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Cao M, Lu H, Yan S, Pang H, Sun L, Li C, Chen X, Liu W, Hu J, Huang J, Xing Y, Zhang N, Chen Y, He T, Zhao D, Sun Y, Zhao L, Liu X, Cai L. Apatinib plus etoposide in pretreated patients with advanced triple-negative breast cancer: a phase II trial. BMC Cancer 2023; 23:463. [PMID: 37208633 DOI: 10.1186/s12885-023-10768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/24/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Treatment options for pretreated triple-negative breast cancer (TNBC) are limited. This study aimed to evaluate the efficacy and safety of apatinib, an antiangiogenic agent, in combination of etoposide for pretreated patients with advanced TNBC. METHODS In this single-arm phase II trial, patients with advanced TNBC who failed to at least one line of chemotherapy were enrolled. Eligible patients received oral apatinib 500 mg on day 1 to 21, plus oral etoposide 50 mg on day 1 to 14 of a 3-week cycle until disease progression or intolerable toxicities. Etoposide was administered up to six cycles. The primary endpoint was progression-free survival (PFS). RESULTS From September 2018 to September 2021, 40 patients with advanced TNBC were enrolled. All patients received previous chemotherapy in the advanced setting, with the median previous lines of 2 (1-5). At the cut-off date on January 10, 2022, the median follow-up was 26.8 (1.6-52.0) months. The median PFS was 6.0 (95% confidence interval [CI]: 3.8-8.2) months, and the median overall survival was 24.5 (95%CI: 10.2-38.8) months. The objective response rate and disease control rate was 10.0% and 62.5%, respectively. The most common adverse events (AEs) were hypertension (65.0%), nausea (47.5%) and vomiting (42.5%). Four patients developed grade 3 AE, including two with hypertension and two with proteinuria. CONCLUSIONS Apatinib combined with oral etoposide was feasible in pretreated advanced TNBC, and was easy to administer. CLINICAL TRIAL REGISTRATION Chictr.org.cn, (registration number: ChiCTR1800018497, registration date: 20/09/2018).
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Affiliation(s)
- Mengru Cao
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hailing Lu
- The First Ward of the Oncology Department, The First Affilliated Hospital of Harbin Medical University, Harbin, China
| | - Shi Yan
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hui Pang
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lichun Sun
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Chunhong Li
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xuesong Chen
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Wei Liu
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jing Hu
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jian Huang
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Ying Xing
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Ningzhi Zhang
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yingqi Chen
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Ting He
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Danni Zhao
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yuanyuan Sun
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lin Zhao
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xiaomeng Liu
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Li Cai
- The Fourth Department of Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China.
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Liu J, Wang Y, Tian Z, Lin Y, Li H, Zhu Z, Liu Q, Su S, Zeng Y, Jia W, Yang Y, Xu S, Yao H, Jiang W, Song E. Multicenter phase II trial of Camrelizumab combined with Apatinib and Eribulin in heavily pretreated patients with advanced triple-negative breast cancer. Nat Commun 2022; 13:3011. [PMID: 35641481 PMCID: PMC9156739 DOI: 10.1038/s41467-022-30569-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/06/2022] [Indexed: 11/08/2022] Open
Abstract
In the later-line setting or for patients with PD-L1-negative tumors, immunotherapy-based regimens remain ineffective against advanced triple-negative breast cancer (TNBC). In this multicentered phase II trial (NCT04303741), 46 patients with pretreated advanced TNBC were enrolled to receive camrelizumab 200 mg (day 1), and apatinib 250 mg daily, plus eribulin 1.4 mg/m2 (day 1 and 8) on a 21-day cycle until progression, or unacceptable toxicity. Primary endpoint was objective response rate (ORR) according to RECIST 1.1. Secondary endpoints included toxicities, disease control rate (DCR), clinical benefit rate, progression-free survival (PFS), and 1-year overall survival. With a median of 3 lines of prior chemotherapy in the advanced setting, 17.4% had received PD-1/PD-L1 blockade plus chemotherapy for advanced disease. The ORR was 37.0% (17/46, 95% CI 23.2-52.5). The DCR was 87.0% (40/46, 95% CI 73.7-95.1). Median PFS was 8.1 (95% CI 4.6-10.3) months. Tertiary lymphoid structure was associated with higher ORR. Patients with lower tumor PML or PLOD3 expression had favorable ORR and PFS. PD-L1 status was not associated with ORR/PFS. Grade 3/4 treatment-related adverse events occurred in 19 (41.3%) of 46 patients. Camrelizumab plus apatinib and eribulin shows promising efficacy with a measurable safety profile in patients with heavily pretreated advanced TNBC.
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Affiliation(s)
- Jieqiong Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ying Wang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenluan Tian
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ying Lin
- Department of Breast and Thyroid Surgery, First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hengyu Li
- Department of Breast and Thyroid Surgery, Changhai Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Zhaowen Zhu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qiang Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shicheng Su
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yinduo Zeng
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Weijuan Jia
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yaping Yang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | | | - Herui Yao
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wen Jiang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Erwei Song
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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3
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Patel F, Sharma SC. Non-Surgical Management of Metastatic Breast Cancer and Palliative Care. Breast Cancer 2022. [DOI: 10.1007/978-981-16-4546-4_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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4
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Vernieri C, Prisciandaro M, Milano M, Cona MS, Maggi C, Brambilla M, Mennitto A, Fabbroni C, Farè E, Cresta S, Celio L, Mariani G, Bianchi G, Capri G, de Braud F. Single-Agent Gemcitabine vs. Carboplatin-Gemcitabine in Advanced Breast Cancer: A Retrospective Comparison of Efficacy and Safety Profiles. Clin Breast Cancer 2019; 19:e306-e318. [DOI: 10.1016/j.clbc.2018.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/26/2018] [Accepted: 12/04/2018] [Indexed: 12/13/2022]
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5
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Rinnerthaler G, Gampenrieder SP, Petzer A, Burgstaller S, Fuchs D, Rossmann D, Balic M, Egle D, Rumpold H, Singer CF, Bartsch R, Petru E, Melchardt T, Ulmer H, Mlineritsch B, Greil R. Ixazomib in combination with carboplatin in pretreated women with advanced triple-negative breast cancer, a phase I/II trial of the AGMT (AGMT MBC-10 trial). BMC Cancer 2018; 18:1074. [PMID: 30400780 PMCID: PMC6220453 DOI: 10.1186/s12885-018-4979-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/21/2018] [Indexed: 12/18/2022] Open
Abstract
Background Triple-negative breast cancer (TNBC) comprises a heterogeneous group of diseases which are generally associated with poor prognosis. Up to now, no targeted treatment beyond anti-VEGF therapy has been approved for TNBC and cytotoxic agents remain the mainstay of treatment. Ixazomib is a selective and reversible inhibitor of the proteasome, which has been mainly investigated in the treatment of multiple myeloma. In a preclinical study TNBC cells were treated with the first-generation proteasome inhibitor bortezomib in combination with cisplatin and synergistic efficacy was demonstrated. Clinical data are available for carboplatin plus bortezomib in metastatic ovarian and lung cancers showing remarkable antitumor activity and good tolerability (Mol Cancer 11:26 2012, J Thorac Oncol 4:87–92 2009, J Thorac Oncol 7:1032–1040, 2012). Based on this evidence, the phase I/II MBC-10 trial will evaluate the toxicity profile and efficacy of the second-generation proteasome inhibitor ixazomib in combination with carboplatin in patients with advanced TNBC. Methods Patients with metastatic TNBC pretreated with at least one prior line of chemotherapy for advanced disease with a confirmed disease progression and measurable disease according to RECIST criteria 1.1 are eligible for this study. Patients will receive ixazomib in combination with carboplatin on days 1, 8, and 15 in a 28-day cycle. The phase I part of this study utilizes an alternate dose escalation accelerated titration design. After establishing the maximum tolerated dose (MTD), the efficacy and safety of the combination will be further evaluated (phase II, including 41 evaluable patients). All patients will continue on study drugs until disease progression, unacceptable toxicity or discontinuation for any other reason. Primary endpoint of the phase II is overall response rate, secondary endpoints include progression-free survival, safety, and quality of life. This trial is open for patient enrollment since November 2016 in six Austrian cancer centers. Accrual is planned to be completed within 2 years. Discussion Based on preclinical and clinical findings an ixazomib and carboplatin combination is thought to be effective in metastatic TNBC patients. The MBC-10 trial is accompanied by a broad biomarker program investigating predictive biomarkers for treatment response and potential resistance mechanisms to the investigational drug combination. Trial registration EudraCT Number: 2016–001421-13 received on March 31, 2016, ClinicalTrials.gov Identifier: NCT02993094 first posted on December 15, 2016. This trial was registered prospectively.
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Affiliation(s)
- Gabriel Rinnerthaler
- IIIrd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.,Salzburg Cancer Research Institute with Laboratory of Immunological and Molecular Cancer Research and Center for Clinical Cancer and Immunology Trials, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Simon Peter Gampenrieder
- IIIrd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.,Salzburg Cancer Research Institute with Laboratory of Immunological and Molecular Cancer Research and Center for Clinical Cancer and Immunology Trials, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Andreas Petzer
- Internal Department I for Medical Oncology and Hematology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Sonja Burgstaller
- IVth Department of Internal Medicine with Hematology and Medical Oncolocy, Klinikum Wels-Grieskirchen, Wels, Austria
| | - David Fuchs
- Department of Internal Medicine 3 - Hematology and Oncology, Kepler University Hospital, Linz, Austria
| | - Dieter Rossmann
- 2nd Medical Department, County Hospital Steyr, Steyr, Austria
| | - Marija Balic
- Division of Oncology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Daniel Egle
- Department of Obstetrics and Gynaecology, Innsbruck Medical University, Innsbruck, Austria
| | - Holger Rumpold
- Department of Oncology, Hematology and Gastroenterology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Christian F Singer
- Department of Obstetrics and Gynecology, Cancer Comprehensive Center, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Department of Internal Medicine 1, Division of Oncology, Cancer Comprehensive Center, Medical University of Vienna, Vienna, Austria
| | - Edgar Petru
- Department of Obstetrics and Gynaecology, Clinical Department of Gynecology, Medical University Graz, Graz, Austria
| | - Thomas Melchardt
- IIIrd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.,Salzburg Cancer Research Institute with Laboratory of Immunological and Molecular Cancer Research and Center for Clinical Cancer and Immunology Trials, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Hanno Ulmer
- Department of Medical Statistics and Informatics, Medical University Innsbruck, Innsbruck, Austria
| | - Brigitte Mlineritsch
- IIIrd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.,Salzburg Cancer Research Institute with Laboratory of Immunological and Molecular Cancer Research and Center for Clinical Cancer and Immunology Trials, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Richard Greil
- IIIrd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria. .,Salzburg Cancer Research Institute with Laboratory of Immunological and Molecular Cancer Research and Center for Clinical Cancer and Immunology Trials, Salzburg, Austria. .,Cancer Cluster Salzburg, Salzburg, Austria.
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6
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Al-Mahmood S, Sapiezynski J, Garbuzenko OB, Minko T. Metastatic and triple-negative breast cancer: challenges and treatment options. Drug Deliv Transl Res 2018; 8:1483-1507. [PMID: 29978332 PMCID: PMC6133085 DOI: 10.1007/s13346-018-0551-3] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The major current conventional types of metastatic breast cancer (MBC) treatments include surgery, radiation, hormonal therapy, chemotherapy, or immunotherapy. Introducing biological drugs, targeted treatment and gene therapy can potentially reduce the mortality and improve the quality of life in patients with MBC. However, combination of several types of treatment is usually recommended. Triple negative breast cancer (TNBC) accounts for 10-20% of all cases of breast carcinoma and is characterized by the low expression of progesterone receptor (PR), estrogen receptor (ER), and human epidermal growth factor receptor 2 (HER2). Consequently, convenient treatments used for MBC that target these receptors are not effective for TNBC which therefore requires special treatment approaches. This review discusses the occurrence of MBC, the prognosis and predictive biomarkers of MBC, and focuses on the novel advanced tactics for treatment of MBC and TNBC. Nanotechnology-based combinatorial approach for the suppression of EGFR by siRNA and gifitinib is described.
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Affiliation(s)
- Sumayah Al-Mahmood
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ, 08854-8020, USA
| | - Justin Sapiezynski
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ, 08854-8020, USA
| | - Olga B Garbuzenko
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ, 08854-8020, USA
| | - Tamara Minko
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ, 08854-8020, USA.
- Rutgers Cancer Institute, New Brunswick, NJ, 08903, USA.
- Environmental and Occupational Health Sciences Institute, Rutgers, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA.
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Ixabepilone and Carboplatin for Hormone Receptor Positive/HER2-neu Negative and Triple Negative Metastatic Breast Cancer. Clin Breast Cancer 2018; 18:e89-e95. [DOI: 10.1016/j.clbc.2017.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 06/09/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
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8
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Rosvig LH, Langkjer ST, Knoop A, Jensen AB. Palliative treatment with carboplatin as late line therapy to patients with metastatic breast cancer. Acta Oncol 2018; 57:156-159. [PMID: 29202627 DOI: 10.1080/0284186x.2017.1407495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Lena H. Rosvig
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Sven T. Langkjer
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ann Knoop
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Anders B. Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Rau KM, Lin YC, Chen YY, Chen JS, Lee KD, Wang CH, Chang HK. Pegylated liposomal doxorubicin (Lipo-Dox®) combined with cyclophosphamide and 5-fluorouracil is effective and safe as salvage chemotherapy in taxane-treated metastatic breast cancer: an open-label, multi-center, non-comparative phase II study. BMC Cancer 2015; 15:423. [PMID: 25994543 PMCID: PMC4440506 DOI: 10.1186/s12885-015-1433-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 05/13/2015] [Indexed: 12/22/2022] Open
Abstract
Background Anthracycline and taxane are classes of drugs that are frequently used in the adjuvant and palliative settings of metastatic breast cancer (MBC); however, treatment failure occurs in most cases. Limited data demonstrated favorable response in MBC after previous taxane-based treatment. The aim of this study was to evaluate the efficacy and safety of pegylated liposomal doxorubicin (Lipo-Dox®) used as part of a combination salvage therapy for patients with MBC whose tumors progressed during or after taxane-based treatment. Methods Patients with MBC who failed to respond to previous taxane-based treatments were recruited. Treatment with pegylated liposomal doxorubicin (40 mg/m2), cyclophosphamide (500 mg/m2), and 5-fluorouracil (500 mg/m2) was administered every 3 weeks. Tumor response to treatment was determined by using the Response Evaluation Criteria in Solid Tumor criteria version 1.0, and left ventricular ejection fraction was measured before and after treatment using echocardiography. Each patient was followed for 30 days after the last dose of study medication or until resolution/stabilization of any drug-related adverse event. Results Forty-five patients were recruited. As of December 2012, the median follow-up duration was 29.8 months, the overall response rate was 41.9 %, the median progression-free survival was 8.2 months, and the median overall survival was 36.6 months for all treated patients. Grade 3/4 neutropenia, leucopenia, and neutropenic fever were observed in 14 %, 9 %, and 1 % of the cycles, respectively. Other non-hematologic adverse effects were mild to moderate and were manageable. No decrease in left ventricular ejection function was noted. Conclusion This regimen of combined of pegylated liposomal doxorubicin, cyclophosphamide, and 5-fluorouracil exhibited a promising overall response rate, progression-free survival rate, and overall survival rate, with a safe cardiac toxicity profile and manageable adverse effects. This regimen could be considered as a treatment option for patients with MBC whose tumors progressed during or after taxane-based treatment.
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Affiliation(s)
- Kun-Ming Rau
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. .,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
| | - Yung-Chang Lin
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan. .,Division of Hematology-Oncology, Department of Internal Medicine, LinKo Chang Gung Memorial Hospital, 5, Fushing St., Gueishan Township, Taoyuan, 333, Taiwan.
| | - Yen-Yang Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. .,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
| | - Jen-Shi Chen
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan. .,Division of Hematology-Oncology, Department of Internal Medicine, LinKo Chang Gung Memorial Hospital, 5, Fushing St., Gueishan Township, Taoyuan, 333, Taiwan.
| | - Kuan-Der Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Chiayia, Chiayia, Taiwan. .,Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelong, Keelong, Taiwan.
| | - Cheng-Hsu Wang
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelong, Keelong, Taiwan.
| | - Hsien-Kun Chang
- Division of Hematology-Oncology, Department of Internal Medicine, LinKo Chang Gung Memorial Hospital, 5, Fushing St., Gueishan Township, Taoyuan, 333, Taiwan.
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Brewster AM, Chavez-MacGregor M, Brown P. Epidemiology, biology, and treatment of triple-negative breast cancer in women of African ancestry. Lancet Oncol 2014; 15:e625-e634. [PMID: 25456381 DOI: 10.1016/s1470-2045(14)70364-x] [Citation(s) in RCA: 154] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Breast cancer incidence is increasing worldwide, and breast cancer-related mortality is highest in women of African ancestry, who are more likely to have basal-like or triple-negative breast cancer (TNBC) than are women of European ancestry. Identification of cultural, epidemiological, and genetic risk factors that predispose women of African ancestry to TNBC is an active area of research. Despite the aggressive behaviour of TNBC, achievement of a pathological complete response with chemotherapy is associated with good long-term survival outcomes, and sensitivity to chemotherapy does not seem to differ according to ethnic origin. Discovery of the molecular signalling molecules that define TNBC heterogeneity has led to the development of targeted agents such as inhibitors of poly (ADP-ribose) polymerase-1 and mTOR and immunomodulatory drugs that are in the early stages of clinical testing. First, we summarise the existing published work on the differences reported on the epidemiology, biology, and response to systemic treatment of TNBC between women of African ancestry and white women, and identify some gaps in knowledge. Second, we review the opportunities for development of new therapeutic agents in view of the potential high clinical relevance for patients with TNBC irrespective of race or ethnic origin.
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Affiliation(s)
- Abenaa M Brewster
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Powel Brown
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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11
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Smith NZ. Treating metastatic breast cancer with systemic chemotherapies: current trends and future perspectives. Clin J Oncol Nurs 2012; 16:E33-43. [PMID: 22459535 DOI: 10.1188/12.cjon.e33-e43] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Treatment selection for metastatic breast cancer (MBC) is guided by multiple factors, most importantly hormone receptor (HR) or HER2 expression, treatment history, and prognostic factors such as short disease-free interval, presence of visceral metastases, performance status, and degree of symptoms. Chemotherapy is indicated as initial therapy for patients with HR-negative disease and following failure of hormonal therapies in HR-positive disease. Patients treated with an anthracycline or a taxane in early-stage settings may no longer be candidates for those drugs in MBC, thus underscoring the need for alternative options. Sequential single-agent therapy or combination therapy are viable strategies. Trials have shown that ixabepilone plus capecitabine significantly improves progression-free survival compared with capecitabine alone in anthracycline- or taxane-pretreated or -resistant patients, and single-agent eribulin improves survival compared with the physician's choice of treatment in patients treated previously with at least two regimens for MBC. Regardless of the regimen, proactive management to detect treatment-related adverse events in a timely manner remains important for ensuring effective delivery of treatment. Many promising investigational agents are in development, including T-DM1 (trastuzumab emtansine) and pertuzumab for HER2-positive disease, as well as PARP-1 (poly[adenosine diphosphate ribose] polymerase-1) inhibitors and cetuximab for triple-negative disease. In addition, new options for the treatment of MBC following failure of an anthracycline and a taxane promise to improve patient outcomes. Nurses should remain vigilant for adverse events and remember that the goal of treatment remains control of the disease and palliation.
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12
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Gemcitabine and carboplatin for pretreated metastatic breast cancer: the predictive value of immunohistochemically defined subtypes. Int J Clin Oncol 2012; 18:343-9. [PMID: 22350024 DOI: 10.1007/s10147-012-0384-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 01/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND We evaluated the efficacy of gemcitabine and carboplatin for patients affected by pretreated metastatic breast cancer. A subgroup analysis was performed to evaluate the predictive value of immunohistochemically defined breast cancer subtypes. METHODS We included human epidermal growth factor 2 (HER-2) negative metastatic breast cancer resistant to previous anthracycline-based and taxane-based chemotherapy, and HER-2 positive metastatic breast cancer with at least two progressions of disease during protracted trastuzumab-based therapy. Treatment consisted of gemcitabine (1000 mg/m(2) intravenous (iv) on days 1 and 8) and carboplatin (area under the curve 5 iv on day 1) applied every 3 weeks. RESULTS Forty-two patients were registered. Disease control was 58%, with a median time-to-progression (TTP) of 7 months (range 1-12) and a median overall survival of 10.5 months (range 1-34). Patients were grouped as triple negative (ER and PR negative, HER-2 negative), HER-2 (HER-2 positive, ER and PR negative), luminal B (ER and/or PR positive and either HER-2 positive and/or high Ki67), and luminal A (ER and/or PR positive and HER-2 negative and low Ki67). For luminal A patients, disease control was lower (luminal A 34 vs. others 67%; P = 0.02), TTP was shorter (luminal A 2.4 months vs. others 6.3 months, P = 0.015), and overall survival was shorter (luminal A 7.5 months vs. others 11.7 months, P = 0.034) than for other subtypes. CONCLUSIONS Gemcitabine and carboplatin are effective for pretreated patients with metastatic breast cancer. Luminal A subtype seems to fare poorly compared with other subtypes. Specific difference in gene expression might account for the different outcome.
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Haug AR, Tiega Donfack BP, Trumm C, Zech CJ, Michl M, Laubender RP, Uebleis C, Bartenstein P, Heinemann V, Hacker M. 18F-FDG PET/CT predicts survival after radioembolization of hepatic metastases from breast cancer. J Nucl Med 2012; 53:371-7. [PMID: 22331219 DOI: 10.2967/jnumed.111.096230] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
UNLABELLED (90)Y radioembolization (selective internal radiation therapy [SIRT]) has emerged as a valuable therapeutic option in unresectable, chemotherapy-refractory hepatic metastases from breast cancer. The objective of the present study was to evaluate (18)F-FDG PET/CT for predicting survival in these patients. METHODS Fifty-eight consecutive patients with hepatic metastases from breast cancer were treated with SIRT. Before therapy, all patients underwent MRI of the liver. (18)F-FDG PET/CT was performed at baseline and 3 mo after SIRT to calculate percentage changes in maximum (18)F-FDG standardized uptake value (SUV(max)) relative to baseline. A decrease of more than 30% in the follow-up scan, compared with the baseline examination, indicated therapy response. Treatment response at 3 mo was also assessed in 43 patients using contrast-enhanced MRI and CT on the basis of the Response Evaluation Criteria in Solid Tumors. All patients were followed to complete survival data. RESULTS Overall median survival after SIRT was 47 wk. Response as assessed with SUV(max) correlated significantly with survival after radioembolization, with responders having significantly longer survival (65 wk) than nonresponders (43 wk; P < 0.05). In multivariate analysis the change in SUV(max) was identified as the only independent predictor of survival (hazard ratio, 0.23; P < 0.005). Furthermore, a high pretherapeutic SUV(max) (>20) was associated with a significantly shorter median survival than was an SUV(max) of 20 or less (21 vs. 52 wk; P < 0.005). The presence of extrahepatic metastases (mean survival in both groups, 47 wk; P = 0.92), hormone receptor status (estrogen, P = 0.53; progesterone, P = 0.79; Her-2/neu, P = 0.49), and MRI/CT response (P = 0.91) did not predict survival. CONCLUSION The change in SUV(max) as assessed by (18)F-FDG PET/CT before and 3 mo after SIRT was identified as the only independent predictor of survival in patients with hepatic metastases of breast cancer.
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Affiliation(s)
- Alexander R Haug
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany.
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Irshad S, Ashworth A, Tutt A. Therapeutic potential of PARP inhibitors for metastatic breast cancer. Expert Rev Anticancer Ther 2012; 11:1243-51. [PMID: 21916578 DOI: 10.1586/era.11.52] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Increasing understanding of the cellular aberrations inherent to cancer cells has allowed the development of therapies to target biological pathways, an important step towards individualization of breast cancer therapy. The clinical development of poly(ADP-ribose) polymerase (PARP) inhibitors, with their novel and selective mechanism of action, are an example of this strategy. PARP plays a key role in DNA repair mechanisms, particularly the base excision repair pathway. Initially developed as inhibitors able to enhance the cytotoxicity of radiation and certain DNA-damaging agents, they have more recently been shown to have single-agent activity in certain tumors. Inhibition of PARP in a DNA repair-defective tumor can lead to gross genomic instability and cell death by exploiting the paradigm of synthetic lethality. Several studies have evaluated the role of PARP inhibitors for treatment of breast cancer, particularly in the context of BRCA-mutated and triple-negative breast cancers. In addition, inhibition of PARPs repair functions for chemotherapy-induced DNA lesions has been shown to potentiate the effect of some chemotherapy regimens. This article discusses the current understanding of PARP inhibition as a treatment for metastatic breast cancer, evidence from clinical trials and addresses its future implications.
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Affiliation(s)
- Sheeba Irshad
- Breakthrough Breast Cancer Unit Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital Campus, Kings College London School of Medicine, London, SE1 9RT, UK
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Shamseddine AI, Farhat FS. Platinum-based compounds for the treatment of metastatic breast cancer. Chemotherapy 2012; 57:468-87. [PMID: 22248721 DOI: 10.1159/000334093] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 08/29/2011] [Indexed: 11/19/2022]
Abstract
The role of platinum-based compounds (PBCs) in the treatment of metastatic breast cancer (MBC) has been extensively studied. As single agents, high response rates have been observed in first-line therapy, while results in pretreated patients were discouraging. Regimens containing cisplatin/carboplatin together with taxanes showed the highest efficacy and safety as both first-line and second-line therapy. When administered with vinorelbine, the combination was also active and well tolerated in anthracycline- and taxane-pretreated patients. Combining PBCs with etoposide or nucleoside analogues showed moderate activity, yet high toxicity in the case of etoposide. The overall results for the combination with anthracyclines were disappointing. Addition of trastuzumab to PBC combinations showed remarkable activity and good tolerability in patients with HER2/neu overexpression. The use of cisplatin or carboplatin alongside novel targeted therapeutics for patients with triple-negative MBC seems promising and is being further evaluated. The use of PBCs against MBC requires careful patient selection and combination with the right chemotherapeutic agent.
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Affiliation(s)
- Ali I Shamseddine
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Lebanon.
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16
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Xu B, Jiang Z, Kim SB, Yu S, Feng J, Malzyner A, del Giglio A, Chung HC, Shen LJ, Pen DLK. Biweekly gemcitabine–paclitaxel, gemcitabine–carboplatin, or gemcitabine–cisplatin as first-line treatment in metastatic breast cancer after anthracycline failure: a phase II randomized selection trial. Breast Cancer 2011; 18:203-12. [DOI: 10.1007/s12282-011-0260-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 03/02/2011] [Indexed: 01/06/2023]
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Stemmler HJ, diGioia D, Freier W, Tessen HW, Gitsch G, Jonat W, Brugger W, Kettner E, Abenhardt W, Tesch H, Hurtz HJ, Rösel S, Brudler O, Heinemann V. Randomised phase II trial of gemcitabine plus vinorelbine vs gemcitabine plus cisplatin vs gemcitabine plus capecitabine in patients with pretreated metastatic breast cancer. Br J Cancer 2011; 104:1071-8. [PMID: 21407218 PMCID: PMC3068513 DOI: 10.1038/bjc.2011.86] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 02/11/2011] [Accepted: 02/21/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An increasing proportion of patients are exposed to anthracyclines and/or taxanes in the adjuvant or neoadjuvant setting. Re-exposure in the metastatic stage is limited by drug resistance, thus evaluation of non-cross-resistant regimens is mandatory. METHODS Anthracycline-pretreated patients were randomly assigned to three gemcitabine-based regimens. Chemotherapy consisted of gemcitabine 1.000 mg m(-2) plus vinorelbin 25 mg m(-2) on days 1+8 (GemVin), or plus cisplatin 30 mg m(-2) on days 1+8 (GemCis), or plus capecitabine 650 mg m(-2) b.i.d. orally days 1-14 (GemCap), q3w. The primary end point was response rate. RESULTS A total of 141 patients were recruited on the trial. The overall response rates were 39.0% (GemVin), 47.7% (GemCis) and 34.7% (GemCap). Median progression-free survival was estimated with 5.7, 6.9 and 8.3 months, respectively. Corresponding median survival times were 17.5 (GemVin), 13.0 (GemCis) and 19.4 months (GemCap). Neutropenia ≥grade 3 occurred in 16.7% (Gem/Vin), 4.4% (GemCis) and 0% (Gem/Cap), whereas non-haematological toxicities were rarely severe except grade 3 hand-foot syndrome in 2.0% of the GemCap patients (per patient analysis). CONCLUSIONS This randomised phase II trial has revealed comparable results for three gemcitabine-based regimens regarding treatment efficacy and toxicity. Gemcitabine-based chemotherapy appears to be a worthwhile treatment option for pretreated patients with metastatic breast cancer.
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Affiliation(s)
- H J Stemmler
- Med. Department III, Ludwig-Maximilians University of Munich, Campus Grosshadern, Munich, Germany.
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Abstract
With more and more breast cancer (BC) patients receiving taxanes and anthracyclines in the adjuvant setting, the number of patients resistant to these drugs is rising. Herein, we review cellular mechanisms (e.g., overexpression of drug efflux pumps) that are associated with clinical anthracycline and/or taxane-resistant BC. We also discuss therapeutic approaches that have received Food and Drug Administration approval in this setting or are in clinical development, including targeted agents that do not employ a cytotoxic mechanism, as well as novel chemotherapeutics such as the epothilones, a class of microtubule stabilizers less susceptible to common cellular resistance mechanisms.
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Affiliation(s)
- Amelia Zelnak
- Department of Hematology and Oncology, Emory University Winship Cancer Institute, Atlanta, Georgia 30322, USA.
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Ciruelos EM, Cortés J, Cortés-Funes H, Mayordomo JI, Bermejo B, Ojeda B, García E, Rodríguez CA, Muñoz M, Gómez P, Manso L, Andrés R, Lluch A, Saura C, Mendiola C, Baselga J. Gemcitabine and capecitabine in previously anthracycline-treated metastatic breast cancer: a multicenter phase II study (SOLTI 0301 trial). Ann Oncol 2009; 21:1442-1447. [PMID: 19940004 DOI: 10.1093/annonc/mdp536] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND On the basis of clinical activity of capecitabine and gemcitabine for metastatic breast cancer, we carried out a multicenter phase II clinical trial on the combination of these two agents in advanced anthracycline-pretreated breast cancer patients. Main objectives were to assess its efficacy and safety profile. PATIENTS AND METHODS Seventy-six anthracycline-pretreated breast cancer patients were evaluated and were stratified according to previous treatment of advanced disease (group-1: not previously treated and group-2: previously treated). Study treatment consisted of gemcitabine 1000 mg/m(2), i.v., as 30 min-infusion, days 1 and 8 every 21 days, plus oral capecitabine 830 mg/m(2) b.i.d., days 1-14 every 21 days. RESULTS Overall response rate was 61% for group-1, 48.5% for group-2 and 55.2% for the whole population. Clinical benefit rate was 73% for group-1, 80% for patients in group-2 and 76% for all patients. Median time to progression was 13.0 months for group-1, 8.2 months for group-2 and 11.1 months for the whole population. Most frequent grade 3-4 observed toxic effects per patient were neutropenia (60%), asymptomatic liver toxicity (13.5%), asthenia (14%) and hand-foot syndrome (16%). Only one patient presented febrile neutropenia. No treatment-related deaths occurred. CONCLUSION Combination of gemcitabine and capecitabine is an active and safe regimen in anthracycline-pretreated breast cancer patients.
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Affiliation(s)
- E M Ciruelos
- Medical Oncology Department, University Hospital 12 de Octubre, Madrid.
| | - J Cortés
- Medical Oncology Division, Hospital Vall d'Hebron, Barcelona
| | - H Cortés-Funes
- Medical Oncology Department, University Hospital 12 de Octubre, Madrid
| | - J I Mayordomo
- Medical Oncology Division, Hospital Clínico de Zaragoza, Zaragoza
| | - B Bermejo
- Medical Oncology Division, Hospital Clínico de Valencia, Valencia
| | - B Ojeda
- Medical Oncology Division, Hospital de Sant Pau, Barcelona
| | - E García
- Medical Oncology Division, Hospital Morales Meseguer, Murcia
| | - C A Rodríguez
- Medical Oncology Division, Hospital Clínico de Salamanca, Salamanca
| | - M Muñoz
- Medical Oncology Division, Hospital Clínico de Barcelona, Barcelona, Spain
| | - P Gómez
- Medical Oncology Division, Hospital Vall d'Hebron, Barcelona
| | - L Manso
- Medical Oncology Department, University Hospital 12 de Octubre, Madrid
| | - R Andrés
- Medical Oncology Division, Hospital Clínico de Zaragoza, Zaragoza
| | - A Lluch
- Medical Oncology Division, Hospital Clínico de Valencia, Valencia
| | - C Saura
- Medical Oncology Division, Hospital Vall d'Hebron, Barcelona
| | - C Mendiola
- Medical Oncology Department, University Hospital 12 de Octubre, Madrid
| | - J Baselga
- Medical Oncology Division, Hospital Vall d'Hebron, Barcelona
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Phase II study of gemcitabine and carboplatin in metastatic breast cancers with prior exposure to anthracyclines and taxanes. Invest New Drugs 2009; 28:859-65. [DOI: 10.1007/s10637-009-9305-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
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Dasanu CA, Herzog TJ, Alexandrescu DT. Carboplatin—gemcitabine in the therapy of advanced ovarian cancer: dose reduction consideration. J Oncol Pharm Pract 2009; 16:63-6. [DOI: 10.1177/1078155209105396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carboplatin—gemcitabine doublet is an important therapeutic option for patients with both previously treated and untreated ovarian cancer (OC). At the currently recommended dosing, its main toxicity is hematological, consisting of thrombocytopenia, neutropenia, including febrile neutropenia, and/or anemia. The use of platelet transfusions, G-CSF and/ or packed red blood cells is often necessary, in order to avoid treatment delays or omission of doses. We report here on the high efficacy of lower doses of gemcitabine at 750 mg/m2 on days 1 and 8 in combination with carboplatin AUC = 4 on day 1, repeated in 21-day cycles, in a small series of patients with advanced/metastatic OC. Using the above dose regimen, durable complete remissions were achieved in all patients in our cohort within 9—12 weeks, with no growth factor support, and no transfusions of blood components being necessary. We believe that lowering the doses of both carboplatin and gemcitabine from the start of therapy would ensure their timely delivery and steady-state plasma drug levels. In conclusion, administration of carboplatin AUC = 4 and gemcitabine 750 mg/m2 appears to be a safe and effective combination for the therapy of advanced/metastatic OC, with clinically tolerable hematological toxicity.
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Affiliation(s)
- Constantin A Dasanu
- Department of Hematology and Oncology, Saint Francis Hospital and Medical Center, Hartford, CT, USA,
| | - Thomas J Herzog
- Division of Gynecologic Oncology, Columbia University, New York Presbyterian Hospital, New York, NY, USA
| | - Doru T Alexandrescu
- Dermatology Clinical Trials Unit, University of California at San Diego, CA, USA
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