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Christopoulos P, Harel M, McGregor K, Brody Y, Puzanov I, Bar J, Elon Y, Sela I, Yellin B, Lahav C, Raveh S, Reiner-Benaim A, Reinmuth N, Nechushtan H, Farrugia D, Bustinza-Linares E, Lou Y, Leibowitz R, Kamer I, Zer Kuch A, Moskovitz M, Levy-Barda A, Koch I, Lotem M, Katzenelson R, Agbarya A, Price G, Cheley H, Abu-Amna M, Geldart T, Gottfried M, Tepper E, Polychronis A, Wolf I, Dicker AP, Carbone DP, Gandara DR. Plasma Proteome-Based Test for First-Line Treatment Selection in Metastatic Non-Small Cell Lung Cancer. JCO Precis Oncol 2024; 8:e2300555. [PMID: 38513170 PMCID: PMC10965206 DOI: 10.1200/po.23.00555] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/15/2023] [Accepted: 01/25/2024] [Indexed: 03/23/2024] Open
Abstract
PURPOSE Current guidelines for the management of metastatic non-small cell lung cancer (NSCLC) without driver mutations recommend checkpoint immunotherapy with PD-1/PD-L1 inhibitors, either alone or in combination with chemotherapy. This approach fails to account for individual patient variability and host immune factors and often results in less-than-ideal outcomes. To address the limitations of the current guidelines, we developed and subsequently blindly validated a machine learning algorithm using pretreatment plasma proteomic profiles for personalized treatment decisions. PATIENTS AND METHODS We conducted a multicenter observational trial (ClinicalTrials.gov identifier: NCT04056247) of patients undergoing PD-1/PD-L1 inhibitor-based therapy (n = 540) and an additional patient cohort receiving chemotherapy (n = 85) who consented to pretreatment plasma and clinical data collection. Plasma proteome profiling was performed using SomaScan Assay v4.1. RESULTS Our test demonstrates a strong association between model output and clinical benefit (CB) from PD-1/PD-L1 inhibitor-based treatments, evidenced by high concordance between predicted and observed CB (R2 = 0.98, P < .001). The test categorizes patients as either PROphet-positive or PROphet-negative and further stratifies patient outcomes beyond PD-L1 expression levels. The test successfully differentiates between PROphet-negative patients exhibiting high tumor PD-L1 levels (≥50%) who have enhanced overall survival when treated with a combination of immunotherapy and chemotherapy compared with immunotherapy alone (hazard ratio [HR], 0.23 [95% CI, 0.1 to 0.51], P = .0003). By contrast, PROphet-positive patients show comparable outcomes when treated with immunotherapy alone or in combination with chemotherapy (HR, 0.78 [95% CI, 0.42 to 1.44], P = .424). CONCLUSION Plasma proteome-based testing of individual patients, in combination with standard PD-L1 testing, distinguishes patient subsets with distinct differences in outcomes from PD-1/PD-L1 inhibitor-based therapies. These data suggest that this approach can improve the precision of first-line treatment for metastatic NSCLC.
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Affiliation(s)
- Petros Christopoulos
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | | | | | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- The Roswell Park Comprehensive Cancer Center Data Bank and BioRepository
| | - Jair Bar
- Institute of Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | | | | | | | | | | | - Anat Reiner-Benaim
- Department of Epidemiology, Biostatistics and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Niels Reinmuth
- Asklepios Kliniken GmbH, Asklepios Fachkliniken Muenchen, Gauting, Germany
- The German Center for Lung Research (DZL), Munich-Gauting, Germany
| | - Hovav Nechushtan
- Oncology Laboratory, Sharett Institute of Oncology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Yanyan Lou
- Division of Hematology and Oncology, Mayo Clinic School of Medicine, Jacksonville, FL
| | - Raya Leibowitz
- Shamir Medical Center, Oncology Institute, Zerifin, Israel
| | - Iris Kamer
- Institute of Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alona Zer Kuch
- Department of Oncology, Rambam Medical Center, Haifa, Israel
| | - Mor Moskovitz
- Thoracic Cancer Service, Davidoff Cancer Center, Beilinson, Petah Tikva, Israel
| | - Adva Levy-Barda
- Biobank, Department of Pathology, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Ina Koch
- Asklepios Kliniken GmbH, Asklepios Fachkliniken Muenchen, Gauting, Germany
| | - Michal Lotem
- Center for Melanoma and Cancer Immunotherapy, Hadassah Hebrew University Medical Center, Sharett Institute of Oncology, Jerusalem, Israel
| | | | - Abed Agbarya
- Institute of Oncology, Bnai Zion Medical Center, Haifa, Israel
| | - Gillian Price
- Department of Medical Oncology, Aberdeen Royal Infirmary NHS Grampian, Aberdeen, United Kingdom
| | | | - Mahmoud Abu-Amna
- Oncology & Hematology Division, Cancer Center, Emek Medical Center, Afula, Israel
| | | | - Maya Gottfried
- Department of Oncology, Meir Medical Center, Kfar-Saba, Israel
| | - Ella Tepper
- Department of Oncology, Assuta Hospital, Tel Aviv, Israel
| | | | - Ido Wolf
- Division of Oncology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - David P. Carbone
- Comprehensive Cancer Center, Ohio State University, Columbus, OH
| | - David R. Gandara
- Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA
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Katopodis P, Anikin V, Kishore U, Carter T, Hall M, Asadi N, Polychronis A, Karteris E. Circulating tumour cells and circulating cell-free DNA in patients with lung cancer: a comparison between thoracotomy and video-assisted thoracoscopic surgery. BMJ Open Respir Res 2021; 8:8/1/e000917. [PMID: 34493540 PMCID: PMC8424856 DOI: 10.1136/bmjresp-2021-000917] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/07/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The type of lung cancer surgery impacts on tumour manipulation during surgery and may drive dissemination of cancer cells into the vasculature, thus facilitating metastatic spread. The aim of this study was to investigate the impact of surgically induced trauma using peripheral blood from preoperative and postoperative patients with non-small cell lung cancer (NSCLC) undergoing thoracotomy or video-assisted thoracoscopic surgery (VATS) resection. METHODS Imaging flow cytometry was used to measure circulating cancer-associated cells (CCs). Circulating cell-free DNA (ccfDNA) isolation was performed using Promega dsDNA HS Assay Kit. DNA integrity measurements were calculated by the ALU247 to ALU115 ratio and cytokine levels measured using the Luminex screening assay. RESULTS CCs were increased in postoperative blood samples in 54 patients with NSCLC. Patients who underwent thoracotomy instead of VATS had higher numbers of EpCAM (p=0.004) and PanCK-labelled (p=0.03) CCs postoperatively. ccfDNA and DNA integrity index were also significantly increased in postoperative samples (p=0.0009 and p=0.04), with concomitant increase in interleukin 6 and interleukin 10 levels in the same cohorts (p=0.0004 and p=0.034, respectively). CONCLUSIONS In this study we have shown the potential clinical utility of several biomarkers from liquid biopsies to guide perioperative management, as well as provide a snapshot of the type of surgical resection in terms of circulating tumour cell release. Obtaining reliable readouts from blood can provide crucial information for disease progression, as well as being of prognostic value monitoring patients' response to treatment.
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Affiliation(s)
- Periklis Katopodis
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK.,Thoracic Surgery, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
| | - Vladimir Anikin
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK.,Thoracic Surgery, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK.,Department of Oncology and Reconstructive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Uday Kishore
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
| | | | - Marcia Hall
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK.,Mount Vernon Cancer Centre, Northwood, UK
| | - Nizar Asadi
- Royal Brompton and Harefield NHS Trust, London, UK
| | | | - Emmanouil Karteris
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK .,Thoracic Surgery, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK
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Park K, Özgüroğlu M, Vansteenkiste J, Spigel D, Yang JCH, Ishii H, Garassino M, de Marinis F, Szczesna A, Polychronis A, Uslu R, Krzakowski M, Lee JS, Calabrò L, Arén Frontera O, Xiong H, Bajars M, Ruisi M, Barlesi F. Avelumab Versus Docetaxel in Patients With Platinum-Treated Advanced NSCLC: 2-Year Follow-Up From the JAVELIN Lung 200 Phase 3 Trial. J Thorac Oncol 2021; 16:1369-1378. [PMID: 33845211 DOI: 10.1016/j.jtho.2021.03.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION In the JAVELIN Lung 200 trial, avelumab (anti-programmed death-ligand 1 [PD-L1] antibody) did not significantly prolong overall survival (OS) versus docetaxel in patients with platinum-treated PD-L1+ NSCLC. We report greater than 2-year follow-up data. METHODS Patients with stage IIIB or IV or recurrent NSCLC with disease progression after platinum-doublet chemotherapy were randomized 1:1 to avelumab 10 mg/kg every 2 weeks or docetaxel 75 mg/m2 every 3 weeks. The primary end point was OS in patients with PD-L1+ tumors (greater than or equal to 1% tumor cell expression; IHC 73-10 pharmDx assay). RESULTS Of 792 patients, 529 had PD-L1+ tumors (264 versus 265 in the avelumab versus docetaxel arms, respectively). As of March 4, 2019, median duration of follow-up for OS in the PD-L1+ population was 35.4 months in the avelumab arm and 34.7 months in the docetaxel arm; study treatment was ongoing in 25 (9.5%) versus 0 patients, respectively. In the PD-L1+ population, 2-year OS rates (95% confidence interval [CI]) with avelumab versus docetaxel were 29.9% (24.5%-35.5%) versus 20.5% (15.6%-25.8%); in greater than or equal to 50% PD-L1+ subgroups, 2-year OS rates were 36.4% (29.1%-43.7%) versus 17.7% (11.8%-24.7%) and in the greater than or equal to 80% subgroup were 40.2% (31.3%-49.0%) versus 20.3% (12.9%-28.8%), respectively. Median duration of response (investigator assessed) was 19.1 months (95% CI: 10.8-34.8) versus 5.7 months (95% CI: 4.1-8.3). Safety profiles for both arms were consistent with the primary analysis. CONCLUSIONS Although the JAVELIN Lung 200 primary analysis (reported previously) revealed that avelumab did not significantly prolong OS versus docetaxel in patients with platinum-treated PD-L1+ NSCLC, posthoc analyses at 2 years of follow-up revealed that 2-year OS rates were doubled with avelumab in subgroups with higher PD-L1 expression (greater than or equal to 50% and greater than or equal to 80%).
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Affiliation(s)
- Keunchil Park
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mustafa Özgüroğlu
- Division of Medical Oncology, Department of Internal Medicine, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Johan Vansteenkiste
- Department of Respiratory Oncology, University Hospital KU Leuven, Leuven, Belgium
| | - David Spigel
- Sarah Cannon Research Institute, Nashville, Tennessee
| | - James C H Yang
- Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Hidenobu Ishii
- Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Marina Garassino
- Thoracic Oncology Unit, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo de Marinis
- Thoracic Oncology Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | | | - Andreas Polychronis
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Ruchan Uslu
- Department of Medical Oncology, Ege University Hospital, Izmir, Turkey
| | - Maciej Krzakowski
- Centrum Onkologii-Instytut im. Marii Skłodowskiej-Curie w Warszawie, Warsaw, Poland
| | - Jong-Seok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Luana Calabrò
- Center for Immuno-Oncology, Medical Oncology and Immunotherapy, University Hospital of Siena, Siena, Italy
| | | | - Huiling Xiong
- EMD Serono Research & Development Institute Inc., Billerica, Massachusetts; an affiliate of Merck KGaA, Darmstadt, Germany
| | - Marcis Bajars
- EMD Serono Research & Development Institute Inc., Billerica, Massachusetts; an affiliate of Merck KGaA, Darmstadt, Germany
| | - Mary Ruisi
- EMD Serono Research & Development Institute Inc., Billerica, Massachusetts; an affiliate of Merck KGaA, Darmstadt, Germany
| | - Fabrice Barlesi
- CRCM, INSERM, CNRS, Aix Marseille University, Marseille, France(∗); Gustave Roussy Cancer Campus, Villejuif, France.
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Katopodis P, Kerslake R, Davies J, Randeva HS, Chatha K, Hall M, Spandidos DA, Anikin V, Polychronis A, Robertus JL, Kyrou I, Karteris E. COVID‑19 and SARS‑CoV‑2 host cell entry mediators: Expression profiling of TMRSS4 in health and disease. Int J Mol Med 2021; 47:64. [PMID: 33649798 PMCID: PMC7914073 DOI: 10.3892/ijmm.2021.4897] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 01/25/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
Abstract
Severe acute respiratory syndrome (SARS) coronavirus‑2 (SARS‑CoV‑2), the causative viral agent for the ongoing COVID‑19 pandemic, enters its host cells primarily via the binding of the SARS‑CoV‑2 spike (S) proteins to the angiotensin‑converting enzyme 2 (ACE2). A number of other cell entry mediators have also been identified, including neuropilin‑1 (NRP1) and transmembrane protease serine 2 (TMPRSS2). More recently, it has been demonstrated that transmembrane protease serine 4 (TMPRSS4) along with TMPRSS2 activate the SARS‑CoV‑2 S proteins, and enhance the viral infection of human small intestinal enterocytes. To date, a systematic analysis of TMPRSS4 in health and disease is lacking. In the present study, using in silico tools, the gene expression and genetic alteration of TMPRSS4 were analysed across numerous tumours and compared to controls. The observations were also expanded to the level of the central nervous system (CNS). The findings revealed that TMPRSS4 was overexpressed in 11 types of cancer, including lung adenocarcinoma, lung squamous cell carcinoma, cervical squamous cell carcinoma, thyroid carcinoma, ovarian cancer, cancer of the rectum, pancreatic cancer, colon and stomach adenocarcinoma, uterine carcinosarcoma and uterine corpus endometrial carcinoma, whilst it was significantly downregulated in kidney carcinomas, acute myeloid leukaemia, skin cutaneous melanoma and testicular germ cell tumours. Finally, a high TMPRSS4 expression was documented in the olfactory tubercle, paraolfactory gyrus and frontal operculum, all brain regions which are associated with the sense of smell and taste. Collectively, these data suggest that TMPRSS4 may play a role in COVID‑19 symptomatology as another SARS‑CoV‑2 host cell entry mediator responsible for the tropism of this coronavirus both in the periphery and the CNS.
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Affiliation(s)
- Periklis Katopodis
- Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
- Division of Thoracic Surgery, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, London UB9 6JH, UK
| | - Rachel Kerslake
- Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
- Division of Thoracic Surgery, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, London UB9 6JH, UK
| | - Julie Davies
- Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
| | - Harpal S. Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
- Aston Medical Research Institute, Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Kamaljit Chatha
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
- Department of Biochemistry and Immunology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
| | - Marcia Hall
- Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
- Mount Vernon Cancer Centre, Middlesex HA6 2RN, UK
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71409 Heraklion, Greece
| | - Vladimir Anikin
- Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
- Division of Thoracic Surgery, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, London UB9 6JH, UK
| | | | - Jan L. Robertus
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
| | - Ioannis Kyrou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
- Aston Medical Research Institute, Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Emmanouil Karteris
- Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
- Division of Thoracic Surgery, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, London UB9 6JH, UK
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Barlesi F, Vansteenkiste J, Spigel D, Ishii H, Garassino M, De Marinis F, Özgüroğlu M, Szczesna A, Polychronis A, Uslu R, Krzakowski M, Lee J, Calabro L, Frontera O, Ellers-Lenz B, Bajars M, Ruisi M, Park K. OA05.05 Avelumab vs Docetaxel for Previously Treated Advanced NSCLC: Primary Analysis of the Phase 3 JAVELIN Lung 200 Trial. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Barlesi F, Vansteenkiste J, Spigel D, Ishii H, Garassino M, de Marinis F, Özgüroğlu M, Szczesna A, Polychronis A, Uslu R, Krzakowski M, Lee JS, Calabrò L, Arén Frontera O, Ellers-Lenz B, Bajars M, Ruisi M, Park K. Avelumab versus docetaxel in patients with platinum-treated advanced non-small-cell lung cancer (JAVELIN Lung 200): an open-label, randomised, phase 3 study. Lancet Oncol 2018; 19:1468-1479. [PMID: 30262187 DOI: 10.1016/s1470-2045(18)30673-9] [Citation(s) in RCA: 311] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antibodies targeting the immune checkpoint molecules PD-1 or PD-L1 have demonstrated clinical efficacy in patients with metastatic non-small-cell lung cancer (NSCLC). In this trial we investigated the efficacy and safety of avelumab, an anti-PD-L1 antibody, in patients with NSCLC who had already received platinum-based therapy. METHODS JAVELIN Lung 200 was a multicentre, open-label, randomised, phase 3 trial at 173 hospitals and cancer treatment centres in 31 countries. Eligible patients were aged 18 years or older and had stage IIIB or IV or recurrent NSCLC and disease progression after treatment with a platinum-containing doublet, an Eastern Cooperative Oncology Group performance status score of 0 or 1, an estimated life expectancy of more than 12 weeks, and adequate haematological, renal, and hepatic function. Participants were randomly assigned (1:1), via an interactive voice-response system with a stratified permuted block method with variable block length, to receive either avelumab 10 mg/kg every 2 weeks or docetaxel 75 mg/m2 every 3 weeks. Randomisation was stratified by PD-L1 expression (≥1% vs <1% of tumour cells), which was measured with the 73-10 assay, and histology (squamous vs non-squamous). The primary endpoint was overall survival, analysed when roughly 337 events (deaths) had occurred in the PD-L1-positive population. Efficacy was analysed in all PD-L1-positive patients (ie, PD-L1 expression in ≥1% of tumour cells) randomly assigned to study treatment (the primary analysis population) and then in all randomly assigned patients through a hierarchical testing procedure. Safety was analysed in all patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT02395172. Enrolment is complete, but the trial is ongoing. FINDINGS Between March 24, 2015, and Jan 23, 2017, 792 patients were enrolled and randomly assigned to receive avelumab (n=396) or docetaxel (n=396). 264 participants in the avelumab group and 265 in the docetaxel group had PD-L1-positive tumours. In patients with PD-L1-positive tumours, median overall survival did not differ significantly between the avelumab and docetaxel groups (11·4 months [95% CI 9·4-13·9] vs 10·3 months [8·5-13·0]; hazard ratio 0·90 [96% CI 0·72-1·12]; one-sided p=0·16). Treatment-related adverse events occurred in 251 (64%) of 393 avelumab-treated patients and 313 (86%) of 365 docetaxel-treated patients, including grade 3-5 events in 39 (10%) and 180 (49%) patients, respectively. The most common grade 3-5 treatment-related adverse events were infusion-related reaction (six patients [2%]) and increased lipase (four [1%]) in the avelumab group and neutropenia (51 [14%]), febrile neutropenia (37 [10%]), and decreased neutrophil counts (36 [10%]) in the docetaxel group. Serious treatment-related adverse events occurred in 34 (9%) patients in the avelumab group and 75 (21%) in the docetaxel group. Treatment-related deaths occurred in four (1%) participants in the avelumab group, two due to interstitial lung disease, one due to acute kidney injury, and one due to a combination of autoimmune myocarditis, acute cardiac failure, and respiratory failure. Treatment-related deaths occurred in 14 (4%) patients in the docetaxel group, three due to pneumonia, and one each due to febrile neutropenia, septic shock, febrile neutropenia with septic shock, acute respiratory failure, cardiovascular insufficiency, renal impairment, leucopenia with mucosal inflammation and pyrexia, infection, neutropenic infection, dehydration, and unknown causes. INTERPRETATION Compared with docetaxel, avelumab did not improve overall survival in patients with platinum-treated PD-L1-positive NSCLC, but had a favourable safety profile. FUNDING Merck and Pfizer.
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Affiliation(s)
- Fabrice Barlesi
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Johan Vansteenkiste
- Department of Respiratory Oncology, University Hospital KU Leuven, Leuven, Belgium
| | - David Spigel
- Sarah Cannon Research Institute, Nashville, TN, USA
| | - Hidenobu Ishii
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Marina Garassino
- Thoracic Oncology Unit, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo de Marinis
- Thoracic Oncology Division, European Institute of Oncology, Milan, Italy
| | - Mustafa Özgüroğlu
- Department of Internal Medicine, Division of Medical Oncology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | - Andreas Polychronis
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, Middlesex, UK
| | - Ruchan Uslu
- Ege University Hospital, Department of Medical Oncology, Izmir, Turkey
| | - Maciej Krzakowski
- Centrum Onkologii-Instytut Im M Skłodowskiej-Curie w Warszawie, Warsaw, Poland
| | - Jong-Seok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Luana Calabrò
- Center for Immuno-Oncology, Medical Oncology and Immunotherapy, University Hospital of Siena, Siena, Italy
| | | | | | | | | | - Keunchil Park
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Gregorc V, Gaafar RM, Favaretto A, Grossi F, Jassem J, Polychronis A, Bidoli P, Tiseo M, Shah R, Taylor P, Novello S, Muzio A, Bearz A, Greillier L, Fontana F, Salini G, Lambiase A, O'Brien M. NGR-hTNF in combination with best investigator choice in previously treated malignant pleural mesothelioma (NGR015): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet Oncol 2018; 19:799-811. [PMID: 29753703 DOI: 10.1016/s1470-2045(18)30193-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/19/2018] [Accepted: 02/26/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Malignant pleural mesothelioma is an aggressive cancer with highly vascularised tumours. It has poor prognosis and few treatment options after failure of first-line chemotherapy. NGR-hTNF is a vascular-targeting drug that increases penetration of intratumoral chemotherapy and T-cell infiltration by modifying the tumour microenvironment. In this trial, we aimed to investigate the efficacy and safety of NGR-hTNF in patients with malignant pleural mesothelioma who had progressed during or after a first-line treatment. METHODS NGR015 was a randomised, double-blind, placebo-controlled phase 3 trial done in 41 centres in 12 countries. Eligible participants had malignant pleural mesothelioma of any histological subtype (epithelial, sarcomatoid, or mixed), were aged 18 years or older, and had an Eastern Cooperative Oncology Group performance status of 0-2 and radiologically documented progressive disease after one pemetrexed-based chemotherapy regimen. Participants were randomly assigned to receive weekly NGR-hTNF 0·8 μg/m2 intravenously plus best investigator choice (n=200), or placebo plus best investigator choice (n=200). Best investigator choice was decided before random assignment and could be single-agent gemcitabine (1000-1250 mg/m2 intravenously), vinorelbine (25 mg/m2 intravenously or 60 mg/m2 orally), doxorubicin (60-75 mg/m2 intravenously), or best supportive care only. Patients were randomised (1:1) with a block size of four after stratification for performance status and best investigator choice. The primary study endpoint was overall survival in the intention-to-treat population. The trial is closed to new participants and is registered with ClinicalTrials.gov (NCT01098266). FINDINGS Between April 12, 2010 and Jan 21, 2013, we enrolled 400 eligible participants. 381 (95%) of 400 patients were selected to receive chemotherapy before all participants were randomly assigned to receive NGF-hTNF plus best investigator choice (n=200) or placebo plus best investigator choice (n=200). At the cutoff date (April 29, 2014), the median follow-up was 18·7 months (IQR 15·1-24·4), and overall survival did not differ between the two treatment groups (median 8·5 months [95% CI 7·2-9·9] in the NGR-hTNF group vs 8·0 months [6·6-8·9] in the placebo group; hazard ratio 0·94, 95% CI 0·75-1·18; p=0·58). Grade 3 or worse study-emergent adverse events occurred in 136 (70%) of patients receiving NGR-hTNF versus 118 (61%) of patients receiving placebo, with the most common being neutropenia (35 [18%] of 193 patients vs 36 [19%] of 193 patients), pain (11 [6%] vs 16 [8%]), dyspnoea (nine [5%] vs seven [4%]), and chills (nine [5%] vs none). 50 (26%) patients in the NGR-hTNF group had a serious adverse event, compared with 47 (24%) in the placebo group. Treatment-related serious adverse events occurred in 17 (9%) patients in the NGR-hTNF group and 20 patients (10%) in the placebo group. There were 12 deaths in the NGR-hTNF group and 13 deaths in the placebo group, but none were treatment related. INTERPRETATION The study did not meet its primary endpoint. The hypothesis-generating findings from the subgroup analyses deserve a confirmatory randomised trial because patients who rapidly progress after first-line treatment have a poor prognosis. FUNDING MolMed.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Silvia Novello
- University of Turin, AOU San Luigi, Orbassano, Turin, Italy
| | | | | | - Laurent Greillier
- Assistance Publique Hôpitaux de Marseille, Aix Marseille University, Marseille, France
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Yip K, Conibear J, Woolf D, Tarver K, Willis B, Hall S, Sun F, Kuhan H, Lambourne B, Piskilidis P, Kussaibati R, Martin L, Satar NA, Gray C, Khan A, Doherty G, Prewett S, Smith M, Dancey G, Patterson D, Rimmer Y, Hollingdale A, Ingle C, Tasigiannopoulos Z, Aslam S, Waite K, Polychronis A, Ghafoor Q, Baijal S, Newsom-Davis T, Shah R, Forster M, Mulatero C, Greystoke A, Postmus P, Blackhall F, Gilligan D. 62: A retrospective multicentre audit of outcome among patients with anaplastic lymphoma kinase (ALK) gene rearrangement positive non-small cell lung cancer (NSCLC) who have been treated with crizotinib in England. Lung Cancer 2017. [DOI: 10.1016/s0169-5002(17)30112-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wood G, Polychronis A. 63 Afatinib in non-small cell lung cancer. Lung Cancer 2016. [DOI: 10.1016/s0169-5002(16)30080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gregorc V, Gaafar R, Favaretto A, Grossi F, Jassem J, Polychronis A, Bidoli P, Tiseo M, O'Brien M, Shah R, Taylor P, Novello S, Muzio A, Bearz A, Badurak P, Greillier L, Fontana F, Colombi S, Lambiase A, Bordignon C. 3099 Phase 3 trial (NGR015) of best investigator choice (BIC) with or without NGR-hTNF in previously treated malignant pleural mesothelioma (MPM). Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)31740-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gaafar RM, Favaretto AG, Gregorc V, Grossi F, Jassem J, Polychronis A, Bidoli P, Tiseo M, O'Brien ME, Shah R, Taylor P, Novello S, Muzio A, Bearz A, Badurak P, Greillier L, Lambiase A, Bordignon C. Phase III trial (NGR015) with NGR-hTNF plus best investigator choice (BIC) versus placebo plus BIC in previously treated patients with advanced malignant pleural mesothelioma (MPM). J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.7501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Vanesa Gregorc
- Department of Oncology, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Grossi
- Lung Cancer Unit, IRCCS AOU San Martino - IST - Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
| | | | | | | | | | | | - Ryaz Shah
- Kent Oncology Centre, Maidstone, United Kingdom
| | - Paul Taylor
- Wythenshawe Hospital, Manchester, United Kingdom
| | | | | | | | - Pawel Badurak
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Laurent Greillier
- Aix Marseille Univ, Assistance Publique - Hôpitaux de Marseille, Marseille, France
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Viola P, Popat S, Khan O, Moule R, Polychronis A, Stokoe J, Dickson J, Montero Fernandez A, Amat Villegas I, Yancheva S, Gonzalez de Castro D, Nicholson A. 83: A review of the first 10 months of screening selected patients for the ALK translocation using immunohistochemistry, and their subsequent treatment. Lung Cancer 2015. [DOI: 10.1016/s0169-5002(15)50082-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sharma A, O'Gorman K, Aman C, Rassl D, Mohamid W, Polychronis A. A rare occurrence of biphasic pulmonary blastoma in an elderly male. Anticancer Res 2013; 33:3911-3915. [PMID: 24023328] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Pulmonary Blastoma (PB) is a rare primary lung malignancy usually occurring in young to middle aged adults. Surgery is the primary mode of treatment, but survival is poor with the mean 5-year survival being approximately 16%. We report on a case of PB arising in a 63-year-old man. Computed tomography, magnetic resonance imaging and positron emission tomography confirmed the mass to be of pulmonary origin. The morphological appearance combined with the immunoprofile of the tumour was consistent with a poorly-differentiated biphasic pulmonary blastoma. Two months after the surgical resection the patient relapsed with multiple sites of metastasis. The patient was treated with four cycles of cyclophosphamide-, doxorubicin- and vincristine-(CAV)-based chemotherapy, achieving a partial response to treatment. He is currently on a two-monthly review and is recovering from chemotherapy-related toxicities.
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Affiliation(s)
- Anand Sharma
- Department of Medical Oncology, Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex, HA6 2RN, U.K.
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Sharma A, Alfa-Wali M, Rodriguez-Justo M, Polychronis A. Squamous cell carcinoma of pancreas: an unusual site of relapse from early-stage lung cancer: 12-month postsurgery. BMJ Case Rep 2013; 2013:bcr-2013-009096. [PMID: 23608858 DOI: 10.1136/bcr-2013-009096] [Citation(s) in RCA: 3] [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] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old man presented with abdominal pain and backache, weight loss of 10 kg and irregular bowel movements. He was previously diagnosed with Stage IB squamous cell carcinoma of lung and had undergone lobectomy 12 months previously. Investigations including imaging revealed a cystic mass in the body and tail of the pancreas which was biopsied and it was confirmed to be a recurrence of the squamous lung cancer involving the pancreas. He was treated with systemic chemotherapy and has shown a partial response on repeat imaging. This case illustrates a rare and unusual site of relapse in lung cancer after adjuvant therapy and a key message for follow-up surveillance for these patients.
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Affiliation(s)
- Anand Sharma
- Department of Oncology, Mount Vernon Hospital, Northwood, UK.
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Sharma A, Kantitlal K, Wheatland G, Polychronis A. 51 Intensive systemic treatment approach may be beneficial in advanced non-small cell lung cancer (NSCLC). Lung Cancer 2013. [DOI: 10.1016/s0169-5002(13)70051-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Potter V, Nikolic M, Knolle M, Hancock D, Polychronis A, Moule R, Win T. 80 Service improvement and impact on the East and North Hertfordshire NHS Trust lung cancer service. Lung Cancer 2012. [DOI: 10.1016/s0169-5002(12)70081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Markopoulos C, Tzorakoleftherakis E, Polychronis A, Venizelos V, Xepapadakis G, Kalogerakos K, Papadiamantis J, Zobolas V, Janinis J, Dafni U. Management of bone loss in breast cancer patients: 24-month results from the ARBI trial of anastrozole with risedronate. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
552 Background: The management of bone mineral density (BMD) in postmenopausal, breast cancer (BC) patients (pts) receiveing anastrozole was investigated in this phase III, multicenter, open label trial. Methods: Pretreatment BMD of 217 eligible pts with hormone receptor-positive BC scheduled to receive anastrozole was evaluated at lumbar spine (LS) and hip (HP). Pts with T-score<-2.0 in LS or HP, received anastrozole 1mg/day plus oral risedronate 35 mg/week (A+R) and pts with T-score>-1 in both sites received anastrozole only (A). Pts with T-score<-1 in either site but T-score>-2.0 in both sites were randomized to receive A+R or A alone. All pts received Calcium and Vit D daily. BMD was then assessed at 12 and 24 months. Results: Comparison of randomized arms (A = 33 pts, A+R = 37 pts): T-score change from baseline was significantly different only for LS at 24 months (-0.23 in A vs 0.41 in A+R, Wilcoxon test p = 0.007) and was significantly higher from baseline for the A+R arm (Signed rank test p = 0.01). At 12 months, among A only pts, 4 (12.1%) had a T-score<-2.0 without becoming osteoporotic, while 2(6.1%) moved to the normal BMD region; from A+R pts, only 2(5.4%) had a T-score<-2.0 without becoming osteoporotic, while 9 (24.3%) moved to the normal BMD region. The same trend in BMD changes was also observed at the 24 month evaluation. Group with T-score<-2.0 in either LS or HP (A+R, n = 99): a significant increase for LS both at 12 and 24 months was detected (median increase of T-score by 0.45 and 0.37, p<0.01 for both time points) with a corresponding non-significant change in HP (p = 0.91 and p = 0.15). BMD in 13(13.3%) pts improved to the osteopenic region (-2.0<T-score<-1.0). Group with T-score>-1 in both sites (A, n = 48): significant decrease was detected for HP and LS, both at 12 and 24 months; however, only 11 (22%) pts became osteopenic and 1(2%) became osteoporotic. Conclusions: The addition of oral risedronate in postmenopausal BC patients with osteopenia receiving anastrozole has a favourable effect in BMD at lumbar spine at 24 months. [Table: see text]
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Affiliation(s)
- C. Markopoulos
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - E. Tzorakoleftherakis
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - A. Polychronis
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - V. Venizelos
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - G. Xepapadakis
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - K. Kalogerakos
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - J. Papadiamantis
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - V. Zobolas
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - J. Janinis
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
| | - U. Dafni
- Medical School, University of Athens, Athens, Greece; Medical School, University of Patra, Patra, Greece; 6th IKA, Athens, Greece; Euroclinic of Athens, Athens, Greece; IASO Hospital, Athens, Greece; Metaxa Anticancer Hospital, Athens, Greece; E. Benizelou Hospital, Athens, Greece; Agios Savas Anticancer Hospital, Athens, Greece; Athens Medical Center, Athens, Greece; University of Athens, Athens, Greece
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McGovern UB, Francis RE, Peck B, Guest SK, Wang J, Myatt SS, Krol J, Kwok JMM, Polychronis A, Coombes RC, Lam EWF. Gefitinib (Iressa) represses FOXM1 expression via FOXO3a in breast cancer. Mol Cancer Ther 2009; 8:582-91. [PMID: 19276163 DOI: 10.1158/1535-7163.mct-08-0805] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gefitinib (Iressa) is a specific and effective epidermal growth factor receptor inhibitor. An understanding of the downstream cellular targets of gefitinib will allow the discovery of biomarkers for predicting outcomes and monitoring anti-epidermal growth factor receptor therapies and provide information for overcoming gefitinib resistance. In this study, we investigated the role and regulation of FOXM1 in response to gefitinib treatment in breast cancer. Using the gefitinib-sensitive breast carcinoma cell lines BT474 and SKBR3 as well as the resistant lines MCF-7, MDA-MB-231, and MDA-MB-453, we showed that gefitinib represses the expression of the transcription factor FOXM1 in sensitive, but not resistant, cells. FOXM1 repression by gefitinib is associated with FOXO3a activation and is mediated at the transcriptional level and gene promoter level. These results were verified by immunohistochemical staining of biopsy samples from primary breast cancer patients obtained from a gefitinib neoadjuvant study. We also showed that ectopic expression of an active FOXO3a represses FOXM1 expression, whereas knockdown of FOXO3a expression using small interfering RNA can up-regulate FOXM1 and its downstream targets polo-like kinase, cyclin B1, and CDC25B and rescue sensitive BT474 cells from gefitinib-induced cell proliferative arrest. These results suggest that gefitinib represses FOXM1 expression via FOXO3a in breast cancer. We further showed that overexpression of a wild-type FOXM1 or a constitutively active FOXM1, DeltaN-FOXM1, abrogates the cell death induced by gefitinib, indicating that FOXM1 has a functional role in mediating the gefitinib-induced proliferative arrest and in determining sensitivity to gefitinib. In summary, our study defined FOXM1 as a cellular target and marker of gefitinib activity in breast cancer.
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Affiliation(s)
- Ursula B McGovern
- Cancer Research UK Labs, Department of Oncology, Imperial College London, MRC Cyclotron Building, Imperial College School of Medicine at Hammersmith Hospital, Du Cane Road, London W12 0NN, United Kingdom
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Markopoulos C, Polychronis A, Dafni U, Koukouras D, Zobolas V, Tzorakoleftherakis E, Xepapadakis G, Gogas H. Lipid changes in breast cancer patients on exemestane treatment: final results of the TEAM Greek substudy. Ann Oncol 2009; 20:49-55. [DOI: 10.1093/annonc/mdn545] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Krol J, Francis RE, Albergaria A, Sunters A, Polychronis A, Coombes RC, Lam EWF. The transcription factor FOXO3a is a crucial cellular target of gefitinib (Iressa) in breast cancer cells. Mol Cancer Ther 2008; 6:3169-79. [PMID: 18089711 DOI: 10.1158/1535-7163.mct-07-0507] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gefitinib is a specific inhibitor of the epidermal growth factor receptor (EGFR) that causes growth delay in cancer cell lines and human tumor xenografts expressing high levels of EGFR. An understanding of the downstream cellular targets of gefitinib will allow the discovery of biomarkers for predicting outcomes and monitoring anti-EGFR therapies and provide information for key targets for therapeutic intervention. In this study, we investigated the role of FOXO3a in gefitinib action and resistance. Using two gefitinib-sensitive (i.e., BT474 and SKBR3) as well as three other resistant breast carcinoma cell lines (i.e., MCF-7, MDA-MB-231, and MDA-MB-453), we showed that gefitinib targets the transcription factor FOXO3a to mediate cell cycle arrest and cell death in sensitive breast cancer cells. In the sensitive cells, gefitinib treatment causes cell cycle arrest predominantly at the G(0)-G(1) phase and apoptosis, which is associated with FOXO3a dephosphorylation at Akt sites and nuclear translocation, whereas in the resistant cells, FOXO3a stays phosphorylated and remains in the cytoplasm. The nuclear accumulation of FOXO3a in response to gefitinib was confirmed in tumor tissue sections from breast cancer patients presurgically treated with gefitinib as monotherapy. We also showed that knockdown of FOXO3a expression using small interfering RNA (siRNA) can rescue sensitive BT474 cells from gefitinib-induced cell-proliferative arrest, whereas reintroduction of active FOXO3a in resistant MDA-MB-231 cells can at least partially restore cell-proliferative arrest and sensitivity to gefitinib. These results suggest that the FOXO3a dephosphorylation and nuclear localization have a direct role in mediating the gefitinib-induced proliferative arrest and in determining sensitivity to gefitinib.
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Affiliation(s)
- Janna Krol
- Cancer Research UK Labs and Department of Cancer Medicine, Imperial College London, MRC Cyclotron Building, Imperial College School of Medicine at Hammersmith Hospital, Du Cane Road, London W12 0NN, United Kingdom
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Affiliation(s)
- Andrew Miles
- Department of Public Health Sciences, Division of Health and Social Care Research, Medical School at Guy's, King's College and St Thomas' Hospitals, King's College School of Medicine, University of London, UK.
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Fountzilas G, Skarlos D, Dafni U, Gogas H, Briasoulis E, Pectasides D, Papadimitriou C, Markopoulos C, Polychronis A, Kalofonos HP, Siafaka V, Kosmidis P, Timotheadou E, Tsavdaridis D, Bafaloukos D, Papakostas P, Razis E, Makrantonakis P, Aravantinos G, Christodoulou C, Dimopoulos AM. Postoperative dose-dense sequential chemotherapy with epirubicin, followed by CMF with or without paclitaxel, in patients with high-risk operable breast cancer: a randomized phase III study conducted by the Hellenic Cooperative Oncology Group. Ann Oncol 2005; 16:1762-71. [PMID: 16148021 DOI: 10.1093/annonc/mdi366] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The aim of this study was to explore the effect of dose-dense sequential chemotherapy with or without paclitaxel primarily on disease-free survival (DFS) and secondarily on overall survival (OS) in patients with high-risk operable breast cancer. PATIENTS AND METHODS From June 1997 until November 2000, 604 patients with T1-3N1M0 or T3N0M0 tumors were randomized to three cycles of epirubicin 110 mg/m2 followed by three cycles of paclitaxel 250 mg/m2 followed by three cycles of 'intensified' CMF (cyclophosphamide 840 mg/m2, methotrexate 47 mg/m2 and fluorouracil 840 mg/m2) (group A), or to four cycles of epirubicin followed by four cycles of CMF, as in group A (group B). All cycles were given every 2 weeks with granulocyte colony-stimulating factor support. RESULTS A total of 595 patients were eligible. Median follow-up was 61.7 months for group A and 62 months for group B. The 3-year DFS was 80% in group A and 77% in group B. Survival rates were 93% and 90%, respectively. The effect of treatment on the hazard of death was different according to hormonal receptor status. More specifically, in patients with negative receptor status the hazard of death was significantly higher for group B (hazard ratio 2.42). Both regimens were well tolerated and severe acute side-effects were infrequent. No cases of severe cardiotoxicity or acute leukemia were recorded. CONCLUSIONS The present study failed to demonstrate a significant difference in DFS or OS between the two treatment groups. However, our study has shown clearly that high-dose paclitaxel can be safely incorporated to dose-dense sequential chemotherapy.
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Affiliation(s)
- G Fountzilas
- Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece.
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Markopoulos C, Polychronis A, Zobolas V, Xepapadakis G, Papadiamantis J, Koukouras D, Lappas H, Gogas H. The Effect of Exemestane on the Lipidemic Profile of Postmenopausal Early Breast Cancer Patients: Preliminary Results of the TEAM Greek Sub-study. Breast Cancer Res Treat 2005; 93:61-6. [PMID: 16184460 DOI: 10.1007/s10549-005-3783-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Long-term endocrine therapy for breast cancer may have clinical implications as drugs that potentially alter the lipid profile may increase the risk of developing cardiovascular disease. In this study, a companion sub-protocol to the TEAM (Tamoxifen and Exemestane Adjuvant Multicenter) International trial, we compared the effect of the steroidal aromatase inactivator exemestane on the lipid profile of postmenopausal women with early breast cancer in the adjuvant setting to that of tamoxifen. PATIENTS AND METHODS In this open-label, randomized, parallel group study, 176 postmenopausal patients with estrogen and/or progesterone receptor positive early breast cancer were randomized to either adjuvant exemestane (25 mg/day; n = 90) or tamoxifen (20 mg/day; n = 86). Assessments of total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and serum triglycerides (TRG) were performed at baseline and every 3 months for the first 12 months. RESULTS Serum triglyceride levels were consistently increased above baseline throughout the study in the tamoxifen arm, while there was a trend towards reduction in the exemestane arm. There was also an overall trend for tamoxifen to decrease the levels of LDL throughout the study period. Exemestane did not demonstrate any other significant change in HDL levels; however, there was a consistent trend for a reduction in total cholesterol in both treatment arms. The atherogenic risk determined by the TC:HDL ratio remained stable in both arms throughout the treatment period. CONCLUSIONS Exemestane appears to have a neutral effect on total cholesterol and HDL levels. Unlike tamoxifen's positive effect on LDL levels, exemestane does not significantly alter LDL levels. Tamoxifen on the other hand increases triglyceride levels, while exemestane results in a beneficial reduction in TRG levels. These data offer additional information with regard to the safety and tolerability of exemestane in postmenopausal breast cancer patients and support further investigation of its potential usefulness in the adjuvant setting.
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Affiliation(s)
- C Markopoulos
- Hellenic Breast Surgeons Society (HBSS), 8 Iassiou Street, Athens, Attica 11521, Greece.
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Polychronis A, Sinnett HD, Hadjiminas D, Singhal H, Mansi JL, Shivapatham D, Shousha S, Jiang J, Peston D, Barrett N, Vigushin D, Morrison K, Beresford E, Ali S, Slade MJ, Coombes RC. Preoperative gefitinib versus gefitinib and anastrozole in postmenopausal patients with oestrogen-receptor positive and epidermal-growth-factor-receptor-positive primary breast cancer: a double-blind placebo-controlled phase II randomised trial. Lancet Oncol 2005; 6:383-91. [PMID: 15925816 DOI: 10.1016/s1470-2045(05)70176-5] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Some oestrogen-receptor (ER) positive breast cancers express epidermal growth factor receptor (EGFR), but whether inhibition of EGFR can suppress proliferation of breast cancer cells and ER function is not known. METHODS In a double-blind, placebo-controlled randomised trial of 56 postmenopausal patients with ER-positive and EGFR-positive primary breast cancer, 27 women were randomly assigned to the tyrosine-kinase inhibitor of EGFR gefitinib (250 mg given orally once a day) and the aromatase inhibitor anastrozole (1 mg given orally once a day), and 29 women to gefitinib (250 mg given orally once a day) and placebo of identical appearance to anastrozole given orally once a day, all given for 4-6 weeks before surgery. Primary outcome was inhibition of tumour-cell proliferation, as measured by Ki67 antigen labelling index. Secondary outcomes were reduction in EGFR phosphorylation at Tyr 845, reduction in ER phosphorylation at Ser 118, tumour size, and toxic effects. Analyses were by intention to treat. FINDINGS Patients assigned gefitinib and anastrozole had a greater reduction from pretreatment values in proliferation-related Ki67 labelling index than did those assigned gefitinib alone (mean % reduction 98.0 [95% CI 96.1-98.9] vs 92.4 [85.1-96.1]; difference between groups 5.6% [5.1-6.0], p=0.0054). Tumour size was reduced by 30-99% (partial response) in 14 of 28 patients assigned gefitinib and [corrected]in 12 of 22 assigned gefitinib, as assessed by ultrasonography. Reduction in phosphorylation of ER at Ser 118 was similar for both groups. Treatment was well tolerated and much the same for both groups. INTERPRETATION Single-agent gefitinib and gefitinib combined with anastrozole are well-tolerated and effective treatments for reducing the size of breast tumours and levels of ER phosphorylation when given as neoadjuvant therapy.
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Affiliation(s)
- Andreas Polychronis
- Cancer Research UK Laboratories, Department of Cancer Medicine, Imperial College, London, UK
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Polychronis A, Sinnett HD, Hadjiminas D, Singhal H, Mansi JL, Ali S, Slade MJ, Shousha S, Morrisson K, Coombes RC. Anti-proliferative and molecular effects of neoadjuvant (pre-operative) gefitinib alone or in combination with anastrozole in epidermal growth factor receptor (EGFR) positive, estrogen receptor alpha (ERα) positive patients with primary breast cancer. J Clin Oncol 2005. [DOI: 10.1200/jco.2005.23.16_suppl.552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- A. Polychronis
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - H. D. Sinnett
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - D. Hadjiminas
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - H. Singhal
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - J. L. Mansi
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - S. Ali
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - M. J. Slade
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - S. Shousha
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - K. Morrisson
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
| | - R. C. Coombes
- Imperial Coll London, London, United Kingdom; Charing Cross Hosp, London, United Kingdom; St Mary’s Hosp, London, United Kingdom; Northwick Park Hosp, London, United Kingdom; St George’s Hosp, London, United Kingdom; AstraZeneca UK Ltd, Luton, United Kingdom
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Markopoulos C, Polychronis A, Farfarelos C, Zobolas V, Papadiamantis J, Bafaloukos D, Misitzis J, Michailidou A, Gogas H. The effect of exemestane on the lipidemic profile of breast cancer patients: Preliminary results of the TEAM trial Greek sub-study. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - V. Zobolas
- Hellenic Breast Surgical Society, Athens, Greece
| | | | | | - J. Misitzis
- Hellenic Breast Surgical Society, Athens, Greece
| | | | - H. Gogas
- Hellenic Breast Surgical Society, Athens, Greece
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Affiliation(s)
- A Miles
- Barts and The London, Queen Mary's School of Medicine and Dentistry, University of London, UK. pat2keyadvances3.demon.co.uk
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Bartlett JB, Michael A, Clarke IA, Dredge K, Nicholson S, Kristeleit H, Polychronis A, Pandha H, Muller GW, Stirling DI, Zeldis J, Dalgleish AG. Phase I study to determine the safety, tolerability and immunostimulatory activity of thalidomide analogue CC-5013 in patients with metastatic malignant melanoma and other advanced cancers. Br J Cancer 2004; 90:955-61. [PMID: 14997189 PMCID: PMC2410215 DOI: 10.1038/sj.bjc.6601579] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We assessed the safety, tolerability and efficacy of the immunomodulatory drug, CC-5013 (REVIMID™), in the treatment of patients with metastatic malignant melanoma and other advanced cancers. A total of 20 heavily pretreated patients received a dose-escalating regimen of oral CC-5013. Maximal tolerated dose, toxicity and clinical responses were evaluated and analysis of peripheral T-cell surface markers and serum for cytokines and proangiogenic factors were performed. CC-5013 was well tolerated. In all, 87% of adverse effects were classified as grade 1 or grade 2 according to Common Toxicity Criteria and there were no serious adverse events attributable to CC-5013 treatment. Six patients failed to complete the study, three because of disease progression, two withdrew consent and one was entered inappropriately and withdrawn from the study. The remaining 14 patients completed treatment without dose reduction, with one patient achieving partial remission. Evidence of T-cell activation was indicated by significantly increased serum levels of sIL-2 receptor, granulocyte–macrophage colony-stimulating factor, interleukin-12 (IL-12), tumour necrosis factor-α and IL-8 in nine patients from whom serum was available. However, levels of proangiogenic factors vascular endothelial growth factor and basic foetal growth factor were not consistently affected. This study demonstrates the safety, tolerability and suggests the clinical activity of CC-5013 in the treatment of refractory malignant melanoma. Furthermore, this is the first report demonstrating T-cell stimulatory activity of this class of compound in patients with advanced cancer.
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Affiliation(s)
- J B Bartlett
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - A Michael
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - I A Clarke
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - K Dredge
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - S Nicholson
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - H Kristeleit
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - A Polychronis
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | - H Pandha
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
| | | | | | - J Zeldis
- Celgene Corporation, Warren, NJ, USA
| | - A G Dalgleish
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK
- Division of Oncology, Department of Cellular & Molecular Medicine, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 ORE, UK. E-mail:
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Fountzilas G, Stathopoulos G, Kouvatseas G, Polychronis A, Klouvas G, Samantas E, Zamboglou N, Kyriakou K, Adamou A, Pectasidis D, Ekonomopoulos T, Kalofonos HP, Bafaloukos D, Georgoulias V, Razis E, Koukouras D, Zombolas V, Kosmidis P, Skarlos D, Pavlidis N. Adjuvant cytotoxic and endocrine therapy in pre- and postmenopausal patients with breast cancer and one to nine infiltrated nodes: five-year results of the Hellenic Cooperative Oncology Group randomized HE 10/92 study. Am J Clin Oncol 2004; 27:57-67. [PMID: 14758135 DOI: 10.1097/01.coc.0000046121.51504.b9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
SUMMARY The present randomized phase III trial was designed to detect a 15% benefit in relapse-free survival (RFS) or overall survival (OS) from the incorporation of adjuvant tamoxifen to the combination of CNF [cyclophosphamide, 500 mg/m2; mitoxantrone (Novantrone), 10 mg/m2; fluorouracil, 500 mg/m2 chemotherapy and ovarian ablation in premenopausal patients with node-positive breast cancer and conversely from the incorporation of CNF chemotherapy to adjuvant tamoxifen in node-positive postmenopausal patients. From April 1992 until March 1998, 456 patients with operable breast cancer and one to nine infiltrated axillary nodes entered the study. Premenopausal patients were treated with six cycles of CNF chemotherapy followed by ovarian ablation with monthly injections of triptoreline 3.75 mg for 1 year (Group A, 84 patients) or the same treatment followed by 5 years of tamoxifen (Group B, 92 patients). Postmenopausal patients received 5 years of tamoxifen (Group C, 145 patients) or 6 cycles of CNF followed by 5 years of tamoxifen (Group D, 135 patients). Adjuvant radiation was administered to all patients with partial mastectomy. After a median follow-up period of 5 years, 125 patients (27%) relapsed and 79 (17%) died. The 5-year actuarial RFS for premenopausal patients was 65% in Group A and 68% in Group B (p = 0.86) and for postmenopausal patients 70% in Group C and 67% in Group D (p = 0.36). Also, the respective OS rates were 77% and 80% (p = 0.68) for premenopausal and 84% and 78% (p = 0.10) for postmenopausal patients. Severe toxicities were infrequently seen, with the exception of leukopenia (18%), among the 311 patients treated with CNF. In conclusion, the present study failed to demonstrate a 15% difference in RFS in favor of node-positive premenopausal patients treated with an additional 5 years of tamoxifen after CNF adjuvant chemotherapy and ovarian ablation. Similarly, six cycles of CNF preceding 5 years of tamoxifen did not translate to a 15% RFS benefit in node-positive postmenopausal patients.
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Affiliation(s)
- George Fountzilas
- 1st Department of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki-Macedonia, Greece
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Stathopoulos G, Malamos N, Samelis G, Papakostas P, Polychronis A, Moschopoulos N, Xepapadakis G. Long term breast cancer treatment with tamoxifen and second primary tumors. Eur J Cancer 1997. [DOI: 10.1016/s0959-8049(97)85253-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Miles A, Bentley P, Polychronis A, Price N, Grey J. Goals and methods of audit should be reappraised. Pragmatic methods need to be developed. BMJ 1996; 313:497. [PMID: 8776346 PMCID: PMC2351888 DOI: 10.1136/bmj.313.7055.497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Abstract
That a treatment selected for a given condition works, or that it works better than alternative treatments, or that it was selected because it works as well as but is cheaper than alternative treatments, should be of pivotal concern to clinicians and is of central concern to patients and to health care managers. Attempts to address these concerns have resulted in what is now widely termed the 'effectiveness movement'. The protagonists of the movement have been concerned to create a culture of evaluation and inquiry within which the formulation of evidence-based clinical guidelines and their introduction into routine practice have played a prominent part. The need to ensure cost effectiveness of clinical intervention has been at least as emphasized as the need to ensure the clinical effectiveness of health care interventions. Although cost-effectiveness analyses are now an indispensable feature of practice guideline formulation and treatment evaluation, few studies have examined any deterioration in patient outcome associated with successful cost containment. An adequate understanding of the concept of clinical effectiveness and the associated aims of the 'effectiveness movement' is central to an understanding of the future nature and extent of health service provision, not simply in the UK but also internationally. Having examined the concepts of efficiency and appropriateness previously (O'Neill, Miles & Polychronis 1996, Journal of Evaluation in Clinical Practice 2, 13-27) we move in this second of two articles to a detailed explanation of the concept of effectiveness, and to an examination of the derivation and use of clinical practice guideline, concluding with a consideration of the role of practice guidelines in ensuring the cost effectiveness of health care intervention. The reservation is expressed that a 'guidelines culture', when established, will be manipulated by health care commissioners for largely political purposes, creating a systematic bias in the purchasing process that will actively disadvantage a range of patient groups.
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Affiliation(s)
- A Miles
- Centre for the Advancement of Clinical Practice, european Institute of Health and Medical Sciences, University of Surrey, Guildford, UK
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Abstract
It is increasingly recognized that the repeated rhetorical emphasis from 1989 to date on achieving measurable benefits to patients from audit, in the face of inattention to the development of methodologies with which to realize such benefits in operational practice, has represented a serious deficiency in strategic planning and direction and a consequent failure to establish functional clinical audit within the NHS. A grand revision of strategy is therefore necessary, and this should begin with the development of a research-based method of audit, the training of clinicians and audit support staff in its use and a subsequent trial of its effectiveness prior to its implementation within the NHS. Only then will measurable improvements become possible, value for money be assured and clinicians' attitudes to audit change.
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Affiliation(s)
- A Miles
- European Institute of Health and Medical Sciences, University of Surrey, UK
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Abstract
Successful audit of clinical practice focuses upon the systematic investigation of key aspects of the everyday work of busy clinicians. We contend that the nature and quality of local clinical practice can be characterized by critical examinations of the effectiveness and appropriateness of practice and the efficiency with which effective, appropriate clinical care is delivered to patients. When such a baseline has been established, it becomes possible to compare and contrast characterized local practice with so-called 'evidence-based' practice and agree changes aimed at narrowing the discrepancy between the two. The nature of such changes can be described and their implementation into practice studied, with subsequent quantitative measurement and qualitative description of the resulting benefits to patients. A proper understanding of the concepts of efficiency, appropriateness and effectiveness in clinical care is clearly fundamental to the successful design and applications of methodologies aimed at securing measurable improvements in the quality of patient care. In this first of two articles we examine the concepts of efficiency and appropriateness in clinical practice, with particular emphasis on cost-effectiveness and utilization review. The clinical effectiveness of health care intervention is treated in detail within the second paper, to be published within Volume 2 Number 2 of the Journal of Evaluation in Clinical Practice (Miles et al. 1996f).
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Affiliation(s)
- D O'Neill
- New South Wales Health Department, Sydney, Australia
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Miles A, Bentley P, Price N, Polychronis A, Grey J, Asbridge J. The Total Health Care Audit System: a systematic methodology for clinical practice evaluation and development in NHS provider organizations. J Eval Clin Pract 1996; 2:37-64. [PMID: 9238575 DOI: 10.1111/j.1365-2753.1996.tb00027.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Writing in Medical Education in 1982, Fowkes (1982) noted the lack of general agreement within the medical profession on methods of audit, a deficiency previously articulated by Shaw (1980) and later emphasized by McIntyre (1985). More recently, a study by Black & Thompson (1993) of consultant and junior medical staff in four London district general hospitals revealed that 'many doctors did not understand how to undertake audit', and major research by both Hopkins (1993, 1994) and Buttery et al. (1994) described a multiplicity of methodological deficiencies in the general approaches to audit adopted by clinicians since the promulgation of the White Paper definition in 1989. Soundness of methodological approach is fundamental to securing the success of clinical audit within Provider organizations and is thus central to the generation of measurable improvements in the quality of clinical care being delivered to patients. It is therefore disturbing that methodological deficiencies may still be observed in general approaches to audit (Buttery et al. 1994), with no author yet recommending a formal system for critical inquiry into clinical practice. It was the recognition of the unsatisfactory nature of this situation which led us to develop a system aimed at assessing, in a critical fashion, the quality of the totality of care dispensed within NHS provider organizations. The system is presented here for the first time.
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Affiliation(s)
- A Miles
- Centre for the Advancement of Clinical Practice, European Institute of Health and Medical Sciences, University of Surrey, UK
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Affiliation(s)
- A Miles
- Health Services Research, University of Westminster, London, UK
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Papaioannou A, Lissaios B, Vasilaros S, Miligos S, Papadimitriou G, Kondilis D, Polychronis A, Kozonis J, Papageorgiou G, Plataniotis G, Razis D, Stathopoulos G, Tsiliakos S, Throuvhlas N, Papavasiliou K, Tsarouhas C, Papaevangelou G. Pre- and postoperative chemoendocrine treatment with or without postoperative radiotherapy for locally advanced breast cancer. Cancer 1983; 51:1284-90. [PMID: 6337698 DOI: 10.1002/1097-0142(19830401)51:7<1284::aid-cncr2820510718>3.0.co;2-m] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
From July, 1978 to September, 1981, 184 patients with localy advanced breast cancer (T3; T4a-b; any N; M0) regardless of their hormonal receptor status, entered a trial to evaluate the contribution of radiotherapy when added to an intensive preoperative chemoendocrine regimen. Seventy-eight patients were ultimately disqualified. All patients underwent sequentially: (1) two cycles of chemotherapy: Day 1--Oncovin 1.4 mg/m2, cyclophosphamide 350 mg/m2, Adriamycin 30 mg/m2; Day 2--methotrexate 20 mg/m2, 5-fluorouracil 350 mg/m2 (in addition, antiestrogens were given to postmenopausal patients); (2) mastectomy with complete axillary dissection combined with oophorectomy in patients before and one year after menopause; (3) radiotherapy randomly to one-half of the patients; and (4) ten additional chemotherapy cycles as above, with antiestrogens to all patients. No serious local sequellae were encountered from mastectomy or radiotherapy, but complications of chemotherapy were numerous, particularly in irradiated patients. One death due to toxicity occurred after preoperative chemotherapy. The results to date suggest that in irradiated patients metastases may become enhanced and that their local disease is not more effectively controlled than in patients not having radiotherapy. Two factors may have been largely responsible for the differences observed between the two groups: the delay of chemotherapy in irradiated patients and the sustained immunosuppression known to occur after mediastinal radiotherapy.
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