The REWRITE Study - REal-WoRld effectIveness of TrifluridinE/tipiracil in Patients with Previously Treated Metastatic Colorectal Cancer

AIMS

In the pivotal RECOURSE trial, trifluridine/tipiracil improved survival outcomes in refractory metastatic colorectal cancer (mCRC), while demonstrating an acceptable toxicity profile. Routine clinical practice evidence is important to support the ongoing value of recently approved medicines. Our objective was to assess the utilisation patterns and real-world effectiveness of trifluridine/tipiracil in previously treated mCRC patients.

MATERIALS AND METHODS

This was a retrospective observational study including consecutive patients who started trifluridine/tipiracil between 1 April 2018 and 30 September 2019 in the medical oncology departments of three major public hospitals in Portugal. The primary outcome measure was overall survival. Associations between overall survival and patient and tumour characteristics were assessed using multivariate Cox regression analyses.

RESULTS

In total, 111 patients were included in the study, with a mean age of 64 years. From these, 45.9% received two prior lines of treatment, 47.8% had three or more previous lines of treatment and 83.6% had Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at baseline. The median duration of trifluridine/tipiracil treatment was 3.7 cycles (95% confidence interval 3.4-4.1). Most patients (80.4%) remained on their planned dose throughout the trifluridine/tipiracil treatment period, fulfilling 100% relative dose intensity. The median overall survival in the total study cohort was 7.9 months (95% confidence interval 6.4-9.8) and the median progression-free survival was 3.4 months (95% confidence interval 3.2-3.9). The median overall survival was significantly higher in patients with a normal serum lactate dehydrogenase (LDH) level (median overall survival 11.2 months for [135, 205] IU/l LDH [95% confidence interval 8.2-NR] and 13.6 months for [205, 251] IU/l LDH [95% confidence interval 8.2-NR]) and in better fitted (ECOG = 0-1) patients (median overall survival 8.0 months; 95% confidence interval 6.7-10.0). The median time to worsening performance status was 6.2 months (95% confidence interval 5.0-8.0). Treatment discontinuation due to adverse events was low (3.1%).

CONCLUSION

Our study confirms the effectiveness of trifluridine/tipiracil in real-life mCRC patients. Overall survival and progression-free survival outcomes are consistent with the efficacy profile reported in the earlier randomised RECOURSE clinical trial. Like other real-world studies, we found no additional safety concerns in the use of trifluridine/tipiracil.

Beyond second-line therapy in patients with metastatic colorectal cancer: a systematic review

Background

The optimal chemotherapeutic regimen for use beyond the second line for patients with metastatic colorectal cancer (mCRC) remains unclear.

Materials and methods

We systematically searched the Cochrane Database of Systematic Reviews, EMBASE and Medline for records published between January 2002 and May 2017, and cancer congress databases for records published between January 2014 and June 2017. Eligible studies evaluated the efficacy, safety and patient-reported outcomes of monotherapies or combination therapies at any dose and number of treatment cycles for use beyond the second line in patients with mCRC. Studies were assessed for design and quality, and a qualitative data synthesis was conducted to understand the impact of treatment on overall survival and other relevant cancer-related outcomes.

Results

The search yielded 938 references of which 68 were included for qualitative synthesis. There was limited evidence to support rechallenge with chemotherapy, targeted therapy or both. Compared with placebo, an overall survival benefit for trifluridine/tipiracil (also known as TAS-102) or regorafenib has been shown for patients previously treated with conventional chemotherapy and targeted therapy. There was no evidence to suggest a difference in efficacy between these treatments. Patient choice and quality of life at this stage of treatment should also be considered when choosing an appropriate therapy.

Conclusions

These findings support the introduction of an approved agent such as trifluridine/tipiracil or regorafenib beyond the second line before any rechallenge in patients with mCRC who have failed second-line treatment.

Cytotoxic drugs for patients with breast cancer in the era of targeted treatment: back to the future?

BACKGROUND

Despite current trend of targeted therapy development, cytotoxic agents are a mainstay of treatment of patients with breast cancer. We reviewed recent advances in cytotoxic therapy for patients with metastatic breast cancer (MBC).

MATERIALS AND METHODS

Medline searches were conducted for English language studies using the term 'MBC' and 'cytotoxic drugs'. The data search was restricted to the period 2000-2011.

RESULTS

Several novel cytotoxic compounds, all microtubule inhibitors, have been approved for clinical use in MBC: (i) nab-paclitaxel, reported to improve tumour response and decrease hypersensitivity reactions in comparison with other taxanes; (ii) ixabepilone, shown to have clinical benefit in taxane- and anthracycline-resistant disease and (iii) eribulin, shown to improve overall survival in heavily pre-treated patients, when compared with best available standard treatment. Agents, such as larotaxel, vinflunine, trabectidin and formulations, including cationic liposomal paclitaxel or paclitaxel poliglumex, are currently under evaluation in phase II/III trials.

CONCLUSION

Toxicity and chemotherapy resistance are still major limitations in the treatment of patients with MBC. Further research into new cytotoxic compounds is needed in order to maximise benefit, whilst minimising toxicity.

P5-01-03: Correlation between Aromatase Expression in Metastatic and Primary Breast Cancer

Background: Estrogens are the major mitogenic factor in hormone dependent breast cancer. In postmenopausal women, estrogen production results mainly from extra-glandular conversion of androstenedione to estrone. This conversion is catalyzed by the enzyme aromatase (Aro). It is known that an higher expression and activity of the enzyme Aro is present in primary breast carcinoma compared with normal breast tissue. These data may indicate that tumors have the ability to produce their own estrogen. However, it is not known whether this process can occur at the level of metastasis. This study aims to determine the expression of aromatase in metastatic breast cancer and to analyze its correlation with expression at primary tumor and response to aromatase inhibitors (AI).

Material and Methods: We selected 41 patients with metastatic breast cancer, followed in the Department of Medical Oncology since 1995, undergoing surgery or biopsy of a metastatic lesion in the course of the disease (24 liver metastases; 10 bone metastases; 6 lung metastases; 1 lymph node metastases). For all these patients a detailed clinical chart review regarding clinical information (including treatment and tumor status) was obtained. Samples (formalin fixed and paraffin embedded) were analyzed for aromatase expression by immunohistochemistry (IHC), using the anti-aromatase monoclonal antibody # 677 (Novartis). Slides were scored considering the proportion of immunoreactive cells and intensity of the staining, and evaluating separately the epithelial and stromal component. The Fisher and log-rank test were used to determine the correlation between Aro expression in metastatic tissue and response to AI. Results: Aromatase was expressed in 51% (21/41) of the samples (13 liver metastases; 8 bone metastases). The average combined score was 130 (10 — 320). The average score was higher in the epithelial component versus the stromal component (123 vs. 17.5). There was a strong expression of Aro in bone metastases (average combined score: 176) compared with other sites.

There was no correlation between Aro expression and estrogen receptors expression. In 15 patients, it was also possible to evaluate the expression of Aro in the primary tumor. Aro was expressed in four cases (36%), with an average combined score of 52.5. The Aro expression between the primary tumor and metastasis was concordant in nine cases.

Thirty-four patients received AI to treat metastatic disease. The median time to progression (TTP) with AI in the entire population was 17.8 months. In the group of patients with Aro expression in metastasis, the median TTP in AI was 19.5 months, significantly higher than that obtained in the group without detectable Aro expression: 6.5 months (p = 0.045). The overall survival in the group with Aro expression was125 months and the 77 months in patients without Aro expression (p = 0.54).

Conclusions: Aromatase is expressed by metastatic tumor cells from breast cancer, with a positive and statistically significant correlation between its expression in the metastasis and the clinical benefit to IA. Its expression was higher in bone metastases compared with other sites of metastasis although this difference was not, in our study, statistically significant.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-03.

Multidisciplinary approach in the treatment of patients with small cell bladder carcinoma

Small cell carcinoma of the urinary bladder (SCCUB) is considered to be a tumor with a neuroendocrine phenotype characterised by aggressive behaviour and poor prognosis. Small cell carcinoma of the urinary bladder comprises 0.35 to 1% of all bladder cancers and is frequently observed in combination with other histological subtypes of carcinoma. Clinical presentation is characterized by advanced stage at diagnosis and rapidly progressive disease. In daily clinical practice there is no gold standard for the management of patients affected by this disease. Treatment of patients with limited disease combines neoadjuvant platinum-based chemotherapy followed by specific local treatment of the primary tumour. Cystectomy or radiotherapy should be proposed on an individual basis. In the metastatic setting, prognosis remains poor with a potential benefit from chemotherapy containing platinum compounds. Treatment of small cell carcinoma of the urinary bladder is based on evidence obtained from case reports and retrospective analyses. Due to low disease frequency there is a lack of randomized trials to provide guidance as to optimal therapy. Thus, systemic and local approaches are extrapolated from the literature available for the treatment of small cell carcinomas at other (non-urological) sites. We provide an overview of the currently available literature with it's main focus on the treatment of either locally advanced or metastatic small cell carcinoma of the urinary bladder.

Effect of altitude and socioeconomic status on VO2max and anaerobic power in prepubertal Bolivian girls

The aim of this work was to evaluate the effects of high altitude and low socioeconomic status (SES) on aerobic and anaerobic power in 11-yr-old Bolivian girls. At both high (3,600 m) and low (420 m) altitudes, low-SES groups of girls were compared to similarly aged, high-SES girls. At low altitude, low-SES girls were also compared with younger high-SES girls with the same anthropometric characteristics. Anthropometric data were similar between high-SES and low-SES girls at both altitudes, but low-SES girls showed a 9-mo growth delay. Maximal O2 uptake was significantly lower for low-SES girls at both altitudes. Values did not differ when expressed relative to body weight at high altitude for high-SES vs. low-SES girls (37.6 +/- 1.2 vs. 39.3 +/- 1.0 ml.min-1.kg body wt-1), but a difference persisted at low altitude between high- and low-SES girls (37.5 +/- 1.0 vs. 34.7 +/- 0.7 ml.min-1.kg body wt-1). Anaerobic power (Pmax, force-velocity test; Pwing, Wingate test) was reduced for low-SES girls at both altitudes, whatever the mode of expression. For a given SES, the relative anaerobic performances were lower at low altitude. At low altitude, low-SES girls developed lower anaerobic power than did younger high-SES girls with similar anthropometric characteristics. In conclusion, at both altitudes, the reduction of anaerobic performances observed in girls of low SES could not be totally explained by anthropometric factors. Structural and/or functional muscle alterations are suggested. Moreover, at low altitude, tropical and other factors may have contributed to differences in performance between low- and high-SES girls.

Circulating proteins and iron status in blood as indicators of the nutritional status of 10- to 12-year-old Bolivian boys

The purpose of the present study was to evaluate the nutritional status of children based on anthropometric measurements, biochemical indicators of protein energy malnutrition as well as hematological variables. The subjects were 93 10- to 12-year-old Bolivian boys: 12 HAHSES, 28 HALSES, 36 LALSES, and 17 LALSES (see Introduction to this Supplement). The overall nutritional status of the boys was evaluated by anthropometric indicators (weight for age [W/A], height for age [H bd, and weight for height [W/H]). The biochemical indicators included proteins total, albumin, prealbumin, orosomucoid and protein C-reactive (for MPE) as well as hematocrit (Ht), hemoglobin (Hb), serum iron, serum ferritin, and transferrin saturation (TS). The prevalence of growth retardation of LSES boys at HA as well as at LA was found to be high when the 3rd percentile was used as the cutoff point. The corresponding prealbumin levels were found to be lower in LSES than in HSES boys at both altitudes. The study shows that LSES boys at both altitudes have significantly lower prealbumin levels than HSES boys. The socioeconomic factor seems to be more critical for the nutritional status of prepubertal boys than altitude. The study also shows that all the boys had hematological parameters within normal range. The HA boys of both SES had higher hemoglobin concentration and hematocrits than the LA boys, a fact that is explained by high-altitude hypoxia. The hematological data do not provide evidence of malnutrition among the boys.

Effects of chronic hypoxia and exercise on plasma erythropoietin in high-altitude residents

The present study was performed to evaluate the effects of chronic inspiratory hypoxia and its combination with physical exercise on plasma erythropoietin concentration ([EPO]). Eight natives from the Bolivian Plateau were investigated at 3,600 m above sea level at rest as well as during and up to 48 h after exhaustive exercise (EE) and 60 min of submaximal (60%) cycle ergometer exercise (SE). Ten sea-level subjects were used as a control group for resting values. The mean resting plasma [EPO] of the high-altitude group (19.5 +/- 0.7 mU/ml) did not differ from that of the sea-level group (18.1 +/- 0.4 mU/ml) but was higher than would be expected from the relationship between [EPO] and hematocrit at sea level. Five hours after both types of exercise, [EPO] decreased by 2.1 +/- 0.8 (EE, P < 0.01) and 1.6 +/- 0.8 mU/ml (SE, P < 0.05); 48 h after SE, [EPO] increased by 2.6 +/- 0.9 mU/ml (P < 0.05). It is concluded that 1) high-altitude natives need relatively high [EPO] to maintain their high hematocrit and 2) exercise at low basal arterial PO2 does not directly increase plasma [EPO] in high-altitude residents but seems to exert suppressive effects.

Effect of chronic hypoxia and socioeconomic status on VO2max and anaerobic power of Bolivian boys

The aim of this work was to analyze the effects of altitude and socioeconomic and nutritional status on maximal oxygen uptake (VO2max) and anaerobic power (P) in 11-yr-old Bolivian boys. At both high (HA) (3,600 m) and low (LA) (420 m) altitudes, the boys were divided into high (HA1, n = 23, LA1, n = 48) and low (HA2, n = 44, LA2, n = 30) socioeconomic levels. Anthropometric characteristics, VO2max, and P [maximal P (Pmax) during a force-velocity test and mean P (P) during a 30-s Wingate test] were measured. Results showed that 1) anthropometric parameters were not different between HA1 and LA1 and HA2 and LA2 boys, but HA2 and LA2 boys were two years behind HA1 and LA1 boys in development; 2) VO2max was not different in boys from the same altitude, but at HA VO2max was 10% lower than at LA (HA1 = 37.2 +/- 5.6, HA2 = 38.9 +/- 6.4, LA1 = 42.5 +/- 5.8, LA2 = 42.5 +/- 5.3 ml.min-1 x kg-1 body wt); and 3) Pmax and P were higher in well-nourished than in undernourished boys, but there was no difference in Pmax and P between HA1 and LA1 and HA2 and LA2 boys (HA1 = 6.8 +/- 1.0, HA2 = 5.5 +/- 0.8, LA1 = 7.1 +/- 1.0, LA2 = 5.3 +/- 0.9 W/kg for Pmax; HA1 = 5.2 +/- 0.8, HA2 = 4.5 +/- 0.9, LA1 = 5.2 +/- 0.7, LA2 = 4.0 +/- 0.6 W/kg for P).(ABSTRACT TRUNCATED AT 250 WORDS)