Eribulin in combination with bevacizumab as second-line treatment for HER2-negative metastatic breast cancer progressing after first-line therapy with paclitaxel and bevacizumab: a multicenter, phase II, single arm trial (GIM11-BERGI)

Background

We evaluated the efficacy and safety of the nontaxane microtubule dynamics inhibitor eribulin plus the humanized anti-VEGF monoclonal antibody bevacizumab in a novel second-line chemotherapy scheme in HER2-negative metastatic breast cancer (MBC) patients progressing after first-line paclitaxel and bevacizumab.

Patients and methods

This is a multicenter, single-arm, Simon's two-stage, phase II study. The primary endpoint was the overall response rate, considered as the sum of partial and complete response based on the best overall response rate (BORR). The secondary endpoints were progression-free survival (PFS), overall survival (OS), and clinical benefit rate.

Results

A total of 58 of the 61 patients enrolled in the study were evaluable for efficacy. The BORR was 24.6% (95% CI 14.5-37.3). The clinical benefit rate was 32.8% (95% CI 21.3-46.0). The median PFS was 6.2 months (95% CI 4.0-7.8), and median OS was 14.8 months (95% CI 12.6-22.8). Overall, adverse events (AEs) were clinically manageable and the most common AEs were fatigue, paresthesia, and neutropenia. Quality of life was well preserved in most patients.

Conclusions

The results of this study suggest that second-line therapy with bevacizumab in combination with eribulin has a meaningful clinical activity and may represent a potential therapeutic option for patients with HER2-negative MBC.

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Bevacizumab + chemotherapy improved progression-free survival in HER2-negative metastatic breast cancer (MBC) patients.

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Eribulin monotherapy improved overall survival in patients with anthracycline- and taxane-pretreated MBC.

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The GIM11-BERGI trial assessed the efficacy and safety of eribulin + bevacizumab as second-line treatment for HER2-MBC.

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Eribulin + bevacizumab showed to be a safe and active treatment after progression to first-line paclitaxel + bevacizumab.

Translation and validation of the italian version of the Psychosocial Impact of Dental Aesthetics Questionnaire (pidaq) among adolescents

AIM

The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) is a valid tool aiming to evaluate the self-reported influence of dental aesthetics on quality of life. This questionnaire was developed in English for young adults, and later translated and validated with an Italian population. A new version of the questionnaire was recently introduced to be used in adolescents (11-17 years- old), but it had not been translated in Italian yet. Hence, the purpose of this study was to translate, cross-culturally adapt and validate the PIDAQ for adolescents, for its use among Italian subjects.

METHODS

To develop the Italian PIDAQ, the original version was translated, back-translated, cross-culturally adapted and pre-tested. Afterwards, the Italian PIDAQ was administered to a convenience sample of 677 subjects, aged 11-17 years, together with two other written questionnaires: the Aesthetic Component of the Index of Orthodontic Treatment Need (IOTN-AC) and the Perception of Occlusion Scale (POS), which are instruments dedicated to assess the self-reported degree of malocclusion. A one-way ANOVA was performed to assess the difference between groups, within each PIDAQ factor, according to POS and IOTN-AC scores. The correlation between PIDAQ factors and POS/IOTN-AC scores was measured as Spearman's rank correlation. The internal consistency was assessed as Cronbach's alpha coef?cient (α), and the test-retest reproducibility as Intra-Class Correlation Coef?cient (ICC).

RESULTS

The one-way ANOVA showed that all the factors of the self- reported impact of dental aesthetics on quality of life significantly increased as the degree of malocclusion worsened (P<0.001). Furthermore, all the factors showed statistically significant correlations with both IOTN-AC and POS scores. The &#945; ranged between 0.79 and 0.90, and the ICC ranged between 0.93-0.97.

CONCLUSION

The Italian adolescent PIDAQ showed good reliability and validity. The psychometric properties of this version of the questionnaire support its use for the assessment of the psychosocial impact of dental aesthetics among Italian adolescents.

Abstract P4-13-04: Not presented

This abstract was not presented at the conference.

Citation Format: Cazzaniga ME, Blasi L, Pronzato P, Giordano M, Garrone O, Donadio M, Del Mastro L, Livi L, Natoli C, Michelotti A, Turletti A, Riccardi F, De Laurentiis M, Marchetti P, Montemurro F, Romagnoli E, De Placido S, Biganzoli L, Bologna A, Bria E, Mustacchi G. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-04.

Abstract P1-12-09: Proposal for integrating the pathologic assessment of lymphovascular invasion and extranodal tumor extension in breast cancer-related lymphedema clinical management

Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to disability, representing a long-term threat to these patients. Given the extremely high incidence of breast cancer worldwide, and the increasing number of long-term survivors, the reduction of BCRL burden represents an urgent clinical need in women's healthcare. However, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL management. Here, we provide a comprehensive clinicopathological characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence.

332 cases of surgically-treated node-positive breast cancers were retrospectively collected (2-10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher's exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model.

En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p=0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p=0.01). Specifically, patients with LVI and left side localization harbored 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients.

Here, we document that LVI and ENE have a strong predictive value for BCRL occurrence. Furthermore, we confirm that the full excision of the axillary nodes is one of the major determinants of BCRL, regardless of the extent of the surgical procedure involving the breast. In conclusion, our results suggest that the pathologic data on LVI and ENE should be integrated with information on the laterality of the tumor and the type of surgical procedure. This new integrative approach could be extremely beneficial to improve BCRL risk stratification.

Citation Format: Fusco N, Corti C, Lopez G, Michelotti A, Despini L, Gambini D, Lorenzini D, Guerini-Rocco E, Maggi S, Noale M, Invernizzi M. Proposal for integrating the pathologic assessment of lymphovascular invasion and extranodal tumor extension in breast cancer-related lymphedema clinical management [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-09.

Two repetitive bouts of intense eccentric-concentric jaw exercises reduce experimental muscle pain in healthy subjects

High-intensity eccentric-concentric contractions of the jaw-closing muscles induce muscle soreness, fatigue and functional impairment of the jaw, resembling the symptoms of myalgia, according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). However, it is claimed that repetition of similar exercises can minimise these detrimental effects. This study aimed to evaluate the response of jaw-closing muscles following two series of intense eccentric-concentric exercises of the masticatory muscles in healthy subjects. Twelve pain-free participants underwent 2 sessions of intense eccentric-concentric jaw exercises, with 1-week interval in between. Each session of jaw exercises comprises 6 sets of 5-minute-long bouts of concentric-eccentric contractions. Self-reported muscle fatigue and pain, maximum mouth opening without pain (MMO), pain pressure thresholds (PPTs) of temporalis and masseter muscles and maximum voluntary bite force (MVBF) were recorded before, immediately after, 24 and 48 hours after each bout of exercises. ANOVA for repeated measurements was used to analyse the data. During session 2, muscle pain and fatigue were statistically significantly decreased (P < .05) as compared to session 1. Furthermore, statistically significant increases of MVBF (P < .005), MMO (P < .005) and PPTs (P < .005) were found at session 2 as compared to session 1. Within the limitations of the study, is can be concluded that the repetition of eccentric-concentric jaw-closing exercises results in signs of muscle training. Future studies can elucidate whether this motor training might be useful for the treatment of myalgia.

A Dose-Finding Study of Ifosfamide by Three-Day Continuous Infusion in Pretreated, Advanced Breast Cancer Patients

The purpose of the study was to establish the maximum tolerated dose of ifosfamide, administered over 72 hr, in metastatic breast cancer patients, pretreated with chemotherapy. Ifosfamide and mesna were given at the same dose, in the same solution, using a portable Pharmacia CADD-1 pump connected to a central venous access, at three dose levels: 7.5 g/m2 (6 patients), 9 g/m2 (8 patients), 10.5 g/m2 (3 patients); the courses were repeated every 3 weeks. Seventeen patients with a median age of 55 years (range, 34-68) and median performance status of 0 (range, 0-2) were treated. The patients were pretreated with a median of 2 (range, 1-3) prior regimens including anthracyclines in 14 patients and paclitaxel in 9. Dose-limiting toxicity was defined as the occurrence of any of the following events in ≥ 2/6 patients: absolute neutrophil count <500/ml for >7 days or <100/ml for >3 days; febrile neutropenia; grade 4 thrombocytopenia; any grade ≥ 3 nonhematologic toxicity. The dose-limiting toxicities were febrile neutropenia and grade 4 thrombocytopenia in 2/3 patients treated at 10.5 g/m2. Seven patients achieved an objective response (response rate 41%; 95% CI, 18% to 67%). We conclude that 72-hr infusion of ifosfamide is feasible in ambulatory patients. The recommended dose for phase II studies is 9 g/m2, with courses repeated every 21 days.

Efficacy and safety of Everolimus and Exemestane in hormone-receptor positive (HR+) human-epidermal-growth-factor negative (HER2-) advanced breast cancer patients: New insights beyond clinical trials. The EVA study

BACKGROUND

The BOLERO-2 trial reported efficacy and safety of Everolimus (EVE) and Exemestane (EXE) combination in HR+ advanced breast cancer (ABC) patients. The BALLET trial further evaluated the safety of EVE-EXE in HR+ ABC patients, without reporting efficacy data. Aim of the EVA real-life study was to collect data of efficacy and safety of EVE-EXE combination in the clinical setting, as well as exploring efficacy according to EVE Dose-Intensity (DI) and to previous treatment with Fulvestrant.

PATIENTS AND METHODS

This study aimed to describe the outcome of ABC pts treated with EVE-EXE combination in terms of median duration of EVE treatment and ORR in a real-life setting.

RESULTS

From July 2013 to December 2015, the EVA study enrolled 404 pts. Median age was 61 years (33-83). Main metastatic sites were: bone (69.1%), soft tissue (34.7%) and viscera (33.2%). Median number of previous treatments was 2 (1-7). 43.3% of the pts had received Fulvestrant. Median exposure to EVE was 31.0 weeks (15.4-58.3) in the whole population. No difference was observed in terms of EVE exposure duration according to DI (p for trend = 0.27) or type of previous treatments (p = 0.33). ORR and Disease Control Rate (DCR) were observed in 31.6% and 60.7% of the patients, respectively, with the lowest ORRs confined in CHT pre-treated patients or in those who received the lowest DI of EVE. Grade 3-4 adverse events (AEs) were reported in 37.9% of the patients. Main AEs were: stomatitis (11.2%), non-infectious pneumonitis - NIP (3.8%), anaemia (3.8%) and fatigue (3.2%).

CONCLUSIONS

The EVA study provided new insights in the use of EVE-EVE combination in HR+ ABC pts many years after the publication of the pivotal trial. The combination is safe and the best response could be obtained in patients receiving the full dose of EVE and/or after hormone-therapy as Fulvestrant in ABC.

Influence of culture on pain comorbidity in women with and without temporomandibular disorder-pain

Evidence on cultural differences in prevalence and impact of common chronic pain conditions, comparing individuals with temporomandibular disorders (TMD) versus individuals without TMD, is limited. The aim was to assess cross-cultural comorbid pain conditions in women with chronic TMD pain. Consecutive women patients (n = 122) with the index condition of chronic TMD pain diagnosed per the research diagnostic criteria for TMD and TMD-free controls (n = 121) matched for age were recruited in Saudi Arabia, Italy and Sweden. Self-report questionnaires assessed back, chest, stomach and head pain for prevalence, pain intensity and interference with daily activities. Logistic regression was used for binary variables, and ancova was used for parametric data analysis, adjusting for age and education. Back pain was the only comorbid condition with a different prevalence across cultures; Swedes reported a lower prevalence compared to Saudis (P < 0·01). Saudis reported higher prevalence of work reduced >50% due to back pain compared to Italians or Swedes (P < 0·01). Headache was the most common comorbid condition in all three cultures. The total number of comorbid conditions did not differ cross-culturally but were reported more by TMD-pain cases than TMD-free controls (P < 0·01). For both back and head pain, higher average pain intensities (P < 0·01) and interference with daily activities (P < 0·01) were reported by TMD-pain cases, compared to TMD-free controls. Among TMD-pain cases, Italians reported the highest pain-related disability (P < 0·01). Culture influences the associated comorbidity of common pain conditions. The cultural influence on pain expression is reflected in different patterns of physical representation.

Tumor-infiltrating lymphocytes and molecular response after neoadjuvant therapy for HR+/HER2- breast cancer: results from two prospective trials

PURPOSE

The aim was to evaluate the role of tumor-infiltrating lymphocytes (TIL) in predicting molecular response after preoperative endocrine or cytotoxic treatment for HR+/HER2- patients who do not achieve a pathological complete response.

METHODS

Stromal (Str) TIL were centrally evaluated on samples from diagnostic core-biopsies of HR+/HER2- patients included in two prospective randomized trials: the LETLOB trial (neoadjuvant endocrine-based treatment) and the GIOB trial (neoadjuvant chemotherapy-based treatment). Pre- and post-treatment Ki67 was centrally assessed.

RESULTS

StrTIL were evaluable in 111 cases (n = 73 from the LETLOB trial and n = 38 from the GIOB trial). Median StrTIL was 2%. Patients with high StrTIL (StrTIL ≥10%, n = 28) had more frequently breast cancer of ductal histology (p = 0.02), high grade (p = 0.049), and high Ki67 (p = 0.02). After neoadjuvant endocrine treatment (LETLOB cohort), a significant Ki67 suppression (p < 0.01) from pre- to post-treatment was observed in both the low and high StrTIL groups. High StrTIL patients achieve more frequently a relative Ki67 suppression ≥50% from baseline as compared to low StrTIL patients (55 vs. 35%, p non significant). After neoadjuvant chemotherapy (GIOB cohort), a significant Ki67 suppression was observed only for low StrTIL patients (Wilcoxon p = 0.001) and not in the high StrTIL group (p = 0.612). In this cohort, the rate of patients achieving a relative Ki67 suppression ≥50% from baseline was significantly higher in the low vs high StrTIL group (64% vs 10%, p = 0.003). Geometric mean Ki67 suppression was evaluated in each cohort according to StrTIL: the lowest value (-41%) was observed for high StrTIL cases treated with chemotherapy.

CONCLUSIONS

This hypothesis-generating study suggests that in HR+/HER2- breast cancer StrTIL at baseline may influence the achievement of a molecular response after neoadjuvant treatment. Further evaluation in large studies is needed, and interaction with the type of treatment warrants to be explored.

Abstract P5-15-07: First and further line choices of treatment for HER2-VE metastatic breast cancer (MBC) according to adjuvant treatment and biological subtype. Preliminary results of the observational “GIM-13 – AMBRA” Italian study

Frequency of CHT regimens according to biological subtypes and Setting of treatmentLuminal TumoursSettingRegimenAdj (%)1st-line (%)2nd-line (%)3rd-line (%)anthra-based (w/o Taxanes)44.27.15.19.9Anthra-Taxanes30.52.60.50CMF-like17.50.61.02.1Taxane mono/combo*6.319.314.521.5Pacliataxel + Bevacizumab020.24.33.7Platinum-based03.61.70.8Capecitabine +/- Vinorelbine019.122.217.4Eribuline002.312.4 TNBCSettingRegimenAdj (%)1st-line (%)2nd-line (%)3rd-line (%)Anthra-based (w/o Taxanes)25.73.15.116.2Anthra-Taxanes36.11.100CMF-like8.22.15.10Taxane mono/combo*6.318.417.810.8Paclitaxel + Bevacizumab024.71.70Platinum-based020.622.42.7Capecitabine +/- Vinorelbine025.720.610.8Eribuline003.429.7**Irrespectively of biological subtype, nab-paclitaxel was used in 3.6%, 15.3% and 16.4% of cases in 1st, 2nd and 3rd line, respectively

BACKGROUND

Breast Cancer prognosis improved in the last years due both to early diagnosis and Adj treatments. The choice of CHT regimens should consider previous Adj treatments, pattern of relapse and biological subtype. There are few information on the treatment of MBC in the clinical practice outside controlled trials, last study has been published 15 yrs ago in Italy.

PATIENTS AND METHODS

The GIM13-AMBRA Study is a multicenter longitudinal cohort study, describing the choice of first and subsequent lines of treatment for MBC in HER2-ve pts. We are collecting data of 30 consecutive pts from 42 Italian Centres who developed the first relapse in the years 2012-2015 and were treated with CHT, (+/- previous endocrine treatments (HT)) for MBC. One of the secondary aims is to evaluate the Time to Treatment Change (TTC) (time between treatment start and its change for any reason) as surrogate endpoint for Time To Progression outside clinical trials. The present report is focused on the choice of treatments in any line and TTC, according to biological subtypes. .

RESULTS

For the present analysis, 683 pts are evaluable. Pts with Luminal A and B tumours received CHT and HT in 65.3% (Adjuvant), 21.7% (1st line), 7.1% (2nd line) and 7% (3rd line) of the cases. The most used regimens according to tumour subtype and line of treatment are shown in Table 1.

Median TTC from 1st to 2nd line was 8.1 and 17.9 months in TNBC and Luminal tumours, respectively, whereas TTC from 2nd to 3rd line was 3.1 and 12.9 months, respectively.

CONCLUSION

Preliminary results of the AMBRA-GIM13 Italian observational study confirm that in most cases treatment for MBC is strongly related to the type of the Adj regimen, being the use of anthracyclines marginal in MBC, whereas taxanes are widely used in any line. In 1st line the most used regimens are Taxane and Bevacizumab or Capecitabine/Vinorelbine combinations. The last one remains the most used CHT in 2nd and 3rd lines. No difference have been observed according to biological subtype, except for Platinum-based regimens in TNBC. HT alone remains the preferred choice in 1st and 2nd line in Luminal cases. TTC seems to be a reliable surrogate for PFS in the “real world” practice . CHT still plays a crucial role in the treatment of MBC HER2-ve pts.

Citation Format: Mustacchi G, Cazzaniga ME, Biganzoli L, De Laurentiis M, Del Mastro L, De Placido S, Donadio M, Garrone O, Giordano M, Latini L, Livi L, Marchetti P, Michelotti A, Montemurro F, Natoli C, Pronzato P, Riccardi F, Turletti A. First and further line choices of treatment for HER2-VE metastatic breast cancer (MBC) according to adjuvant treatment and biological subtype. Preliminary results of the observational “GIM-13 – AMBRA” Italian study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-15-07.

Abstract P4-22-17: Safety of the combination of everolimus plus exemestane in the Italian cohort of patients enrolled in the expanded access “BALLET” study

Background:The expanded access “BALLET” study has been designed toevaluate the safety of EVE plus EXE combination in hormone receptor-positive (HR+), human epidermal growth factor-receptor-2-negative (HER2-) metastatic Breast Cancer (mBC). The Italian population was predominantly enrolled in trial.

Patients and methods: Patients has been included according to the inclusion and exclusion criteria provided previously in the BALLET study. The aim of our analysis was the safety everolimus and exemestane analysed in two sets of population: a subpopulation including only patients who never received chemotherapy in metastatic setting (416 patients – 36.1% of the safety population) and a subpopulation including only patients who received at least one chemotherapy in metastatic setting, whatever the line of treatment (735 patients – 63.9%).

Results:One thousand two hundred seventy nine (1279) Italian female patients were screened, 1153 (90.1% of the screened set) out of these were included in the analysis and 1151 (90.0% of the screened set) were included in the safety population. 1116 (97.0% of the safety population) prematurely discontinued the study drug and the main reasons reported were disease progression (39.1%), local reimbursement of everolimus (31.1%) and adverse event(s) (16.1%). The mean duration of study treatment exposure was 158.3±106.79 days (median 139.5) for exemestane and 153.9±108.48 days (median 135.0) for everolimus with a treatment compliance (higher than 90%) of 94.4% and 58.6% and (lower than 60%) of 0.1% and 15.1% for exemestane and everolimus, respectively. 92.5% of patients of the safety population (91.1% and . 93.3% patients without and with chemotherapy respectively) experienced at least one adverse event: gastrointestinal disorders” (67.3% vs. 64.6% in without and with chemo group); general disorders (48.6% vs. 48.3%); metabolism and nutrition disorders (35.6% vs. 37.4%) and skin and subcutaneous tissue disorders (32.2% vs. 27.5%). The incidence of everolimus related adverse events was higher (83.9%) when compared to those which occurred with exemestane. The most commonly reported adverse event was stomatitis (51.3% of patients) with 22.5% Grade 1; 18.2% Grade 2; 10.5% Grade 3; 0.2% Grade 4. The 49.7% of the patients experienced at least one stomatitis related to everolimus. No relevant difference was observed between the two groups of patients without and with chemo in metastatic setting.

Conclusions: The administration of chemotherapy before starting EVE plus EXE combination did not affect the safety profile of EXE/EVE in the treatment of mBC. The stomatitis is the most frequent and relevant adverse event to be clinically focused on.

Citation Format: Generali D, Bordonaro R, Febbraro A, Madoffa A, Romito S, Michelotti A, Savastano C, Mariani G, Tondini C, Piovano P, Iona MT, Bighin C, Roviello G, Ascione G, Goffredo F, Sartori D, Frassoldati A, Simoncini E. Safety of the combination of everolimus plus exemestane in the Italian cohort of patients enrolled in the expanded access “BALLET” study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-17.

Abstract P5-14-09: Luminal A breast cancer: Is it really a “good prognosis” disease? Prelimary results of the GIM-13 - AMBRA study

This abstract was not presented at the symposium.

Unilateral Posterior Crossbite is Not Associated with TMJ Clicking in Young Adolescents

Unilateral posterior crossbite has been considered as a risk factor for temporomandibular joint clicking, with conflicting findings. The aim of this study was to investigate a possible association between unilateral posterior crossbite and temporomandibular disk displacement with reduction, by means of a survey carried out in young adolescents recruited from three schools. The sample included 1291 participants (708 males and 583 females) with a mean age of 12.3 yrs (range, 10.1–16.1 yrs), who underwent an orthodontic and functional examination performed by two independent examiners. Unilateral posterior crossbite was found in 157 participants (12.2%). Fifty-three participants (4.1%) were diagnosed as having disk displacement with reduction. Logistic regression analysis failed to reveal a significant association between unilateral posterior crossbite and disk displacement with reduction (odds ratio = 1.3; confidence limits = 0.6–2.9). Posterior unilateral crossbite does not appear to be a risk factor for temporomandibular joint clicking, at least in young adolescents.

Safety of everolimus plus exemestane in patients with hormone-receptor-positive, HER2-negative locally advanced or metastatic breast cancer progressing on prior non-steroidal aromatase inhibitors: primary results of a phase IIIb, open-label, single-arm, expanded-access multicenter trial (BALLET)

BACKGROUND

This European phase IIIb, expanded-access multicenter trial evaluated the safety of EVE plus EXE in a patient population similar to BOLERO-2.

PATIENTS AND METHODS

Post-menopausal women aged ≥18 years with hormone receptor-positive, human epidermal growth factor-receptor-2-negative advanced breast cancer (ABC) recurring/progressing during/after prior non-steroidal aromatase inhibitors were enrolled. The primary objective was safety of EVE plus EXE based on frequency of adverse events (AEs), and serious AEs (SAEs). The secondary objective was to evaluate AEs of grade 3/4 severity.

RESULTS

The median treatment duration was 5.1 months [95% confidence interval (CI) 4.8-5.6] for EVE and 5.3 months (95% CI 4.8-5.6) for EXE. Overall, 2131 patients were included in the analysis; 81.8% of patients experienced EVE- or EXE-related or EVE/EXE-related AEs (investigator assessed); 27.2% were of grade 3/4 severity. The most frequently reported non-hematologic AEs were (overall %, % EVE-related) stomatitis (52.8%; 50.8%) and asthenia (22.8%; 14.6%). The most frequently reported hematologic AEs were (overall %, % EVE-related) anemia (14.4%; 8.1%) and thrombocytopenia (5.9%; 4.6%). AE-related treatment discontinuations were higher in elderly (≥70 years) versus non-elderly patients (23.8% versus 13.0%). The incidence of EVE-related AEs in both elderly and non-elderly patients appeared to be lower in first-line ABC versus later lines. The incidence of AEs (including stomatitis/pneumonitis) was independent of BMI status (post hoc analysis). Overall, 8.5% of patients experienced at least one EVE-related SAE. Of the 121 on-treatment deaths (5.7%), 66 (3.1%) deaths were due to disease progression and 46 (2.2%) due to AEs; 4 deaths were suspected to be EVE-related.

CONCLUSIONS

This is the largest ever reported safety dataset on a general patient population presenting ABC treated with EVE plus EXE and included a sizeable elderly subset. Although the patients were more heavily pretreated, the safety profile of EVE plus EXE in BALLET was consistent with BOLERO-2.

CLINICAL TRIAL REGISTRATION

EudraCT Number: 2012-000073-23.

Targeting immune response with therapeutic vaccines in premalignant lesions and cervical cancer: hope or reality from clinical studies

Human papillomavirus (HPV) is widely known as a cause of cervical cancer (CC) and cervical intraepithelial neoplasia (CIN). HPVs related to cancer express two main oncogenes, i.e. E6 and E7, considered as tumorigenic genes; their integration into the host genome results in the abnormal regulation of cell cycle control. Due to their peculiarities, these oncogenes represent an excellent target for cancer immunotherapy. In this work the authors highlight the potential use of therapeutic vaccines as safe and effective pharmacological tools in cervical disease, focusing on vaccines that have reached the clinical trial phase. Many therapeutic HPV vaccines have been tested in clinical trials with promising results. Adoptive T-cell therapy showed clinical activity in a phase II trial involving advanced CC patients. A phase II randomized trial showed clinical activity of a nucleic acid-based vaccine in HPV16 or HPV18 positive CIN. Several trials involving peptide-protein-based vaccines and live-vector based vaccines demonstrated that these approaches are effective in CIN as well as in advanced CC patients. HPV therapeutic vaccines must be regarded as a therapeutic option in cervical disease. The synergic combination of HPV therapeutic vaccines with radiotherapy, chemotherapy, immunomodulators or immune checkpoint inhibitors opens a new and interesting scenario in this disease.

Dental and skeletal effects of palatal expansion techniques: a systematic review of the current evidence from systematic reviews and meta-analyses

The aim was to assess the quality and to summarise the findings of the Systematic Reviews (SRs) and Meta-Analyses (MAs) on the dental and skeletal effects of maxillary expansion. Electronic and manual searches have been independently conducted by two investigators, up to February 2015. SRs and MAs on the dentoalveolar and skeletal effects of fixed expanders were included. The methodological quality was assessed using the AMSTAR (A Measurement Tool to Assess Systematic Reviews). The design of the primary studies included in each SR/MA was assessed with the LRD (Level of Research Design scoring). The evidence for each outcome was rated applying a pre-determined scale. Twelve SRs/MAs were included. The AMSTAR scores ranged from 4 to 10. Two SRs/MAs included only RCTs. The current findings from SRs/MAs support with high evidence a significant increase in the short-term of maxillary dentoalveolar transversal dimensions after Rapid Maxillary Expansion (RME). The same effect is reported with moderate evidence after Slow Maxillary Expansion (SME). However, there is moderate evidence of a non-significant difference between the two expansion modalities concerning the short-term dentoalveolar effects. With both RME and SME, significant increase of skeletal transversal dimension in the short-term is reported, and the skeletal expansion is always smaller than the dentoalveolar. Even though dental relapse to some extent is present, long-term results of the dentoalveolar effects show an increase of the transversal dimension, supported by moderate evidence for RME and low evidence for SME. Skeletal long-term effects are reported only with RME, supported by very low evidence.

Abstract P4-13-10: Stomatitis following everolimus (EVE) plus exemestane (EXE) in patients with hormone receptor-positive (HR+), HER2– advanced breast cancer (ABC) in the BALLET trial (CRAD001YIC04)

Background

Stomatitis is the most common adverse event (AE) associated with mTOR inhibitors, including EVE. In the pivotal BOLERO-2 trial, stomatitis was reported for 59% vs 12% (Gr3, 8% vs &lt;1%) of pts with HR+, HER2– ABC who received EVE + EXE vs EXE alone. Of the limited real world evidence available, the BRAWO trial showed a stomatitis incidence of 39.8% (Gr3, 3.4%) in a similar pt population. Additional data are warranted to better understand the stomatitis incidence and time-course in order to minimize treatment discontinuations.

Methods

BALLET is a Phase 3b, European, multi-center, open-label, single-arm, expanded-access study that evaluated safety of EVE (10 mg/d) and EXE (25 mg/d) in 2131 postmenopausal women with HR+, HER2– ABC that progressed on prior NSAI treatment. Primary endpoint was safety; secondary endpoint was characterization of grade 3/4 AEs. In this exploratory analysis, we split the pts in two groups based on having experienced at least one all grade stomatitis event in the first 8 wks (cut-off chosen based on reports that 89.4% of stomatitis events occurred within 8 wks of EVE initiation [Rugo, ASCO 2014]) vs none.

Results

This subgroup analysis included 919 pts with stomatitis (43.1% of the full population). Baseline pt characteristics were comparable to the overall study population, except for more comorbidity (cardiovascular and metabolic disorder) in stomatitis subset. Pts with stomatitis had a longer EVE treatment duration vs pts who didn't (5.8 mo [95%CI, 5.0-6.2] vs 4.7 mo [95%CI, 4.4-5.3]; hazard ratio, 1.121 [95%CI, 0.97-1.28] censored by pts who switched to commercial drug). The relative risk of initial onset of stomatitis at 6 wks was ∼40%; median time to onset was 28 days. Majority of stomatitis events were of grade 1/2 severity (80%); grade 3/4 stomatitis was reported for 20% of pts. Most frequent reasons for treatment discontinuation in pts with stomatitis were reimbursement (37.6%), disease progression (35.0%), and AEs (16.2%). Most frequent AEs which led to treatment discontinuation in these pts were stomatitis in 3.7% (Grade 3/4, 2%), pneumonitis in 2.9% (Grade 3/4, 1.3%) and asthenia in 1.8% (Grade 3/4, 1%). Median EVE relative dose intensity in pts with stomatitis was 0.92. In the stomatitis subset, dose interruptions and reductions were required for 66.7% and 37.6% of pts, respectively; most frequent reasons for dose adjustments were AEs (65.9%) which included stomatitis (46.8%), asthenia (6.3%), and pneumonitis (5.3%). Median time to first dose modification in pts with stomatitis was 30 days; median duration of dose interruptions was 16 days. On-treatment deaths (4.4%) were due to progressive disease (2.1%), AEs (1.7%), and other reasons (0.5%).

Conclusions

These results confirmed the stomatitis time-course observed previously and that the majority of these events are of low grade. Stomatitis was the most common cause of dose reductions and interruptions due to AEs and was manageable with dose adjustments; there was a positive association between stomatitis and longer treatment duration. Therefore, proactive management, diligent monitoring and appropriate dose modifications, are recommended to keep pts on treatment.

Citation Format: Ciruelos EM, Jerusalem G, Generali D, Lang I, Gavila JG, Michelotti A, Tjan-Heijnn VCG, Mariani G, Conte P, Beliera A, Camozzi M, Lorizzo K, Martin M. Stomatitis following everolimus (EVE) plus exemestane (EXE) in patients with hormone receptor-positive (HR+), HER2– advanced breast cancer (ABC) in the BALLET trial (CRAD001YIC04). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-10.