: 22832933 DOI: 10.1158/1078-0432.ccr-12-0891] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE Previously, we developed a radiosensitivity molecular signature [radiosensitivity index (RSI)] that was clinically validated in 3 independent datasets (rectal, esophageal, and head and neck) in 118 patients. Here, we test RSI in radiotherapy (RT)-treated breast cancer patients. EXPERIMENTAL DESIGN RSI was tested in 2 previously published breast cancer datasets. Patients were treated at the Karolinska University Hospital (n = 159) and Erasmus Medical Center (n = 344). RSI was applied as previously described. RESULTS We tested RSI in RT-treated patients (Karolinska). Patients predicted to be radiosensitive (RS) had an improved 5-year relapse-free survival when compared with radioresistant (RR) patients (95% vs. 75%, P = 0.0212), but there was no difference between RS/RR patients treated without RT (71% vs. 77%, P = 0.6744), consistent with RSI being RT-specific (interaction term RSI × RT, P = 0.05). Similarly, in the Erasmus dataset, RT-treated RS patients had an improved 5-year distant metastasis-free survival over RR patients (77% vs. 64%, P = 0.0409), but no difference was observed in patients treated without RT (RS vs. RR, 80% vs. 81%, P = 0.9425). Multivariable analysis showed RSI is the strongest variable in RT-treated patients (Karolinska, HR = 5.53, P = 0.0987, Erasmus, HR = 1.64, P = 0.0758) and in backward selection (removal α of 0.10), RSI was the only variable remaining in the final model. Finally, RSI is an independent predictor of outcome in RT-treated ER(+) patients (Erasmus, multivariable analysis, HR = 2.64, P = 0.0085). CONCLUSIONS RSI is validated in 2 independent breast cancer datasets totaling 503 patients. Including prior data, RSI is validated in 5 independent cohorts (621 patients) and represents, to our knowledge, the most extensively validated molecular signature in radiation oncology.
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Affiliation(s)
- Steven A Eschrich
- Department of Bioinformatics, H Lee Moffitt Cancer Center, Tampa, Florida 33612, USA
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12
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High-dose chemotherapy followed by autologous stem cell transplantation as a first-line therapy for high-risk primary breast cancer: a meta-analysis. PLoS One 2012; 7:e33388. [PMID: 22428041 PMCID: PMC3299795 DOI: 10.1371/journal.pone.0033388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 02/13/2012] [Indexed: 11/28/2022] Open
Abstract
Background and Objectives Several trials have generated conflicting results about the results of high-dose chemotherapy followed by autologous stem cell transplantation (HDCT) for primary breast cancer. This meta-analysis summarizes the available evidence from all suitable studies. Design and Methods Prospective, randomized trials with HDCT as a first-line therapy for primary breast cancer were included in this meta-analysis. The primary outcome of interest for our analysis was survival (disease-free survival and overall survival); secondary endpoints included treatment-related mortality (TRM) and second (non-breast) cancers. We used a median age of 47, a PR positive rate of 50% and a premenopausal rate of 70% as cutoff values to complete the subgroup analyses, which were pre-planned according to the prepared protocol. Results Fourteen trials with 5747 patients were eligible for the meta-analysis. Compared with non-HDCT, non-significant second (non-breast) cancers (RR = 1.28; 95% CI = 0.82–1.98) and higher TRM (RR = 3.42; 95% CI = 1.32–8.86) were associated with HDCT for primary breast cancer. A significant DFS benefit of HDCT was documented (HR = 0.89; 95% CI = 0.79–0.99). No difference in OS (overall survival) was found when the studies were pooled (HR = 0.91; 95% CI = 0.82–1.00, p = 0.062). In subgroup analysis, age and hormone receptor status had a significant interaction with prolonged DFS and OS. Conclusions HDCT has a benefit on DFS and OS compared to SDC in some special patients with high-risk primary breast cancer.
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13
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VanderWalde A, Ye W, Frankel P, Asuncion D, Leong L, Luu T, Morgan R, Twardowski P, Koczywas M, Pezner R, Paz IB, Margolin K, Wong J, Doroshow JH, Forman S, Shibata S, Somlo G. Long-term survival after high-dose chemotherapy followed by peripheral stem cell rescue for high-risk, locally advanced/inflammatory, and metastatic breast cancer. Biol Blood Marrow Transplant 2012; 18:1273-80. [PMID: 22306735 DOI: 10.1016/j.bbmt.2012.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 01/29/2012] [Indexed: 10/14/2022]
Abstract
Patients with high-risk locally advanced/inflammatory and oligometastatic (≤3 sites) breast cancer frequently relapse or experience early progression. High-dose chemotherapy combined with peripheral stem cell rescue may prolong progression-free survival/relapse-free survival (PFS/RFS) and overall survival (OS). In this study, patients initiated high-dose chemotherapy with STAMP-V (carboplatin, thiotepa, and cyclophosphamide), ACT (doxorubicin, paclitaxel, and cyclophosphamide), or tandem melphalan and STAMP-V. Eighty-six patients were diagnosed with locally advanced/inflammatory (17 inflammatory) breast cancer, and 12 were diagnosed with oligometastatic breast cancer. Median follow-up was 84 months (range, 6-136 months) for patients with locally advanced cancer and 40 months (range, 24-62 months) for those with metastatic cancer. In the patients with locally advanced cancer, 5-year RFS and OS were 53% (95% CI, 41%-63%) and 71% (95% CI, 60%-80%), respectively, hormone receptors were positive in 74%, and HER2 overexpression was seen in 23%. In multivariate analysis, hormone receptor-positive disease and lower stage were associated with better 5-year RFS (60% for ER [estrogen receptor]/PR [progesterone receptor]-positive versus 30% for ER/PR-negative; P < .01) and OS (83% for ER/PR-positive versus 38% for ER/PR-negative; P < .001). In the patients with metastatic cancer, 3-year PFS and OS were 49% (95% CI, 19%-73%) and 73% (95% CI, 38%-91%), respectively. The favorable long-term RFS/PFS and OS for high-dose chemotherapy with peripheral stem cell rescue in this selected patient population reflect the relative safety of the procedure and warrant validation in defined subgroups through prospective, randomized, multi-institutional trials.
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Affiliation(s)
- A VanderWalde
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte,CA 91010, USA
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14
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Individually tailored treatment with epirubicin and paclitaxel with or without capecitabine as first-line chemotherapy in metastatic breast cancer: a randomized multicenter trial. Breast Cancer Res Treat 2011; 131:939-47. [PMID: 22094937 DOI: 10.1007/s10549-011-1880-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/07/2011] [Indexed: 10/15/2022]
Abstract
Anthracyclines and taxanes are active cytotoxic drugs in the treatment of early metastatic breast cancer. It is yet unclear whether addition of capecitabine to the combination of these drugs improves the treatment outcome. Patients with advanced breast cancer were randomized to first-line chemotherapy with a combination of epirubicin (Farmorubicin(®)) and paclitaxel (Taxol(®)) alone (ET) or in combination with capecitabine (Xeloda(®), TEX). Starting doses for ET were epirubicin 75 mg/m(2) plus paclitaxel 175 mg/m(2), and for TEX epirubicin 75 mg/m(2), paclitaxel 155 mg/m(2), and capecitabine 825 mg/m(2) BID for 14 days. Subsequently, doses were tailored related to side effects. Primary endpoint was progression-free survival (PFS); secondary endpoints were overall survival (OS), time to treatment failure (TTF), objective response (OR), safety and quality of life (QoL). 287 patients were randomized, 143 to ET and 144 to TEX. Median PFS was 10.8 months for patients treated with ET, and 12.4 months for those treated with TEX (HR 0.84, 95% CI 0.65-1.07, P = 0.16); median OS was 26.0 months for women in the ET versus 29.7 months in the TEX arm (HR 0.84, 95% CI 0.63-1.11, P = 0.22). OR was achieved in 44.8% (ET) and 54.2% (TEX), respectively (χ(2) 3.66, P = 0.16). TTF was significantly longer for patients treated with TEX, 6.0 months, versus 5.2 months following ET (HR 0.73, 95% CI 0.58-0.93, P = 0.009). Severe hematological side effects related to epirubicin and paclitaxel were evenly distributed between the treatment arms, mucositis, diarrhea, and Hand-Foot syndrome were significantly more frequent in the TEX arm. Toxicity-adjusted treatment with ET and TEX showed similar efficacy in terms of PFS, OS, and OR. In this trial with limited power, the addition of capecitabine to epirubicin and paclitaxel as first-line treatment did not translate into clinically relevant improvement of the outcome.
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Berry DA, Ueno NT, Johnson MM, Lei X, Caputo J, Rodenhuis S, Peters WP, Leonard RC, Barlow WE, Tallman MS, Bergh J, Nitz UA, Gianni AM, Basser RL, Zander AR, Coombes RC, Roché H, Tokuda Y, de Vries EGE, Hortobagyi GN, Crown JP, Pedrazzoli P, Bregni M, Demirer T. High-dose chemotherapy with autologous stem-cell support as adjuvant therapy in breast cancer: overview of 15 randomized trials. J Clin Oncol 2011; 29:3214-23. [PMID: 21768471 DOI: 10.1200/jco.2010.32.5910] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Adjuvant high-dose chemotherapy (HDC) with autologous hematopoietic stem-cell transplantation (AHST) for high-risk primary breast cancer has not been shown to prolong survival. Individual trials have had limited power to show overall benefit or benefits within subsets. METHODS We assembled individual patient data from 15 randomized trials that compared HDC versus control therapy without stem-cell support. Prospectively defined primary end points were relapse-free survival (RFS) and overall survival (OS). We compared the effect of HDC versus control by using log-rank tests and proportional hazards regression, and we adjusted for clinically relevant covariates. Subset analyses were by age, number of positive lymph nodes, tumor size, histology, hormone receptor (HmR) status, and human epidermal growth factor receptor 2 (HER2) status. RESULTS Of 6,210 total patients (n = 3,118, HDC; n = 3,092 control), the median age was 46 years; 69% were premenopausal, 29% were postmenopausal, and 2% were unknown menopausal status; 49.5% were HmR positive; 33.5% were HmR negative, and 17% were unknown HmR status. The median follow-up was 6 years. After analysis was adjusted for covariates, HDC was found to prolong relapse-free survival (RFS; hazard ratio [HR], 0.87; 95% CI, 0.81 to 0.93; P < .001) but not overall survival (OS; HR, 0.94; 95% CI, 0.87 to 1.02; P = .13). For OS, no covariates had statistically significant interactions with treatment effect, and no subsets evinced a significant effect of HDC. Younger patients had a significantly better RFS on HDC than did older patients. CONCLUSION Adjuvant HDC with AHST prolonged RFS in high-risk primary breast cancer compared with control, but this did not translate into a significant OS benefit. Whether HDC benefits patients in the context of targeted therapies is unknown.
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Affiliation(s)
- Donald A Berry
- Division of Quantitative Sciences, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA.
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Cheng YC, Ueno NT. Is high-dose chemotherapy with autologous hematopoietic stem cell transplantation in breast cancer patients a done deal? ACTA ACUST UNITED AC 2011; 6:481-5. [PMID: 20597609 DOI: 10.2217/whe.10.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Bonnefoi H, Piccart M, Bogaerts J, Mauriac L, Fumoleau P, Brain E, Petit T, Rouanet P, Jassem J, Blot E, Zaman K, Cufer T, Lortholary A, Lidbrink E, André S, Litière S, Lago LD, Becette V, Cameron DA, Bergh J, Iggo R. TP53 status for prediction of sensitivity to taxane versus non-taxane neoadjuvant chemotherapy in breast cancer (EORTC 10994/BIG 1-00): a randomised phase 3 trial. Lancet Oncol 2011; 12:527-39. [PMID: 21570352 DOI: 10.1016/s1470-2045(11)70094-8] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND TP53 has a crucial role in the DNA damage response. We therefore tested the hypothesis that taxanes confer a greater advantage than do anthracyclines on breast cancers with mutated TP53 than in those with wild-type TP53. METHODS In an open-label, phase 3 study, women (age <71 years) with locally advanced, inflammatory, or large operable breast cancers were randomly assigned in a 1:1 ratio to either a standard anthracycline regimen (six cycles of intravenous fluorouracil 500 mg/m², epirubicin 100 mg/m², and cyclophosphamide 500 mg/m² every 21 days [FEC100], or fluorouracil 600 mg/m², epirubicin 75 mg/m², cyclophosphamide 900 mg/m² [tailored FEC] starting on day 1 and then every 21 days) or a taxane-based regimen (three cycles of docetaxel 100 mg/m², intravenously infused over 1 h on day 1 every 21 days, followed by three cycles of intravenous epirubicin 90 mg/m² and docetaxel 75 mg/m² on day 1 every 21 days [T-ET]) at 42 centres in Europe. Randomisation was by use of a minimisation method that stratified patients by institution and initial tumour stage. The primary endpoint was progression-free survival (PFS) according to TP53 status. Analysis was by intention to treat. This is the final analysis of this trial. The study is registered with ClinicalTrials.gov, number NCT00017095. FINDINGS 928 patients were enrolled in the FEC group and 928 in the T-ET group. TP53 status was not assessable for 183 (20%) patients in the FEC group and 204 (22%) patients in the T-ET group mainly because of low tumour-cell content in the biopsy. 361 primary endpoint events were recorded in the FEC group and 314 in the T-ET group. In patients with TP53-mutated tumours, 5-year PFS was 59·5% (95% CI 53·4-65·1) in the T-ET group (n=326) and 55·3% (49·2-60·9) in the FEC group (n=318; hazard ratio 0·84, 98% CI 0·63-1·14; p=0·17). In patients with TP53 wild-type tumours, 5-year PFS was 66·8% (95% CI 61·4-71·6) in the T-ET group (n=398) and 64·7% (59·6-69·4) in the FEC group (n=427; 0·89, 98% CI 0·68-1·18; p=0·35). For all patients, irrespective of TP53 status, 5-year PFS was 65·1% (95% CI 61·6-68·3) in the T-ET group and 60·8% (57·3-64·2) in the FEC group (0·85, 98% CI 0·71-1·02; p=0·035). At the sites using FEC100 versus T-ET, the most common grade 3 or 4 adverse events were febrile neutropenia (75 [9%] of 803 vs 173 [21%] of 809, respectively), and neutropenia (653 [81%] vs 730 [90%], respectively). At the sites using tailored FEC versus T-ET, the most common grade 3 or 4 adverse events were febrile neutropenia (ten [8%] of 118 vs 26 [22%] of 116, respectively), and neutropenia (100 [85%] vs 115 [99%], respectively). Two patients died of toxicity during or within 30 days of chemotherapy completion and without disease relapse (one in each group). INTERPRETATION Although TP53 status was prognostic for overall survival, it was not predictive of preferential sensitivity to taxanes. TP53 status tested by use of the yeast assay in this patient population cannot be used to select patients for an anthracycline-based chemotherapy versus a taxane-based chemotherapy. FUNDING US National Cancer Institute, La Ligue Nationale Contre le Cancer, European Union, Pharmacia, and Sanofi-Aventis.
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Affiliation(s)
- Hervé Bonnefoi
- Institut Bergonié, Université de Bordeaux, INSERM U916, Bordeaux, France.
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Iiristo M, Wiklund T, Wilking N, Bergh J, Brandberg Y. Tailored chemotherapy doses based on toxicity in breast cancer result in similar quality of life values, irrespective of given dose levels. Acta Oncol 2011; 50:338-43. [PMID: 21323491 DOI: 10.3109/0284186x.2011.557089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND From March 1994 to March 1998, breast cancer patients (an estimated relapse risk with 70% or more within five years with standard therapy) were randomised to treatment with tailored fluorouracil, epirubicin, and cyclophosphamide (FEC) therapy or FEC followed by marrow-supported high dose therapy in the Scandinavian Breast Group 9401 study. The aim of the present paper was to investigate differences in toxicity and eight health-related quality of life (HRQoL) variables (physical functioning, role functioning, emotional functioning, social functioning, cognitive functioning, fatigue, nausea-vomiting, and global quality of life) between women in the six dose steps used in the tailored and granulocyte colony stimulating factor supported FEC-arm at the assessment point 16 weeks after random assignment to treatment. METHODS The European Organization and Treatment of Cancer Quality of Life Questionnaire EORTC QLQ-C30 were mailed to the patients. RESULTS A total of 157 (87%) in the tailored FEC-group responded to the questionnaire within the time frame 16 weeks after inclusion in the study. Overall, toxicity was low, reaching grade 1-2 also in the higher dose steps. There were no overall differences between the dose steps on any of the tested HRQoL variables. Patients at dose step 4 scored statistically significantly higher on physical functioning than patients at dose step 1 (p = 0.022) and compared to those at dose step 2 (p = 0.014). Patients at dose steps -2 and -1 (combined to one group) reported statistically significantly higher mean scores on cognitive functioning than patients at dose step 1 (p = 0.022). CONCLUSION Patients who received higher doses, based on the tailored dosing strategy, did not seem to have worse HRQoL than those who had lower doses.
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Affiliation(s)
- Mariann Iiristo
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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Edlund P, Ahlgren J, Bjerre K, Andersson M, Bergh J, Mouridsen H, Holmberg SB, Bengtsson NO, Jakobsen E, Møller S, Lindman H, Blomqvist C. Dose-tailoring of FEC adjuvant chemotherapy based on leukopenia is feasible and well tolerated. Toxicity and dose intensity in the Scandinavian Breast Group phase 3 adjuvant Trial SBG 2000-1. Acta Oncol 2011; 50:329-37. [PMID: 21299448 DOI: 10.3109/0284186x.2011.554435] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The SBG 2000-1 trial is a randomised study that investigates if dose-tailored adjuvant FEC therapy based on the individual's leukocyte nadir value can improve outcome. The study has included 1535 women with medium and high-risk breast cancer. PATIENTS AND METHODS After a first standard dosed FEC course (5-fluorouracil 600 mg/m(2), epirubicin 60 mg/mg(2) and cyclophosphamide 600 mg/m(2)), patients who did not reach leukopenia grade III or IV were randomised to standard doses (group standard) or doses tailored to achieve grade III leukopenia (group tailored) at courses 2-7. Patients who achieved leukopenia grade III or more after the first course were not randomised but continued on standard doses (group registered). RESULTS Both planned and actually delivered number of courses (seven) were the same in all three arms. The relative dose intensity was increased by a factor of 1.31 (E 1.22, C 1.43) for patients in the tailored arm compared to the expected on standard dose. Ninety percent of the patients in the tailored arm achieved leukopenia grade III-IV compared with 29% among patients randomised to standard dosed therapy. Dose tailoring was associated with acceptable acute non-haematological toxicity with more total alopecia, nausea, vomiting and fatigue. CONCLUSION Dose tailoring according to leukopenia was feasible. It led to an increased dose intensity and was associated with acceptable excess of acute non-haematological toxicity.
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Affiliation(s)
- Per Edlund
- Department of Oncology, Gävle Hospital, Sweden
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Dranitsaris G, Truter I, Lubbe MS, Amir E, Evans W. Advances in cancer therapeutics and patient access to new drugs. PHARMACOECONOMICS 2011; 29:213-224. [PMID: 21184619 DOI: 10.2165/11584210-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Globally, there are approximately 7.4 million cancer deaths annually, approximately 13% of deaths from all causes. Cancer is a disease of older people and, as the population ages over the next 10-20 years, we can expect an increase in the cancer incidence. Encouragingly, cancer mortality has stabilized in many countries. Part of this success may be attributed to the development of new cancer agents, collectively called 'targeted therapies', that are more specific to key components of tumour growth. Worldwide, however, one of the main factors that limit patient access to these important new drugs is their cost, which is higher than traditional chemotherapy. In this review, the clinical and pharmacoeconomic data of selected targeted agents are discussed. In the second part of this article, the challenges faced by healthcare systems in making such drugs available to patients is reviewed. Current strategies used by many countries around the world to manage cancer drug budgets are presented, along with a proposed approach using pharmacoeconomic methodology that may increase patient access.
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Affiliation(s)
- George Dranitsaris
- Department of Pharmacy, Nelson Mandela Metropolitan University, Port Elizabeth, South Africa.
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Margolin S, Bengtsson NO, Carlsson L, Edlund P, Hellstrøm M, Karlsson P, Lidbrink E, Linderholm B, Lindman H, Malmström P, Pettersson Skøld D, Søderberg M, Villman K, Bergh J. A randomised feasibility/phase II study (SBG 2004-1) with dose-dense/tailored epirubicin, cyclophoshamide (EC) followed by docetaxel (T) or fixed dosed dose-dense EC/T versus T, doxorubicin and C (TAC) in node-positive breast cancer. Acta Oncol 2011; 50:35-41. [PMID: 21174610 DOI: 10.3109/0284186x.2010.535847] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of the study was to evaluate the feasibility of tailored and dose-dense epirubicin and cyclophosphamide followed by docetaxel as adjuvant breast cancer therapy. Material and methods. Patients with node-positive breast cancer received either four cycles of biweekly and tailored EC (epirubicin 38-60-75-90-105-120 mg/m(2), cyclophosphamide 450-600-900-1200 mg/m(2)) followed by four cycles of docetaxel (60-75-85-100 mg/m(2)) (arm A) or the same regimen with fixed doses (E(90)C(600) + 4 → T(75) + 4) (arm B) or docetaxel, doxorubicin and cyclophosphamide (T(75)A(50)C(500)) every three weeks for six cycles (arm C). All patients received G-CSF support and prophylactic ciprofloxacin. Results. One-hundred and twenty-four patients were randomised in the study. In the A, B and C arm, 17% 19% and 3% of the patients had one or more cycles delayed due to side-effects whereas 24%, 5% and 15% experienced a grade 3 infection or febrile neutropenia. After the introduction of an extra week between the EC and T parts in the A and B arms, grade 3 hand-foot-skin reactions were reduced from 5 to 0.2%. Twenty-nine percent (A and B) and 20% (C) of the patients were hospitalised due to side-effects. Discussion. Dose-dense and tailored EC/T can be given with manageable toxicity and is after adjustment presently studied in the phase III Panther trial.
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Affiliation(s)
- Sara Margolin
- Department of Oncology, Karolinska Institute and University Hospital, Stockholm, Sweden.
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Abstract
The treatment and survival outcome of acute leukemia in women is generally similar to that of men. However, acute leukemia in women poses additional challenges in clinical practice. In addition to important precautions during therapy, such as prevention of abnormal uterine bleeding in premenopausal women and therapy during pregnancy, women who are survivors of acute leukemia face unique and potentially long-term health-related problems. In this review, we address the aforementioned issues, as well as the various health and psychosocial challenges faced by women who survive childhood leukemia during their path to adulthood. Finally, we address the issue of therapy-related acute leukemia in the category of women who are survivors of breast and ovarian cancer.
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Abstract
The treatment of acute leukemia is usually similar in women and men. The outcome is also generally the same. However, diagnosis in women poses additional challenges in clinical practice such as leukemia following breast or ovarian cancers, prevention of abnormal uterine bleeding in premenopausal females, treatment during pregnancy related-problems in long-term survivors. All these special issues are addressed in this review of the literature.
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Bridges JF, Cohen JP, Grist PG, Mühlbacher AC. International experience with comparative effectiveness research: Case studies from England/Wales and Germany. PHARMACEUTICAL MARKETS AND INSURANCE WORLDWIDE 2010; 22:29-50. [DOI: 10.1108/s0731-2199(2010)0000022005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Gluz O, Mengele K, Schmitt M, Kates R, Diallo-Danebrock R, Neff F, Royer HD, Eckstein N, Mohrmann S, Ting E, Kiechle M, Poremba C, Nitz U, Harbeck N. Y-Box–Binding Protein YB-1 Identifies High-Risk Patients With Primary Breast Cancer Benefiting From Rapidly Cycled Tandem High-Dose Adjuvant Chemotherapy. J Clin Oncol 2009; 27:6144-51. [DOI: 10.1200/jco.2008.19.6261] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose To investigate the potential of Y-box–binding protein YB-1, a multifunctional protein linked to tumor aggressiveness and multidrug resistance, to identify patients with breast cancer likely to benefit from dose-intensified chemotherapy regimens. Patients and Methods YB-1 was immunohistochemically determined in 211 primary tumors from the prospective, randomized West German Study Group WSG-AM-01 trial in high-risk (≥ 10 involved lymph-nodes) breast cancer (HRBC). Predictive impact of YB-1 was assessed by multivariate survival analysis, including time-varying factor-therapy interactions. Results At median follow-up of 61.7 months, patients receiving rapidly cycled tandem high-dose therapy (HD; two cycles [2×] epirubicin 90 mg/m2 and cyclophosphamide 600 mg/m2 every 14 days, followed by 2× epirubicin 90 mg/m2, cyclophosphamide 3,000 mg/m2, and thiotepa 400 mg/m2 every 21 days) had better disease-free survival (DFS; hazard ratio [HR] = 0.62; 95% CI, 0.44 to 0.89) and overall survival (OS; HR = 0.59; 95% CI, 0.4 to 0.89) than those receiving conventional dose-dense chemotherapy (DD; 4× epirubicin 90 mg/m2 and cyclophosphamide 600 mg/m2, followed by 3× cyclophosphamide 600 mg/m2, methotrexate 40 mg/m2, and fluorouracil 600 mg/m2 every 14 days). High YB-1 was associated with aggressive tumor phenotype (negative steroid hormone receptor status, positive human epidermal growth factor receptor 2 and p53 status, high MIB-1, unfavorable tumor grade) and poor OS (median 78 v 97 months; P = .01). In patients with high YB-1, HD yielded a 63-month median DFS (P = .001) and a 46-month median OS advantage (P = .002) versus DD. In multivariate models, patients with high B-1 receiving HD (v DD) had one third the hazard rate after 20 months for DFS and one sixth after 40 months for OS. Conclusion In a randomized prospective cancer therapy trial, for the first time, a strong predictive impact of YB-1 on survival has been demonstrated: enhanced benefit from HD (v DD) therapy occurs in HRBC with high YB-1. Future trials could therefore address optimal chemotherapeutic strategies,taking YB-1 into account.
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Affiliation(s)
- Oleg Gluz
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Karin Mengele
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Manfred Schmitt
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Ronald Kates
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Raihana Diallo-Danebrock
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Frauke Neff
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Hans-Dieter Royer
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Niels Eckstein
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Svjetlana Mohrmann
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Evelyn Ting
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Marion Kiechle
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Christopher Poremba
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Ulrike Nitz
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
| | - Nadia Harbeck
- From the Departments of Obstetrics and Gynecology and Pathology, Technische Universitaet Muenchen, Munich; West German Study Group, Heinrich-Heine-University Duesseldorf/Breast Center Niederrhein, Moenchengladbach; Department of Pathology, Heinrich-Heine-University Duesseldorf, Duesseldorf; Research Group for Neurological Therapeutics, Philipps University Marburg, Marburg; and Center of Advanced European Studies and Research, Bonn, Germany
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Rosendahl M, Ahlgren J, Andersen J, Bergh J, Blomquist C, Lidbrink E, Lindman H, Mouridsen H, Bjerre K, Andersson M. The risk of amenorrhoea after adjuvant chemotherapy for early stage breast cancer is related to inter-individual variations in chemotherapy-induced leukocyte nadir in young patients: Data from the randomised SBG 2000-1 study. Eur J Cancer 2009; 45:3198-204. [DOI: 10.1016/j.ejca.2009.09.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 09/15/2009] [Accepted: 09/15/2009] [Indexed: 11/29/2022]
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27
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High-dose chemotherapy for high-risk primary and metastatic breast cancer: is another look warranted? Curr Opin Oncol 2009; 21:150-7. [DOI: 10.1097/cco.0b013e328324f48b] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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28
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Gianni L, Gelber S, Ravaioli A, Price KN, Panzini I, Fantini M, Castiglione-Gertsch M, Pagani O, Simoncini E, Gelber RD, Coates AS, Goldhirsch A. Second non-breast primary cancer following adjuvant therapy for early breast cancer: a report from the International Breast Cancer Study Group. Eur J Cancer 2008; 45:561-71. [PMID: 19062268 DOI: 10.1016/j.ejca.2008.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 07/29/2008] [Accepted: 10/16/2008] [Indexed: 11/24/2022]
Abstract
The incidence of second non-breast primary cancer following adjuvant treatment was evaluated using data from patients enrolled from 1978 to 1999 in four International Breast Cancer Study Group (IBCSG) trials. The occurrence of these tumours as sites of the first failure was assessed separately for two treatment comparisons: toremifene versus tamoxifen for 5 years in 1035 patients in IBCSG Trials 12-93 and 14-93 with a median follow-up of 8 years and endocrine therapy (toremifene or tamoxifen) versus chemo-endocrine therapy (CMF or AC plus toremifene or tamoxifen) in 1731 patients from IBCSG Trials III, VII and 12-93, with a combined median follow-up of 14 years. No significant differences in second non-breast primary tumours were observed in either comparison. In particular, the incidences of second primary uterine tumours with toremifene and tamoxifen were similar and no significant increase of secondary leukaemias was observed with chemo-endocrine therapy compared with endocrine therapy.
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Affiliation(s)
- Lorenzo Gianni
- Department of Oncology, Ospedale Infermi, Rimini and Istituto Scientifico Romagnolo per lo Studio e Cura dei Tumori, Meldola (FC), Italy.
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29
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Ferretti G, Papaldo P. Acute myeloid leukaemia or myelodysplastic syndrome following use of granulocyte colony-stimulating factors during breast cancer adjuvant chemotherapy. Breast Cancer Res Treat 2007; 109:187-8. [PMID: 17616805 DOI: 10.1007/s10549-007-9639-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 05/30/2007] [Indexed: 11/26/2022]
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