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Angelis V, Okines AFC. Systemic Therapies for HER2-Positive Advanced Breast Cancer. Cancers (Basel) 2023; 16:23. [PMID: 38201451 PMCID: PMC10777942 DOI: 10.3390/cancers16010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024] Open
Abstract
Despite recent advances, HER2-positive advanced breast cancer (ABC) remains a largely incurable disease, with resistance to conventional anti-HER2 drugs ultimately unavoidable for all but a small minority of patients who achieve an enduring remission and possibly cure. Over the past two decades, significant advances in our understanding of the underlying molecular mechanisms of HER2-driven oncogenesis have translated into pharmaceutical advances, with the developing of increasingly sophisticated therapies directed against HER2. These include novel, more potent selective HER2 tyrosine kinase inhibitors (TKIs); new anti-HER2 antibody-drug conjugates; and dual epitope targeting antibodies, with more advanced pharmacological properties and higher affinity. With the introduction of adjuvant T-DM1 for incomplete responders to neoadjuvant therapy, fewer patients are relapsing, but for those who do relapse, disease that may be resistant to standard first- and second-line therapies requires new approaches. Furthermore, the risk of CNS relapse has not been abrogated by current (neo)adjuvant strategies; therefore, current research efforts are being directed towards this challenging site of metastatic disease. In this article, we review the currently available clinical data informing the effective management of HER2-positive breast cancer beyond standard first-line therapy with pertuzumab, trastuzumab, and taxanes, and the management of relapse in patients who have already been exposed to both these agents and T-DM1 for early breast cancer (EBC). We additionally discuss novel anti-HER2 targeted agents and combinations in clinical trials, which may be integrated into standard treatment paradigms in the future.
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Affiliation(s)
| | - Alicia F. C. Okines
- Department of Medicine, Royal Marsden NHS Foundation Trust, Fulham Road, Chelsea, London SW3 6JJ, UK;
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Copson ER, Abraham JE, Braybrooke JP, Cameron D, McIntosh SA, Michie CO, Okines AFC, Palmieri C, Raja F, Roylance R, Spensley S. Expert UK consensus on the definition of high risk of recurrence in HER2-negative early breast cancer: A modified Delphi panel. Breast 2023; 72:103582. [PMID: 37769521 PMCID: PMC10539921 DOI: 10.1016/j.breast.2023.103582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND There is currently no standardised definition for patients at high risk of recurrence of human epidermal growth factor receptor 2 (HER2)-negative early breast cancer (eBC; stages 1-3) after surgery. This modified Delphi panel aimed to establish expert UK consensus on this definition, separately considering hormone receptor (HR)-positive and triple-negative (TN) patients. METHODS Over three consecutive rounds, results were collected from 29, 24 and 22 UK senior breast cancer oncologists and surgeons, respectively. The first round aimed to determine key risk factors in each patient subgroup; subsequent rounds aimed to establish appropriate risk thresholds. Consensus was pre-defined as ≥70% of respondents. RESULTS Expert consensus was achieved on need to assess age, tumour size, tumour grade, number of positive lymph nodes, inflammatory breast cancer and risk prediction tools in all HER2-negative patients. There was additional agreement on use of tumour profiling tests and biomarkers in HR-positive patients, and pathologic complete response (pCR) status in TN patients. Thresholds for high recurrence risk were subsequently agreed. In HR-positive patients, these included age <35 years, tumour size >5 cm (as independent risk factors); tumour grade 3 (independently and combined with other high-risk factors); number of positive nodes ≥4 (independently) and ≥1 (combined). For TN patients, the following thresholds reached consensus, both independently and in combination with other factors: tumour size >2 cm, tumour grade 3, number of positive nodes ≥1. CONCLUSIONS The results may be a valuable reference point to guide recurrence risk assessment and decision-making after surgery in the HER2-negative eBC population.
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Affiliation(s)
- E R Copson
- Cancer Sciences Academic Unit, University of Southampton, Southampton, UK.
| | - J E Abraham
- Precision Breast Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J P Braybrooke
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - D Cameron
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - S A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - C O Michie
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - A F C Okines
- The Royal Marsden NHS Foundation Trust, London, UK
| | - C Palmieri
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK; Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - F Raja
- University College London Hospitals NHS Foundation Trust, London, UK; North Middlesex University Hospital, North Middlesex University Hospital NHS Trust, London, UK
| | - R Roylance
- University College London Hospitals NHS Foundation Trust, London, UK; NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - S Spensley
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
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Turner NC, Swift C, Jenkins B, Kilburn L, Coakley M, Beaney M, Fox L, Goddard K, Garcia-Murillas I, Proszek P, Hall P, Harper-Wynne C, Hickish T, Kernaghan S, Macpherson IR, Okines AFC, Palmieri C, Perry S, Randle K, Snowdon C, Stobart H, Wardley AM, Wheatley D, Waters S, Winter MC, Hubank M, Allen SD, Bliss JM. Results of the c-TRAK TN trial: a clinical trial utilising ctDNA mutation tracking to detect molecular residual disease and trigger intervention in patients with moderate- and high-risk early-stage triple-negative breast cancer. Ann Oncol 2023; 34:200-211. [PMID: 36423745 DOI: 10.1016/j.annonc.2022.11.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Post-treatment detection of circulating tumour DNA (ctDNA) in early-stage triple-negative breast cancer (TNBC) patients predicts high risk of relapse. c-TRAK TN assessed the utility of prospective ctDNA surveillance in TNBC and the activity of pembrolizumab in patients with ctDNA detected [ctDNA positive (ctDNA+)]. PATIENTS AND METHODS c-TRAK TN, a multicentre phase II trial, with integrated prospective ctDNA surveillance by digital PCR, enrolled patients with early-stage TNBC and residual disease following neoadjuvant chemotherapy, or stage II/III with adjuvant chemotherapy. ctDNA surveillance comprised three-monthly blood sampling to 12 months (18 months if samples were missed due to coronavirus disease), and ctDNA+ patients were randomised 2 : 1 to intervention : observation. ctDNA results were blinded unless patients were allocated to intervention, when staging scans were done and those free of recurrence were offered pembrolizumab. A protocol amendment (16 September 2020) closed the observation group; all subsequent ctDNA+ patients were allocated to intervention. Co-primary endpoints were (i) ctDNA detection rate and (ii) sustained ctDNA clearance rate on pembrolizumab (NCT03145961). RESULTS Two hundred and eight patients registered between 30 January 2018 and 06 December 2019, 185 had tumour sequenced, 171 (92.4%) had trackable mutations, and 161 entered ctDNA surveillance. Rate of ctDNA detection by 12 months was 27.3% (44/161, 95% confidence interval 20.6% to 34.9%). Seven patients relapsed without prior ctDNA detection. Forty-five patients entered the therapeutic component (intervention n = 31; observation n = 14; one observation patient was re-allocated to intervention following protocol amendment). Of patients allocated to intervention, 72% (23/32) had metastases on staging at the time of ctDNA+, and 4 patients declined pembrolizumab. Of the five patients who commenced pembrolizumab, none achieved sustained ctDNA clearance. CONCLUSIONS c-TRAK TN is the first prospective study to assess whether ctDNA assays have clinical utility in guiding therapy in TNBC. Patients had a high rate of metastatic disease on ctDNA detection. Findings have implications for future trial design, emphasising the importance of commencing ctDNA testing early, with more sensitive and/or frequent ctDNA testing regimes.
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Affiliation(s)
- N C Turner
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK; Breast Unit, The Royal Marsden Hospital, London, UK.
| | - C Swift
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - B Jenkins
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - L Kilburn
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - M Coakley
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - M Beaney
- The Institute of Cancer Research, London, UK
| | - L Fox
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - K Goddard
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - P Proszek
- NIHR Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - P Hall
- University of Edinburgh, Edinburgh, UK
| | - C Harper-Wynne
- Maidstone Hospital, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - T Hickish
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - S Kernaghan
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - A F C Okines
- Breast Unit, The Royal Marsden Hospital, London, UK
| | - C Palmieri
- Clatterbridge Cancer Centre NHS Trust, Liverpool, Wirral, UK
| | - S Perry
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - K Randle
- Independent Cancer Patients' Voice, London, UK
| | - C Snowdon
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - H Stobart
- Independent Cancer Patients' Voice, London, UK
| | - A M Wardley
- Outreach Research & Innovation Group Ltd, Manchester, UK
| | - D Wheatley
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - S Waters
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK
| | - M C Winter
- Sheffield Teaching Hospitals NHS Foundation Trust, Weston Park Hospital, Sheffield, UK
| | - M Hubank
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - S D Allen
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - J M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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Cunningham N, Shepherd S, Mohammed K, Lee KA, Allen M, Johnston S, Kipps E, McGrath S, Noble J, Parton M, Ring A, Turner NC, Okines AFC. Neratinib in advanced HER2-positive breast cancer: experience from the royal Marsden hospital. Breast Cancer Res Treat 2022; 195:333-340. [PMID: 35976513 PMCID: PMC9382612 DOI: 10.1007/s10549-022-06703-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/31/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the tolerability and efficacy of neratinib as a monotherapy and in combination with capecitabine in advanced HER2-positive breast cancer in a real-world setting. METHODS Patients who received neratinib for advanced HER2-positive at the Royal Marsden Hospital NHS Trust between August 2016 and May 2020 were identified from electronic patient records and baseline characteristics, previous treatment and response to treatment were recorded. The primary endpoint of the study was progression-free survival (PFS). Secondary endpoints included overall survival (OS) and safety. RESULTS Seventy-two patients were eligible for the analysis. Forty-five patients received neratinib in combination with capecitabine and 27 patients received monotherapy. After a median duration of follow-up of 38.5 months, the median PFS for all patients was 5.9 months (95% confidence interval (CI) 4.9-7.4 months) and median OS was 15.0 months (95% Cl 10.4-22.2 months). Amongst the 52.7% (38/72) patients with confirmed brain metastases at baseline, median PFS was 5.7 months (95% CI 2.9-7.4 months) and median OS was 12.5 months (95% CI 7.7-21.4 months). Despite anti-diarrhoeal prophylaxis, diarrhoea was the most frequent adverse event, reported in 64% of patients which was grade 3 in 10%. There were no grade 4 or 5 toxicities. Seven patients discontinued neratinib due to toxicity. CONCLUSIONS Neratinib monotherapy or in combination with capecitabine is a useful treatment for patients with and without brain metastases. PFS and OS were found to be similar as previous trial data. Routine anti-diarrhoeal prophylaxis allows this combination to be safely delivered to patients in a real-world setting.
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Affiliation(s)
| | - Scott Shepherd
- The Royal Marsden Hospital, Fulham Road, London , SW3 6JJ, UK
| | - Kabir Mohammed
- The Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
| | - Karla A Lee
- The Royal Marsden Hospital, Fulham Road, London , SW3 6JJ, UK
| | - Mark Allen
- The Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
| | - Stephen Johnston
- The Royal Marsden Hospital, Fulham Road, London , SW3 6JJ, UK
- The Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
| | - Emma Kipps
- The Royal Marsden Hospital, Fulham Road, London , SW3 6JJ, UK
| | - Sophie McGrath
- The Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
| | - Jillian Noble
- The Royal Marsden Hospital, Fulham Road, London , SW3 6JJ, UK
| | - Marina Parton
- The Royal Marsden Hospital, Fulham Road, London , SW3 6JJ, UK
| | - Alistair Ring
- The Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
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Abstract
HER2 amplification heterogeneity is associated with resistance to trastuzumab emtansine in the neoadjuvant setting, emphasizing the importance of assessing whether heterogeneous HER2-positive cancers require different treatment pathways.See related article by Metzger Filho et al., p. 2474.
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Affiliation(s)
- Alicia F C Okines
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Nicholas C Turner
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom.
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Affiliation(s)
- Alicia F C Okines
- Department of Breast Oncology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Lara Ulrich
- Department of Breast Oncology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
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Ulrich L, Okines AFC. Treating Advanced Unresectable or Metastatic HER2-Positive Breast Cancer: A Spotlight on Tucatinib. Breast Cancer (Dove Med Press) 2021; 13:361-381. [PMID: 34079368 PMCID: PMC8164963 DOI: 10.2147/bctt.s268451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
The management of HER2 positive breast cancer has been transformed by the development of targeted therapies. Dual blockade with the monoclonal antibodies, trastuzumab and pertuzumab, added to first-line taxane chemotherapy and second-line therapy with the antibody-drug conjugate, T-DM1, are internationally agreed standards of care for advanced HER2 positive breast cancer, where available. However, until recently, options for patients for third-line therapy and beyond were of modest efficacy or limited by toxicity. In 2019, the results of trials of two exciting new agents for this space were presented. A third-generation HER2 tyrosine kinase inhibitor, tucatinib, combines the efficacy of the second-generation drug, neratinib, with a more manageable toxicity profile and has become a new standard of care after T-DM1, in combination with capecitabine and trastuzumab. The antibody-drug conjugate, trastuzumab deruxtecan, demonstrated remarkable efficacy in heavily pre-treated patients and received accelerated approval in the United States, whilst confirmatory Phase 3 trials are completed. This review will discuss the available data for the post-T-DM1 setting, focusing on tyrosine kinase inhibitors including tucatinib.
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Affiliation(s)
- Lara Ulrich
- Department of Breast Oncology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Alicia F C Okines
- Department of Breast Oncology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
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Okines AFC, Kipps E, Irfan T, Coakley M, Angelis V, Asare B, Mohammed K, Walsh G, Ring A, Johnston SRD, Parton M, Turner NC, Smith IE. Impact of timing of adjuvant chemothapy for early breast cancer: the Royal Marsden Hospital experience. Br J Cancer 2021; 125:299-304. [PMID: 34017085 DOI: 10.1038/s41416-021-01428-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 03/23/2021] [Accepted: 04/28/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The optimal time to deliver adjuvant chemotherapy has not been defined. METHODS A retrospective study of consecutive patients receiving adjuvant anthracycline and/or taxane 1993-2010. Primary endpoint included 5-year disease-free survival (DFS) in patients commencing chemotherapy <31 versus ≥31 days after surgery. Secondary endpoints included 5-year overall survival (OS) and sub-group analysis by receptor status. RESULTS We identified 2003 eligible patients: 1102 commenced chemotherapy <31 days and 901 ≥31 days after surgery. After a median follow-up of 115 months, there was no difference in 5-year DFS rate with chemotherapy <31 compared to ≥31 days after surgery in the overall population (81 versus 82% hazard ratio (HR) 1.15, 95% confidence interval (95% CI) 0.92-1.43, p = 0.230). The 5-year OS rate was similar in patients who received chemotherapy <31 or ≥31 days after surgery (90 versus 91%, (HR 1.21, 95% CI 0.89-1.64, p = 0.228). For 250 patients with triple-negative breast cancer OS was significantly worse in patients who received chemotherapy ≥31 versus <31 days (HR = 2.18, 95% CI 1.11-4.30, p = 0.02). DISCUSSION Although adjuvant chemotherapy ≥31 days after surgery did not affect DFS or OS in the whole study population, in TN patients, chemotherapy ≥31 days after surgery significantly reduced 5-year OS; therefore, delays beyond 30 days in this sub-group should be avoided.
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Affiliation(s)
| | - Emma Kipps
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Tazia Irfan
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Maria Coakley
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | | | - Bernice Asare
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Kabir Mohammed
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Geraldine Walsh
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Alistair Ring
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | | | - Marina Parton
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | | | - Ian E Smith
- The Royal Marsden NHS Foundation Trust, London and Surrey, UK
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Pascual J, Lim JSJ, Macpherson IR, Armstrong AC, Ring A, Okines AFC, Cutts RJ, Herrera-Abreu MT, Garcia-Murillas I, Pearson A, Hrebien S, Gevensleben H, Proszek PZ, Hubank M, Hills M, King J, Parmar M, Prout T, Finneran L, Malia J, Swales KE, Ruddle R, Raynaud FI, Turner A, Hall E, Yap TA, Lopez JS, Turner NC. Triplet Therapy with Palbociclib, Taselisib, and Fulvestrant in PIK3CA-Mutant Breast Cancer and Doublet Palbociclib and Taselisib in Pathway-Mutant Solid Cancers. Cancer Discov 2021. [PMID: 32958578 DOI: 10.1158/2159-8290.cd-20-0553/333474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Cyclin-dependent kinase 4/6 (CDK4/6) and PI3K inhibitors synergize in PIK3CA-mutant ER-positive HER2-negative breast cancer models. We conducted a phase Ib trial investigating the safety and efficacy of doublet CDK4/6 inhibitor palbociclib plus selective PI3K inhibitor taselisib in advanced solid tumors, and triplet palbociclib plus taselisib plus fulvestrant in 25 patients with PIK3CA-mutant, ER-positive HER2-negative advanced breast cancer. The triplet therapy response rate in PIK3CA-mutant, ER-positive HER2-negative cancer was 37.5% [95% confidence interval (CI), 18.8-59.4]. Durable disease control was observed in PIK3CA-mutant ER-negative breast cancer and other solid tumors with doublet therapy. Both combinations were well tolerated at pharmacodynamically active doses. In the triplet group, high baseline cyclin E1 expression associated with shorter progression-free survival (PFS; HR = 4.2; 95% CI, 1.3-13.1; P = 0.02). Early circulating tumor DNA (ctDNA) dynamics demonstrated high on-treatment ctDNA association with shorter PFS (HR = 5.2; 95% CI, 1.4-19.4; P = 0.04). Longitudinal plasma ctDNA sequencing provided genomic evolution evidence during triplet therapy. SIGNIFICANCE: The triplet of palbociclib, taselisib, and fulvestrant has promising efficacy in patients with heavily pretreated PIK3CA-mutant ER-positive HER2-negative advanced breast cancer. A subset of patients with PIK3CA-mutant triple-negative breast cancer derived clinical benefit from palbociclib and taselisib doublet, suggesting a potential nonchemotherapy targeted approach for this population.This article is highlighted in the In This Issue feature, p. 1.
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Affiliation(s)
- Javier Pascual
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom.,The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Joline S J Lim
- National University Cancer Institute, Singapore (NCIS), National University Hospital, Singapore
| | - Iain R Macpherson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Anne C Armstrong
- Department of Medical Oncology, Christie Hospital NHS Foundation Trust and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alistair Ring
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Alicia F C Okines
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Rosalind J Cutts
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Maria Teresa Herrera-Abreu
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Isaac Garcia-Murillas
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Alex Pearson
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Hrebien
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | | | - Paula Z Proszek
- Centre for Molecular Pathology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Michael Hubank
- Centre for Molecular Pathology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Margaret Hills
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Jenny King
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Mona Parmar
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Toby Prout
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Laura Finneran
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Jason Malia
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Karen E Swales
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Ruth Ruddle
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Florence I Raynaud
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Alison Turner
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Timothy A Yap
- Department of Investigational Cancer Therapeutics (Phase I Program), The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juanita S Lopez
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas C Turner
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom. .,The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom.,Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
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10
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Pascual J, Lim JSJ, Macpherson IR, Armstrong AC, Ring A, Okines AFC, Cutts RJ, Herrera-Abreu MT, Garcia-Murillas I, Pearson A, Hrebien S, Gevensleben H, Proszek PZ, Hubank M, Hills M, King J, Parmar M, Prout T, Finneran L, Malia J, Swales KE, Ruddle R, Raynaud FI, Turner A, Hall E, Yap TA, Lopez JS, Turner NC. Triplet Therapy with Palbociclib, Taselisib, and Fulvestrant in PIK3CA-Mutant Breast Cancer and Doublet Palbociclib and Taselisib in Pathway-Mutant Solid Cancers. Cancer Discov 2021; 11:92-107. [PMID: 32958578 DOI: 10.1158/2159-8290.cd-20-0553] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/11/2020] [Accepted: 09/16/2020] [Indexed: 11/16/2022]
Abstract
Cyclin-dependent kinase 4/6 (CDK4/6) and PI3K inhibitors synergize in PIK3CA-mutant ER-positive HER2-negative breast cancer models. We conducted a phase Ib trial investigating the safety and efficacy of doublet CDK4/6 inhibitor palbociclib plus selective PI3K inhibitor taselisib in advanced solid tumors, and triplet palbociclib plus taselisib plus fulvestrant in 25 patients with PIK3CA-mutant, ER-positive HER2-negative advanced breast cancer. The triplet therapy response rate in PIK3CA-mutant, ER-positive HER2-negative cancer was 37.5% [95% confidence interval (CI), 18.8-59.4]. Durable disease control was observed in PIK3CA-mutant ER-negative breast cancer and other solid tumors with doublet therapy. Both combinations were well tolerated at pharmacodynamically active doses. In the triplet group, high baseline cyclin E1 expression associated with shorter progression-free survival (PFS; HR = 4.2; 95% CI, 1.3-13.1; P = 0.02). Early circulating tumor DNA (ctDNA) dynamics demonstrated high on-treatment ctDNA association with shorter PFS (HR = 5.2; 95% CI, 1.4-19.4; P = 0.04). Longitudinal plasma ctDNA sequencing provided genomic evolution evidence during triplet therapy. SIGNIFICANCE: The triplet of palbociclib, taselisib, and fulvestrant has promising efficacy in patients with heavily pretreated PIK3CA-mutant ER-positive HER2-negative advanced breast cancer. A subset of patients with PIK3CA-mutant triple-negative breast cancer derived clinical benefit from palbociclib and taselisib doublet, suggesting a potential nonchemotherapy targeted approach for this population.This article is highlighted in the In This Issue feature, p. 1.
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Affiliation(s)
- Javier Pascual
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Joline S J Lim
- National University Cancer Institute, Singapore (NCIS), National University Hospital, Singapore
| | - Iain R Macpherson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Anne C Armstrong
- Department of Medical Oncology, Christie Hospital NHS Foundation Trust and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alistair Ring
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Alicia F C Okines
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Rosalind J Cutts
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Maria Teresa Herrera-Abreu
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Isaac Garcia-Murillas
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Alex Pearson
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Hrebien
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | | | - Paula Z Proszek
- Centre for Molecular Pathology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Michael Hubank
- Centre for Molecular Pathology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Margaret Hills
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Jenny King
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Mona Parmar
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Toby Prout
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Laura Finneran
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Jason Malia
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Karen E Swales
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Ruth Ruddle
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Florence I Raynaud
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Alison Turner
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Timothy A Yap
- Department of Investigational Cancer Therapeutics (Phase I Program), The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juanita S Lopez
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas C Turner
- Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom.
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
- Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
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11
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Affiliation(s)
- Ian E Smith
- Royal Marsden Hospital and Institute of Cancer Research, London, UK.
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12
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Smyth EC, Fassan M, Cunningham D, Allum WH, Okines AFC, Lampis A, Hahne JC, Rugge M, Peckitt C, Nankivell M, Langley R, Ghidini M, Braconi C, Wotherspoon A, Grabsch HI, Valeri N. Effect of Pathologic Tumor Response and Nodal Status on Survival in the Medical Research Council Adjuvant Gastric Infusional Chemotherapy Trial. J Clin Oncol 2016; 34:2721-7. [PMID: 27298411 PMCID: PMC5019747 DOI: 10.1200/jco.2015.65.7692] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial established perioperative epirubicin, cisplatin, and fluorouracil chemotherapy as a standard of care for patients with resectable esophagogastric cancer. However, identification of patients at risk for relapse remains challenging. We evaluated whether pathologic response and lymph node status after neoadjuvant chemotherapy are prognostic in patients treated in the MAGIC trial. MATERIALS AND METHODS Pathologic regression was assessed in resection specimens by two independent pathologists using the Mandard tumor regression grading system (TRG). Differences in overall survival (OS) according to TRG were assessed using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate analyses using the Cox proportional hazards method established the relationships among TRG, clinical-pathologic variables, and OS. RESULTS Three hundred thirty resection specimens were analyzed. In chemotherapy-treated patients with a TRG of 1 or 2, median OS was not reached, whereas for patients with a TRG of 3, 4, or 5, median OS was 20.47 months. On univariate analysis, high TRG and lymph node metastases were negatively related to survival (Mandard TRG 3, 4, or 5: hazard ratio [HR], 1.94; 95% CI, 1.11 to 3.39; P = .0209; lymph node metastases: HR, 3.63; 95% CI, 1.88 to 7.0; P < .001). On multivariate analysis, only lymph node status was independently predictive of OS (HR, 3.36; 95% CI, 1.70 to 6.63; P < .001). CONCLUSION Lymph node metastases and not pathologic response to chemotherapy was the only independent predictor of survival after chemotherapy plus resection in the MAGIC trial. Prospective evaluation of whether omitting postoperative chemotherapy and/or switching to a noncross-resistant regimen in patients with lymph node-positive disease whose tumor did not respond to preoperative epirubicin, cisplatin, and fluorouracil may be appropriate.
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Affiliation(s)
- Elizabeth C Smyth
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Matteo Fassan
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - David Cunningham
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - William H Allum
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Alicia F C Okines
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Andrea Lampis
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jens C Hahne
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Massimo Rugge
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Clare Peckitt
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Matthew Nankivell
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ruth Langley
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michele Ghidini
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Chiara Braconi
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Andrew Wotherspoon
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Heike I Grabsch
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Nicola Valeri
- Elizabeth C. Smyth, David Cunningham, William H. Allum, Alicia F.C. Okines, Clare Peckitt, Chiara Braconi, Andrew Wotherspoon, and Nicola Valeri, Royal Marsden Hospital; Andrea Lampis, Jens C. Hahne, Michele Ghidini, Chiara Braconi, and Nicola Valeri, The Institute of Cancer Research, London and Sutton; Matthew Nankivell and Ruth Langley, Medical Research Council Clinical Trials Unit at UCL, London; Heike I. Grabsch, University of Leeds, Leeds, United Kingdom; Matteo Fassan and Massimo Rugge, University of Padua, Padua, Italy; and Heike I. Grabsch, Maastricht University Medical Center, Maastricht, the Netherlands.
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13
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Davidson M, Okines AFC, Starling N. Current and Future Therapies for Advanced Gastric Cancer. Clin Colorectal Cancer 2015; 14:239-50. [PMID: 26524924 DOI: 10.1016/j.clcc.2015.05.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/29/2015] [Indexed: 12/23/2022]
Abstract
The treatment of patients with advanced gastric cancer remains a challenging area of oncology. Extensive trials of differing chemotherapy regimens have yielded no international consensus on the optimal combination, and overall survival with chemotherapy alone remains poor. Recently an improved understanding of the molecular drivers of the disease has opened up promising new avenues of treatment through the use of biological targeted agents. The anti-HER2 monoclonal antibody trastuzumab was the first targeted agent to significantly prolong survival in the first-line treatment of a molecularly-selected subgroup of patients. More recently the anti-vascular endothelial growth factor receptor 2 monoclonal antibody ramucirumab has demonstrated a modest survival benefit in previously treated patients as both a monotherapy and in combination with chemotherapy. Immunotherapy and the use of checkpoint inhibitors are a further exciting area of development with promising preliminary results for the activity of the anti-Programmed Death 1 Receptor antibody pembrolizumab and ongoing trials of a number of immune-modulating agents. Continuing research to identify novel targets and therapies aims to make further incremental gains in survival. In this review we outline the evidence base supporting current chemotherapy regimens and describe the latest advances in the development and use of molecularly targeted and immune-modulating agents.
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Affiliation(s)
- Michael Davidson
- The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Alicia F C Okines
- The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Naureen Starling
- The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom.
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14
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Okines AFC, Langley RE, Thompson LC, Stenning SP, Stevenson L, Falk S, Seymour M, Coxon F, Middleton GW, Smith D, Evans L, Slater S, Waters J, Ford D, Hall M, Iveson TJ, Petty RD, Plummer C, Allum WH, Blazeby JM, Griffin M, Cunningham D. Bevacizumab with peri-operative epirubicin, cisplatin and capecitabine (ECX) in localised gastro-oesophageal adenocarcinoma: a safety report. Ann Oncol 2012; 24:702-9. [PMID: 23108952 DOI: 10.1093/annonc/mds533] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Peri-operative chemotherapy and surgery is a standard treatment of localised oesophagogastric adenocarcinoma; however, the outcomes remain poor. PATIENTS AND METHODS ST03 is a multicentre, randomised, phase II/III study comparing peri-operative ECX with or without bevacizumab (ECX-B). The primary outcome measure of phase II (n = 200) was safety, specifically gastrointestinal (GI) perforation rates and cardiotoxicity. RESULTS Two hundred patients were randomised between October 2007 and April 2010. Ninety-one/101 (90%) ECX and 86/99 (87%) ECX-B patients completed pre-operative chemotherapy; 7 ECX and 9 ECX-B patients stopped due to toxicity. Gastrointestinal perforations (3 ECX, 1 ECX-B), cardiac events (1 ECX, 4 ECX-B) and venous thromboembolic events (VTEs, 8 ECX, 7 ECX-B) were uncommon. Arterial thromboembolic events (ATEs, myocardial infarction (MI) or cerebrovascular accident) were more frequent with ECX-B (5 versus 1 with ECX). Delayed wound healing, anastomotic leaks and GI bleeding rates were similar. More asymptomatic left ventricular ejection fraction (LVEF) falls (≥15% and/or to <50%) occurred with ECX-B (21.2% versus 11.1% with ECX). Clinically significant falls (≥10% to below lower limit of normal, LLN) occurred in (15.3%) and (8.9%) respectively, with no associated cardiac failure (median 22 months follow-up). CONCLUSIONS Addition of bevacizumab to peri-operative ECX chemotherapy is feasible with acceptable toxicity and no negative impact on surgical outcomes.
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Affiliation(s)
- A F C Okines
- Department of Medicine, The Royal Marsden Hospital NHS Foundation Trust London & Surrey SM2 5PT, London
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15
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Abstract
Oesophageal cancer is the eighth most common cancer diagnosed worldwide, with almost half a million new cases diagnosed each year. Despite improvements in surgical and radiotherapy techniques and refinements of chemotherapeutic regimens, long-term survival, even from localized oesophageal cancer, remains poor. Surgical resection alone remains the standard approach for very early stage disease (stage I), but whilst surgery remains fundamental to the treatment of stage II-III resectable adenocarcinoma, multimodality therapy with chemotherapy or chemoradiation (CRT) is internationally accepted as the standard of care. Data from two large, randomized phase III trials support the use of perioperative combination chemotherapy in lower oesophageal and oesophagogastric junction adenocarcinomas, but the contribution of the adjuvant therapy is uncertain. There are conflicting data from randomized studies of a purely neoadjuvant approach; however, recent meta-analyses have demonstrated that chemotherapy or CRT given prior to radical surgery improves survival in patients with adenocarcinoma of the oesophagus. Neoadjuvant CRT but not chemotherapy alone is also beneficial for patients with squamous cell carcinoma. Definitive CRT has emerged as a useful option for the treatment of resectable squamous cell carcinoma of the oesophagus, avoiding potential surgical morbidity and mortality for most patients, with salvage surgery reserved for those with persistent disease. In this review, we focus on the pharmacotherapy of resectable oesophageal and oesophagogastric junction cancers and how clinical trials and meta-analyses inform current clinical practice.
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16
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Abstract
Oesophageal cancer is the eighth most common cancer diagnosed worldwide, with almost half a million new cases diagnosed each year. Despite improvements in surgical and radiotherapy techniques and refinements of chemotherapeutic regimens, long-term survival, even from localized oesophageal cancer, remains poor. Surgical resection alone remains the standard approach for very early stage disease (stage I), but whilst surgery remains fundamental to the treatment of stage II-III resectable adenocarcinoma, multimodality therapy with chemotherapy or chemoradiation (CRT) is internationally accepted as the standard of care. Data from two large, randomized phase III trials support the use of perioperative combination chemotherapy in lower oesophageal and oesophagogastric junction adenocarcinomas, but the contribution of the adjuvant therapy is uncertain. There are conflicting data from randomized studies of a purely neoadjuvant approach; however, recent meta-analyses have demonstrated that chemotherapy or CRT given prior to radical surgery improves survival in patients with adenocarcinoma of the oesophagus. Neoadjuvant CRT but not chemotherapy alone is also beneficial for patients with squamous cell carcinoma. Definitive CRT has emerged as a useful option for the treatment of resectable squamous cell carcinoma of the oesophagus, avoiding potential surgical morbidity and mortality for most patients, with salvage surgery reserved for those with persistent disease. In this review, we focus on the pharmacotherapy of resectable oesophageal and oesophagogastric junction cancers and how clinical trials and meta-analyses inform current clinical practice.
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17
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Abstract
The possibility of targeting tumor angiogenesis was postulated almost 40 years ago. The vascular endothelial growth factor (VEGF) family and its receptors have since been characterized and extensively studied. VEGF overexpression is a common finding in solid tumors, including esophagogastric cancer, and frequently correlates with poor prognosis. Monoclonal antibodies, soluble receptors, and small-molecule tyrosine kinase inhibitors have been developed to inhibit tumor angiogenesis, and antiangiogenic therapy is now a component of standard treatment for advanced renal cell, hepatocellular, colorectal, breast, and non-small cell lung carcinomas. The small-molecule tyrosine kinase inhibitors sunitinib and sorafenib have been evaluated in phase II studies in esophagogastric cancer but appear to have only modest activity. Similarly, despite promising efficacy signals from phase II studies, the addition of the anti-VEGF-A monoclonal antibody bevacizumab to cisplatin plus capecitabine failed to result in a longer overall survival duration than with the chemotherapy doublet plus placebo. The response rate and progression-free survival interval were significantly greater with bevacizumab, confirming some efficacy in advanced gastric cancer, but with inadequate benefit to justify the high cost of treatment. Evaluation of bevacizumab in the neoadjuvant and perioperative settings continues, hypothesizing that a higher response rate will translate into longer survival in patients with operable disease. Despite extensive research, the discovery of a reliable predictive biomarker for antiangiogenic therapy continues to elude the scientific and oncology communities, and mechanisms of primary and acquired resistance are incompletely understood. We are therefore currently unable to personalize antiangiogenic therapy for established indications, or use molecular selection for clinical trials evaluating novel indications.
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MESH Headings
- Adenocarcinoma/drug therapy
- Angiogenesis Inhibitors/therapeutic use
- Animals
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/therapeutic use
- Benzenesulfonates/therapeutic use
- Bevacizumab
- Biomarkers, Tumor
- Clinical Trials, Phase III as Topic
- Disease Models, Animal
- Disease-Free Survival
- Esophageal Neoplasms/drug therapy
- Gene Expression Regulation, Neoplastic
- Humans
- Indoles/therapeutic use
- Neovascularization, Pathologic/drug therapy
- Niacinamide/analogs & derivatives
- Phenylurea Compounds
- Polymorphism, Genetic
- Protein Kinase Inhibitors/therapeutic use
- Pyridines/therapeutic use
- Pyrroles/therapeutic use
- Randomized Controlled Trials as Topic
- Receptors, Vascular Endothelial Growth Factor/antagonists & inhibitors
- Sorafenib
- Sunitinib
- Vascular Endothelial Growth Factor A/antagonists & inhibitors
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Affiliation(s)
- Alicia F C Okines
- The Royal Marsden Hospital NHS Foundation Trust London & Surrey, Surrey, UK
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18
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Abstract
The possibility of targeting tumor angiogenesis was postulated almost 40 years ago. The vascular endothelial growth factor (VEGF) family and its receptors have since been characterized and extensively studied. VEGF overexpression is a common finding in solid tumors, including esophagogastric cancer, and frequently correlates with poor prognosis. Monoclonal antibodies, soluble receptors, and small-molecule tyrosine kinase inhibitors have been developed to inhibit tumor angiogenesis, and antiangiogenic therapy is now a component of standard treatment for advanced renal cell, hepatocellular, colorectal, breast, and non-small cell lung carcinomas. The small-molecule tyrosine kinase inhibitors sunitinib and sorafenib have been evaluated in phase II studies in esophagogastric cancer but appear to have only modest activity. Similarly, despite promising efficacy signals from phase II studies, the addition of the anti-VEGF-A monoclonal antibody bevacizumab to cisplatin plus capecitabine failed to result in a longer overall survival duration than with the chemotherapy doublet plus placebo. The response rate and progression-free survival interval were significantly greater with bevacizumab, confirming some efficacy in advanced gastric cancer, but with inadequate benefit to justify the high cost of treatment. Evaluation of bevacizumab in the neoadjuvant and perioperative settings continues, hypothesizing that a higher response rate will translate into longer survival in patients with operable disease. Despite extensive research, the discovery of a reliable predictive biomarker for antiangiogenic therapy continues to elude the scientific and oncology communities, and mechanisms of primary and acquired resistance are incompletely understood. We are therefore currently unable to personalize antiangiogenic therapy for established indications, or use molecular selection for clinical trials evaluating novel indications.
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MESH Headings
- Adenocarcinoma/drug therapy
- Angiogenesis Inhibitors/therapeutic use
- Animals
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/therapeutic use
- Benzenesulfonates/therapeutic use
- Bevacizumab
- Biomarkers, Tumor
- Clinical Trials, Phase III as Topic
- Disease Models, Animal
- Disease-Free Survival
- Esophageal Neoplasms/drug therapy
- Gene Expression Regulation, Neoplastic
- Humans
- Indoles/therapeutic use
- Neovascularization, Pathologic/drug therapy
- Niacinamide/analogs & derivatives
- Phenylurea Compounds
- Polymorphism, Genetic
- Protein Kinase Inhibitors/therapeutic use
- Pyridines/therapeutic use
- Pyrroles/therapeutic use
- Randomized Controlled Trials as Topic
- Receptors, Vascular Endothelial Growth Factor/antagonists & inhibitors
- Sorafenib
- Sunitinib
- Vascular Endothelial Growth Factor A/antagonists & inhibitors
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Affiliation(s)
- Alicia F C Okines
- The Royal Marsden Hospital NHS Foundation Trust London & Surrey, Surrey, UK
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Hawkes EA, Okines AFC, Plummer C, Cunningham D. Cardiotoxicity in patients treated with bevacizumab is potentially reversible. J Clin Oncol 2011; 29:e560-2. [PMID: 21606423 DOI: 10.1200/jco.2011.35.5008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
MESH Headings
- Angiogenesis Inhibitors/administration & dosage
- Angiogenesis Inhibitors/adverse effects
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bevacizumab
- Breast Neoplasms/complications
- Breast Neoplasms/drug therapy
- Capecitabine
- Clinical Trials as Topic/statistics & numerical data
- Clinical Trials, Phase II as Topic/statistics & numerical data
- Cyclophosphamide/administration & dosage
- Deoxycytidine/administration & dosage
- Deoxycytidine/analogs & derivatives
- Dose-Response Relationship, Drug
- Doxorubicin/administration & dosage
- Doxorubicin/adverse effects
- Drug Labeling
- Early Termination of Clinical Trials
- Epirubicin/administration & dosage
- Epirubicin/adverse effects
- Female
- Fluorouracil/administration & dosage
- Fluorouracil/analogs & derivatives
- Heart Failure/chemically induced
- Heart Failure/prevention & control
- Humans
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Meta-Analysis as Topic
- Paclitaxel/administration & dosage
- Prednisone/administration & dosage
- Razoxane/therapeutic use
- Remission, Spontaneous
- Rituximab
- Trastuzumab
- Vincristine/administration & dosage
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20
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Hawkes E, Okines AFC, Papamichael D, Rao S, Ashley S, Charalambous H, Koukouma A, Chau I, Cunningham D. Docetaxel and irinotecan as second-line therapy for advanced oesophagogastric cancer. Eur J Cancer 2011; 47:1146-51. [PMID: 21269822 DOI: 10.1016/j.ejca.2010.12.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 12/10/2010] [Accepted: 12/15/2010] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Systemic chemotherapy improves survival in oesophagogastric cancer however no standard second-line regimen exists due to a paucity of randomised data. Docetaxel combined with irinotecan (DI) provides a suitable option due to the lack of cross-reactivity with first-line therapeutics and a tolerable toxicity profile. METHODS We retrospectively reviewed a cohort of patients with advanced oesophagogastric cancer in two institutions treated with the combination of docetaxel 35 mg/m(2) plus irinotecan 60 mg/m(2) day 1 and day 8 every 21 days, following progression with first-line platinum-based therapy. RESULTS Between January 2000 and September 2009, 41 eligible patients were identified. Median age was 58 years, male:female 25:16, adenocarcinoma:squamous cell carcinoma 37:4, oesophageal:oesophagogastric junction:gastric 7:10:24. Locally advanced:metastatic disease 6:35. Previous radical surgery:radiotherapy:both 6:4:7. 27/41 had progressed within 90 days of receiving platinum-based therapy. Median number of chemotherapy cycles: 3 (range 1-12). Eight patients required dose reductions due to DI toxicity. 10/28 evaluable patients had a response, median progression-free survival (PFS) was 11 weeks (95% confidence intervals (CI): 9-13 weeks) with median overall survival 24 weeks (95%CI: 12-35 weeks). No significant prognostic factors were identified. CONCLUSION Weekly docetaxel combined with irinotecan has acceptable safety and modest efficacy in the second-line treatment of advanced oesophagogastric cancer. Further prospective evaluation of this regimen is warranted.
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Affiliation(s)
- Eliza Hawkes
- The Royal Marsden Hospital, London and Surrey, UK
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21
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Okines AFC, Ashley SE, Cunningham D, Oates J, Turner A, Webb J, Saffery C, Chua YJ, Chau I. Epirubicin, oxaliplatin, and capecitabine with or without panitumumab for advanced esophagogastric cancer: dose-finding study for the prospective multicenter, randomized, phase II/III REAL-3 trial. J Clin Oncol 2010; 28:3945-50. [PMID: 20679619 DOI: 10.1200/jco.2010.29.2847] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Epirubicin, oxaliplatin, and capecitabine (EOC) is a standard treatment in advanced esophagogastric cancer. Panitumumab (P) is a fully human, immunoglobulin G2 monoclonal antibody targeting epidermal growth factor receptor. Randomized Trial of EOC +/- Panitumumab for Advanced and Locally Advanced Esophagogastric Cancer (REAL-3) will evaluate whether the addition of P to EOC improves survival in patients with advanced esophagogastric adenocarcinoma and undifferentiated carcinoma. PATIENTS AND METHODS The original design of REAL-3 added P 9 mg/kg to the standard dose of EOC (dose level [DL] + 1). Due to toxicity, a dose de-escalation was made to EOC + P DL-1 (epirubicin 50 mg/m(2), oxaliplatin130 mg/m(2), capecitabine 1,000 mg/m(2)/d + P 9 mg/kg every 3 weeks). After additional toxicity was observed, the study was amended to include two additional EOC + P dose levels. Using a 3 + 3 design, dose-limiting toxicities (DLTs) were assessed weekly during cycle 1. Patients were randomly assigned 1:1 to EOC +/- P. RESULTS Between July 2008 and October 2009, 29 patients were randomly selected for standard-dose EOC (n = 13) or EOC + P (n = 16). Five patients were treated at DL + 1, with grade 3 diarrhea in four of five patients by cycle 4. At DL-1, one patient had grade 3 diarrhea and grade 5 infection. Three patients were treated at DL-3, and then six were treated at DL-2, without DLTs. CONCLUSION The recommended dose for EOC + P is epirubicin 50 mg/m(2), oxaliplatin 100 mg/m(2), capecitabine 1,000 mg/m(2)/d, and P 9 mg/kg every 3 weeks. This dose has been selected for the ongoing phase II/III REAL-3 study.
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22
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Okines AFC, Hawkes EA, Rao S, VAN As N, Marsh H, Riddell A, Wilson POG, Osin P, Wotherspoon AC. Metastatic breast cancer presenting as a primary hindgut neuroendocrine tumour. Anticancer Res 2010; 30:3015-3018. [PMID: 20683048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The examination of limited, potentially non-representative fragments of tumour tissue from a core biopsy can be misleading and misdirect subsequent treatment, especially in cases where a primary tumour has not been identified. This case report is of a 65-year-old woman presenting with a destructive sacral mass, diagnosed on radiological imaging and core biopsy as a hindgut neuroendocrine tumour, which on histopathological review of the subsequently resected tumour was found instead to represent a metastasis from an occult hormone-positive breast cancer with neuroendocrine features.
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Affiliation(s)
- Alicia F C Okines
- Department of Medicine, Royal Marsden Hospital, Downs Road, Sutton, Surrey, SM2 5PT, U.K
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23
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Abstract
Trastuzumab is a fully humanised monoclonal antibody directed at the human epidermal growth factor receptor-2 (HER-2) which has been a component of standard therapy for advanced and resected HER-2-positive breast cancers for almost a decade. HER-2 over-expression, defined as HER-2 protein over-expression using immunohistochemistry scored as 3+ and/or erbB-2 amplification detected by fluorescent in situ hybridisation, was detected in 22.1% of 3807 patients with advanced gastric and oesophagogastric junction (OGJ) adenocarcinoma screened for eligibility for the phase III ToGA study. The validated scoring system for HER-2 positivity in gastric cancers differs from that recommended for breast cancer due to an increased frequency of incomplete membranous immunoreactivity and heterogeneity of HER-2 expression in gastric cancers. The highest rates of HER-2 over-expression are observed in patients with OGJ rather than gastric tumours and intestinal-type rather than diffuse or mixed histology. The international multicentre randomised phase III ToGA study assessed the addition of trastuzumab to a cisplatin plus fluoropyrimidine (FP) chemotherapy doublet for patients with HER-2-positive advanced gastric or OGJ adenocarcinoma. The investigators reported a clinically and statistically significant benefit in terms of response rate (47.3% versus 34.5%, p=0.0017), median progression-free survival (6.7 versus 5.5 months, p=0.0002) and median overall survival (13.8 versus 11.1 months, p=0.0046). Trastuzumab plus FP chemotherapy is now the standard of care for patients with advanced gastric and OGJ cancers which over-express HER-2. Further research to evaluate trastuzumab delivered beyond progression, in combination with alternative first-line chemotherapy regimens, and in the perioperative and adjuvant setting is urgently needed. Additionally, research into mechanisms of resistance and strategies to overcome primary or acquired resistance to trastuzumab must now be expedited, using lessons learnt over the past decade in HER-2-positive breast cancer to maximise the benefit from this agent.
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24
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25
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Okines AFC, Norman AR, McCloud P, Kang YK, Cunningham D. Meta-analysis of the REAL-2 and ML17032 trials: evaluating capecitabine-based combination chemotherapy and infused 5-fluorouracil-based combination chemotherapy for the treatment of advanced oesophago-gastric cancer. Ann Oncol 2009; 20:1529-1534. [PMID: 19474114 DOI: 10.1093/annonc/mdp047] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The REAL-2 and ML17032 trials demonstrated that the oral fluoropyrimidine, capecitabine, is noninferior to 5-fluorouracil (5-FU) for overall survival (OS) and progression-free survival (PFS), respectively, in advanced oesophago-gastric cancer. METHODS Individual patient data were collected on all patients randomised within the trials (n = 1318). Kaplan-Meier survival curves were generated and the log-rank test was used to compare OS and PFS between patients receiving 5-FU combinations and capecitabine combinations. Stepwise multivariate Cox regression analysis was used to calculate corrected hazard ratios (HRs) and 95% confidence intervals (CIs) for OS and PFS. Logistic regression was used for objective response rate. Forest plots with tests of heterogeneity were generated. RESULTS OS was superior in the 654 patients treated with capecitabine combinations compared with the 664 patients treated with 5-FU combinations; HR 0.87 (95% CI 0.77-0.98, P = 0.02). Poor performance status, age <60 and metastatic disease were independent predictors of poor survival. There was no significant difference in PFS between treatment groups on multivariate analysis. Assessable patients treated with capecitabine combinations were significantly more likely to have an objective response to treatment than those treated with 5-FU combinations; odds ratio 1.38 (95% CI 1.10-1.73, P = 0.006). CONCLUSION OS is superior in patients treated with capecitabine combinations compared with 5-FU combinations in advanced oesophago-gastric cancer.
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Affiliation(s)
- A F C Okines
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - A R Norman
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - P McCloud
- Roche Products Pty Ltd, Dee Why, Australia
| | - Y-K Kang
- Division of Oncology, Department of Internal Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Songpa Gu, Seoul, South Korea
| | - D Cunningham
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK.
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26
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Okines AFC, Morris R, Hancock BW. An evaluation of FIGO 2000: the first 5 years. J Reprod Med 2008; 53:615-622. [PMID: 18773627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To evaluate the International Federation of Gynecology and Obstetrics 2000 Gestational Trophoblastic Neoplasia (GTN) staging and classification system and to identify any factors predictive of failure of first-line chemotherapy. STUDY DESIGN Patients registered at 1 center between January 2000 and December 2004 (n = 2,209) were identified from a dedicated database. Data were collected on all patients who received treatment for GTN at the center (n = 132). Survival analysis (Kaplan Meier method) and chi2 tests were performed. RESULTS One hundred twenty-two eligible patients were identified. Of those, 38 of 107 (35.5%) of patients who scored as low risk and 2 of 15 (13.3%) of patients who scored as high risk required salvage chemotherapy. Three of 107 (2.8%) of low-risk patients and 3 of 15 (20%) of high-risk patients had salvage surgery. No statistically significant predictive factors for treatment failure were identified. There was a trend toward association with increased age at diagnosis: 48.8% of patients aged > or = 30 required second-line therapy compared to 33.3% aged < 30 (p = 0.098). CONCLUSION Approximately one third of women treated on the low-risk regimen will require salvage chemotherapy, but this does not affect their survival. Women aged > or = 30 may be at particular risk of treatment failure so could be offered high-risk chemotherapy from the outset.
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Affiliation(s)
- Alicia F C Okines
- Department of Medicine, The Royal Marsden Hospital, Sutton, Surrey, UK
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