Medical Oncology and Home Care in Italy

Aims and Background

Home care programs are designed to provide care for cancer patients in their homes. Aim of the study is to describe the activities of home care program, to examine the organization and efficiency of this type of care in Italy.

Methods

A questionnaire was sent to the regional representatives of the National Society of Medical Oncology and to the regional health departments.

Results

a) the home care program is uniformly distributed throughout the country; b) the number of personnel in the different centers varies greatly from one area to another; c) approximately 50 % of the centers do not cover emergency situations (at night or on holidays); and d) there is little involvement of the public sector.

Conclusions

In spite of these problems, the home care system is taking on a fundamental role, especially for advanced cancer patients.

Abstract P1-17-02: Ado-trastuzumab emtansine (TDM-1) treatment and brain metastases in HER2 positive metastatic breast cancer patients: Final analysis of an italian multicenter study

Background: Ado-trastuzumab emtansine (T-DM1) is a drug-antibody conjugate whose activity has been confirmed in HER2+ advanced breast cancer (BC) patients by the phase 3 EMILIA trial (Verma et al, NEJM 2012). Within the 991 patients enrolled in this trial, about 10% were affected with brain metastases (BM); in this subgroup, safety and efficacy of T-DM1 were confirmed although without any PFS improvement.

Patients and methods: In an Italian, multicenter, retrospective analysis involving 303 patients with advanced BC treated with T-DM1 (Fabi et al, Oncotarget 2017), we analyzed 87 patients with BM (BM-group). The study wanted to evaluate the efficacy of T-DM1 on BM; furthermore we compared BM-group with the remaining 216 patients without BM (nBM-group) in order to study outcome of disease. MRI was used as assessment imaging.

The number of extracranial metastatic sites in the BM-group and in the nBM-group was 1 for 10 (11.5%) and for 74 patients (34.3%), 2 for 23 (26.4%) and 93 (43%) patients, 3 for 25 (28.7% and 38 (17.6%) and 4 or more for 29 (33%) and 11 (5%), respectively.

In the BM-group, 5 patients (5.7%) had received surgery alone as local treatment for brain metastases, 13 (14.9%) surgery plus stereotactic radio-surgery (SRS), 4 (4.7%) surgery plus whole-brain radiotherapy (WBRT), 23 (26.5%) SRS alone, 40 (45.9%)WBRT alone and 2 (2.3%) WBRT followed by SRS. Twenty-eight patients (32.9%) and 89 (42.4%) in the BM-group and nBM-group, respectively, received T-DM1 as second line, 24 (28.2%) and 49 (23.3%) as third line and 33 (38.8%) and 72 (34.3%) as fourth line. Mean number of cycles was 6 in both groups.

Results:Among BM-group, 53 patients (60.9%) were evaluable for response. Two (3.8%) obtained brain complete response, 14 (26.4%) partial response and 13 (24.5%) stable disease [brain disease control rate: 54.7%); 24 (45.3%) progressed during T-DM1.

Regarding extracranial metastases, overall response rate was 35.1% in the BM-group and 38.3% in the nBM-group; 6 months-clinical benefit was 50.6% and 52.3%, respectively. Median PFS was 7 months in the BM-group and 8 months in the nBM-group; when T-DM1 was given as second line, median PFS was 5 months in the BM-group and 11 months in nBM-group (p=0.01) while as third, line in which 76% of patients received lapatinib/capacitabine before TDM1, median PFS was 12 and 13 months (p=NS), respectively.

Conclusions: T-DM1 showed a good activity on BM in BC patients. A better outcome was shown in patients previously treated with lapatinib. The identification of clinical and biological prognostic factors could be needed to better select more responder patients with BM to T-DM1.

Citation Format: Fabi A, Alesini D, Valle E, Carbognin L, Arpino G, Montemurro F, Ciccarese M, Cannita K, Paris I, Cursano MC, Moscetti L, Ferretti G, De Laurentiis M, Zambelli A, La Verde N, Nisticò C, Gasparro S, Giannarelli D, Cognetti F. Ado-trastuzumab emtansine (TDM-1) treatment and brain metastases in HER2 positive metastatic breast cancer patients: Final analysis of an italian multicenter study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-17-02.

Short-term (ST) versus long-term (LT) hormone treatment (HT) in combination with radiotherapy (RT) for locally advanced prostate cancer (LAPC): Meta-analysis of randomized trials (RCTs)

5128

Background: Hormone suppression plus RT is able to significantly decrease the recurrences and the mortality of patients (pts) affected by LAPC. In order to determine if difference exists between ST-HT (HT ≤6 months), and LT-HT (HT ≥8 months) in combination with RT for LAPC, a literature-based meta-analysis was conducted. Methods: Event-based relative risks (RR) with 95% confidence intervals (CI) were derived through a random-effect model. Differences in primary (biochemical failure, BF, and cancer-specific survival, CSS), and secondary outcomes (overall survival, OS, and pattern of recurrence, local or distant, LR/DM) were explored. Absolute differences (AD) and the number of patients needed to treat (NNT) were calculated. Heterogeneity test, a meta-regression analysis with clinico-pathological predictors for outcomes and a correlation analysis for surrogate end-points were conducted as well. Results: Four trials (3,148 patients) were gathered. Data were available for all RCTs only for BF; patient population ranged from 297 to 1,521 pts. Three predictors were identified: median PSA (range 9.5–20.35), Gleason score 7–10 (27–55% pts/trial) and T3–4 (13–77% pts/trial). None of the selected predictors did significantly affect any outcomes. A significant correlation and trend between the log of the BF-RR and DM and OS were found (p=0.029 and p=0.07, respectively). Conclusions: Although with significant heterogeneity (reflecting different patient’ risk stratifications), LT-HT seems to significantly decrease biochemical, local and distant recurrences, and increase cancer specific survival in comparison with ST-HT. Balancing these advantages with toxicities and costs represents the next step of the current analysis.

[Table: see text]

No significant financial relationships to disclose.

Magnitude of benefit of the addition of bevacizumab (BEVA) to first-line chemotherapy (CT) for advanced/metastatic colorectal cancer (MCRC): Meta-analysis of randomized clinical trials

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Background: The monoclonal antibody against vascular endothelial growth factor BEVA has recently demonstrated to improve survival for MRC patients (pts). Nevertheless, the magnitude of the provided benefit in the daily practice is still controversial. In order to quantify the benefit of adding BEVA to CT for MCRC, a literature-based meta-analysis was conducted. Methods: Survival Hazard Ratios (HR) were extracted from prospective, randomized clinical trials (RCTs, either phase II/III) reports. HR and event-based relative risks (RR) with 95% confidence intervals (CI) were derived through a random-effect model. Differences in primary (progression-free- and overall-survival, PFS/OS) and secondary outcomes (overall, partial and complete response rates, ORR/PR/CR) were explored. Absolute differences (AD) and the number of patients needed to treat (NNT) were calculated. Heterogeneity test and a meta-regression analysis with clinical predictors for outcomes were conducted as well. A sensitivity analysis according to the trial phase-design was accomplished. Results: Five trials (2,728 pts), 2 phase II (313 pts) and 3 phase III (2,415 pts), were gathered. No significant interaction was found in the sensitivity analysis between phase II and III, although a trend showed a better PFS results for BEVA in phase II trials (p=0.057). At the meta-regression analysis female gender and rectal primary site were significant predictors for PFS (p=0.003, p=0.005). Toxicity analysis is ongoing. Conclusions: Although concerns regarding costs and toxicities still exist, BEVA significantly improves the outcome of untreated MCRC pts. The absolute benefit provided into an unselected population for molecular features should be considered of paramount importance for advanced disease.

[Table: see text]

No significant financial relationships to disclose.

Disease-free survival (DFS) as surrogate end point for overall survival (OS) in adjuvant aromatase inhibitors (AIs) trials for breast cancer (BC): Meta-analysis of 10 randomized clinical trials (RCTs) exploring the magnitude of the benefit

539

Background. The issue regarding the eventual correlation of DFS with OS has not actually been explored in trials addressing the role of AIs. For this purpose, we meta-analyzed all RCTs in which patients were randomized to receive standard tamoxifen or AIs, whatever applied strategies. Methods. A literature-based meta-analysis was accomplished, and event-based relative risk ratios (RRs) with 95% confidence interval (CI) were derived. A fixed- (FEM) and a random-effect (REM) model and heterogeneity test were applied as well. Absolute benefits (AB) and the Number of patients Needed to Treat (NNT) were calculated. A linear regression model considering both each single outcome pair (5-years DFS and OS) has been adopted to explore for correlation, estimated according to Pearson, R2 (parametric) and Spearman (non-parametric) coefficients. Results. Ten RCTs were gathered (27,653 patients); two RCTs did not report the OS result, so they were not evaluable. DFS was significantly improved with AIs, with a AB of 2.3–3.5%, which translate into 29–43 NNT. OS was significantly improved in both overall and early switch strategy, with an AB of 0.8–1.61%, which translate into 120 and 62 NNT, respectively. A strong correlation was found between DFS and OS in the overall (r=0.78, R2=0.60, p=0.001; Rho=0.77, p=0.001) and in the early switch strategy (r=0.83, R2=0.68, p=0.003; Rho=0.84, p=0.002). Although a stronger correlation was found in the upfront strategy, the low number of RCTs did not allow to reaching statistical significance. Conclusions. The strong correlation between DFS and OS in AIs adjuvant endocrine treatment for early BC underlines the choice of DFS as a surrogate end-point for OS. The predictive value of earlier DFS (3-years) estimation for overall survival deserves a further analysis.

[Table: see text]

No significant financial relationships to disclose.

Meta-analysis of adjuvant trastuzumab for early breast cancer: Cardiotoxicity and brain metastases incidence

543

Background: The introduction of adjuvant trastuzumab (T) for early breast cancer overexpressing HER-2 has extraordinarily decreased the risk of both recurrence and death in 5 randomized clinical trials (RCTs). Nevertheless, the issue regarding the long-term safety profile of such drug is still open; in particular, questions remain about long-term cardiotoxicity, and specific pattern of relapse such as brain metastases (BM). In order to quantify the magnitude of these 2 risks, together with the survival outcome, a literature-based meta-analysis was performed. Methods: All phase III trials were considered eligible. A literature-based meta-analysis was accomplished, and event-based relative risk ratios (RR) with 95% confidence interval (CI) were derived. A fixed- and a random-effect model according to the inverse variance and the Mantel-Haenzel method were applied. Heterogeneity test was applied as well. Absolute differences (AD) and the number of patients needed to treat or to harm (NNT/NNH) were calculated. Primary end-points were: 1) chronic heart failure grade III-IV rate (CHF), 2) 10% reduction of L-FEV rate (L-FEV) and 3) BM rate. In order to quantify the magnitude of the significant benefit already found in the original RCTs, secondary end-points were: 1) disease-free survival (DFS) and 2) overall survival (OS). Results: Five RCTs were gathered (11,187 patients); at an average 2-yrs follow-up, all data were available for the cardiotoxicity and outcome end-points, while 3 RCTs reported results for BM analysis (6,738 patients). Conclusions: The overall outcome stresses that trastuzumab is likely to be one of the most important discovery in clinical oncology. Nevertheless, the biological activity of trastuzumab needs to be investigated more extensively to explore both long-term safety and specific relapse pattern.

[Table: see text]

No significant financial relationships to disclose.

Cardiotoxicity of weekly trastuzumab (T) plus epirubicin (E) and paclitaxel (P) for HER2-positive locally advanced (LA) and/or metastatic (M) breast cancer (BC): A feasibility phase II study

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Background: The introduction of T for patients (pts) overexpressing HER-2 changed the natural history of BC. The adjunction of T to anthracyclines and taxanes for both LABC and MBC provided a significant incidence of unexpected cardiotoxicity. Given the low cardiac toxicity in our previous experience with weekly ET in unselected MBC pts, a feasibility phase II study aimed to cardiotoxicity was planned. Methods: Pts affected by untreated LABC/MBC overexpressing HER-2 by FISH/CISH amplification or 3-positive Dako- Test, underwent weekly T (4–2 mg/kg/week), day 1, and E (25 mg/m2/week) plus P (80 mg/m2/week), day 2, plus G-CSF support, for 16/24 consecutive weeks in absence of progression or toxicity, in LA/M pts, respectively. Pts with significant cardiac disease/L-FEV<50% were excluded. Primary endpoint was the rate of pts with L-FEV reduction >10% after 12 weeks. An optimal 2-stage Simon design was applied. With a power of 90% at a 5% significance level, assuming a toxicity rate of 30% as unacceptable, and less than 10% as acceptable, an initial group of 15 pts was required; with 11 pts with no toxicity, a second step with further 21 pts (total 36) was planned. Non-cardiac toxicity and activity were evaluated as secondary end-points. Results: From May 2004 to November 2006, 15 pts entered the study. Patient characteristics: median age=47 (range 37–69); LABC/MBC=4/11; positive hormonal receptor 8/7; menopausal pre/post=7/8; PS 0/1=14/1; number of met sites 1/2/3=7/6/2. Median baseline- and post-week-12-L-FEV was 69% (range 64–77) and 65% (range 61–76), respectively. With a median number of courses of 13 (range 8–24), 3 pts had a >10% L-FEV reduction (20%), with an overall median L-FEV reduction of 5.2%. No EKG alteration or specific symptoms were registered. With a 17-months median follow-up, 13 pts were evaluable for response. Eight response (61.5%, 95% CI 9- 87) were documented, with a median response duration of 9 months. No grade 3–4 toxicity were registered, with the exception of severe alopecia. Conclusions: The weekly administration of T plus E and P is extremely tolerable, also with regard to L-FEV reduction. The low L- FEV reduction rate allowed entering the second step of the study.

No significant financial relationships to disclose.

Does progression-free-survival (PFS) correlate with overall- and cancer-specific survival (OS/CSS) in randomized clinical trials (RCTs) exploring the addition of hormonal therapy (HT) to radiotherapy (RT) for early prostate cancer (EPC)? Analysis of six RCTs

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Background: Although PFS is considered the standard primary end-point in EPC, the correlation with OS has never been explored in RCTs randomizing patients (pts) to HT plus radiotherapy (RT) versus RT. Given the relatively long prognosis in this disease setting, the correlation between PFS and CSS should be investigated as well. Methods: All phase III trials reporting all outcome’ data were considered eligible. The correlation has been explored according to a linear regression model considering both each single outcome pair (PFS, OS and CSS rates) for all arms, and each reported Hazard Ratio (HRs). The correlation was estimated according to both the Pearson- (r) and R2-coefficient (parametric) and the Spearman coefficient (Rho, non-parametric). A sensitivity analysis in 2 subgroups (long- and short-term HT) to test for effect robustness has been accomplished as well. A model to determine the target sample size to determine CSS benefit of 3%, 4%, 6% and 7% months, respectively, was calculated as well. Results: Six RCTs (4,212 pts) were collected (follow-up range: 4.5–7.6 years). In the overall population, when considering the crude rates, a linear stronger correlation was found between PFS and CSS (r=0.71, R2=0.51, p=0.003; Rho=0.75, p=0.005), rather than with OS (r=0.55, R2=0.30, p=0.06; Rho=0.78, p=0.11). Again, when considering HRs, a linear stronger correlation was found between PFS and CSS (r=0.87, R2=0.76, p=0.02; Rho=0.94, p=0.005), rather than with OS (r=0.75, R2=0.56, p=0.08; Rho=0.77, p=0.07). Similar correlations were found whatever subgroups was explored. The sample size model (on the basis of the beta-coefficient=0.71), calculate 4,575, 2,006, 1,115 and 700 pts to improve PFS of 4%, 6%, 8%, and 10% months, which means to improve CSS of 2.8%, 4.3%, 5.7% and 7.1%, respectively. Conclusions: The correlation between PFS and CSS in RCTs exploring the benefit of adding HT to RT for EPC is significant, and suggests its further investigation as surrogate end-point. The natural history of the disease clearly explains the stronger correlation of PFS with CSS rather than with OS.

No significant financial relationships to disclose.

Three-year disease-free survival (DFS) as surrogate end-point for predicting five-year overall survival (OS) benefit in adjuvant taxane-based chemotherapy for breast cancer (BC): Analysis of 10 randomized clinical trials (RCTs)

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Background: The issue regarding the eventual correlation between DFS at earlier follow-up (i.e. 3-yrs) with 5-yrs OS has not actually been explored in trials addressing the role of taxanes in BC. All RCTs in which patients were randomized to receive a standard or a taxane-based regimen for early BC were analyzed to evaluate this topic. Methods: All phase III trials with at least 60 month follow-up were considered eligible. The correlation has been explored according to a linear regression model considering both each single outcome pair (DFS/OS) for all arms (extracted by curves), their differences, and each outcome Hazard Ratio (HR) or calculated Relative Risk (RRs), following 2 steps: 1) correlation between 5-yrs DFS and OS (to confirm the evidence); 2) correlation between 3-yrs DFS and 5-yrs OS (predictive role). The correlation was estimated according to Pearson (r) and R2 coefficients (parametric) and Spearman (Rho) coefficient (non- parametric). A model to calculate the target sample size to determine 5-yrs OS benefit of 3%, 5% and 7%, respectively, was calculated as well. Results: Ten RCTs (17,067 patients) with available data for outcomes were gathered. For 5-yrs DFS/OS, a linear correlation was found between rates (r=0.74, R2=0.55; p<0.0001; Rho=0.83; p<0.0001), and HRs (r=0.90, R2=0.81; p<0.0001; Rho=0.91; p<0.0001). Three-yrs DFS correlates with 5-yrs OS, with both rates (r=0.81, R2=0.66; p<0.0001; Rho=0.92; p<0.0001), and RRs (r=0.84, R2=0.71; p=0.002; Rho=0.85; p=0.002). Three-yrs DFS and 5-yrs OS absolute differences strongly correlate (r=0.86, R2=0.74; p=0.001; Rho=0.84; p=0.002). The sample size model (on the basis of the r-coefficient=0.81), calculates 2,733, 863, and 389 pts to improve 3-yrs DFS of 4%, 7% and 10%, which means to improve 5-yrs OS of 3.2%, 5.7% and 8.1%, respectively. Conclusions: By these data, 3-yrs DFS is a reliable surrogate end-point for OS when testing new drugs in early BC, and is able to predict a late survival benefit. Thanks to the smaller patient sample size, RCTs with this design will provide early results in a shorter time period, allowing a faster data transfer to clinical practice.

No significant financial relationships to disclose.

Surrogate endpoints for overall survival (OS) in advanced pancreatic cancer (APC): Analysis of randomized clinical trials (RCTs) exploring gemcitabine (G)-based combinations

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Background: G-based combinations often result in an improved overall response rate (ORR) in APC; this improvement in ORR, however, seldom translates into a significant OS advantage. We therefore evaluated the appropriateness of ORR and progression-free survival (PFS) as surrogate endpoints for OS in RCTs comparing single-agent G and G-based combinations as first-line treatment for APC. Methods: Phase III trials reporting ORR or PFS and OS data were considered eligible. Potential correlations were explored according to a linear regression model considering both the actual outcome (ORR or PFS and OS) for each single arm and the calculated relative risk (RR) for each outcome in paired comparisons. Correlation was estimated according to Pearson’s (r) and R2 coefficients (parametric) and Spearman’s (Rho) coefficient (non-parametric). A model to calculate the target sample size to correctly identify 0.4, 0.7, and 1.5 mos benefits in OS was derived as well. Results: Nineteen (6,288 pts) and 17 (4,882 pts) RCTs were identified for the ORR/OS and PFS/OS correlation, respectively. When considering ORR rates and medians, ORR did not significantly correlate with OS (r=0.23, R2=0.06, p=0.14; Rho=0.16, p=0.33), while PFS showed a strong linear correlation (r=0.75, R2=0.56, p<0.0001; Rho=0.90, p<0.0001). Similarly, when considering RRs, ORR did not significantly correlate with OS (r=-0.17, R2=0.03, p=0.46; Rho=-0.18, p=0.44), while PFS showed a strong linear correlation (r=0.91, R2=0.82, p<0.0001; Rho=0.59, p=0.01). Based on these data, we derived a sample size model (beta-coefficient=0.75) to calculate how many patients would be necessary to demonstrate a significant OS advantage of 0.4, 0.7 and 1.5 mos, respectively, using PFS as a surrogate endpoint; according to this model, 0.5, 1, and 2 months improvements in PFS would be necessary to translate into the target OS advantages, requiring 2,370, 678 and 222 pts, respectively. Conclusions: In APC, ORR does not seem to correlate with OS. Conversely, PFS could be a reliable surrogate endpoint for survival in this setting, although the detection of relatively small differences in PFS would require a remarkably large sample size.

No significant financial relationships to disclose.

Adjuvant LH-RH agonists for premenopausal early breast cancer: A meta-analysis of randomized clinical trials (RCTs) exploring the magnitude of the disease-free and overall survival (DFS/OS) benefit

592

Background: LH-RH agonists are considered as a milestone for adjuvant treatment for premenopausal early breast cancer patients (pts). All RCTs in which ovarian ablation (OA) with/without tamoxifen (TAM) and/or chemotherapy (CT) was compared with tamoxifen (TAM) and/or chemotherapy (CT) were pooled to estimate the magnitude of the benefit in both DFS and OS. Methods: A literature-based meta-analysis was accomplished, and event-based relative risk ratios (RRs) with 95% confidence interval (CI) were derived. A fixed- (FEM) and a random-effect (REM) model according to the inverse variance and heterogeneity (Het) test were applied as well. Absolute benefits (AB) and the number of pts needed to treat (NNT) were calculated. A sensitivity analysis to test for effect robustness in 4 sub-populations (OA/OS vs CT; OA/OS + CT vs CT; OA + TAM vs CT; OA + TAM vs observation) was accomplished. Results: Fifteen RCTs were gathered (12,545 pts); one RCT did not report the OS result. Results are depicted in the table . Conclusions: Although differences across RCTs exist in median follow-up time (as demonstrated by heterogeneity), OA seems to significantly improve DFS when combined with CT over CT alone, when combined with TAM versus CT alone and when combined with TAM versus observation. Actually, these DFS benefits do not translate into an OS benefit, with the exception of the last subgroup.

[Table: see text]

No significant financial relationships to disclose.

Single-agent vinorelbine in pretreated breast cancer patients: comparison of two different schedules

This retrospective study compared toxicity and activity of vinorelbine according to two schedules with different projected dose intensities in heavily pretreated breast cancer patients. Forty patients were assessable for toxicity and activity in each group; group A received vinorelbine 25 mg/m2 week + lenograstim (150 microg/m2 s.c. on day 3); group B received 25 mg/m2 on days 1 and 8 every 3 weeks. The projected dose intensity was 25 mg/m2/week and 16.6 mg/m2/week, and delivered dose intensity 95.2% and 94.5% in group A and B, respectively. Grade 3-4 afebrile neutropenia was recorded in 25% and 37.5% of patients in A and B, respectively. Overall response rate, 52.5% and 35%; no change, 35% and 40%; progression of disease, 12.5% and 25% in A and B, respectively. Median duration of the response was 10 months for group A and 7 months for B. Median time to progression: 9.0 months and 4.0 months for A and B, respectively. At a median follow-up of 45 months for group A and 19 months for group B, median overall survival was 19 months and 16, respectively. In conclusion the results of the study showed that dose intensity of vinorelbine could have an improvement in terms of time to progression in pretreated advanced breast cancer.

Single-agent oxaliplatin in pretreated advanced breast cancer patients: a phase II study

PURPOSE

Oxaliplatin (L-OHP), a new platinum analogue, is an active drug in colorectal and ovarian cancer. In this phase II study we explored tolerability and activity of oxaliplatin as a single agent in metastatic breast carcinoma patients.

PATIENTS AND METHODS

Fourteen anthracycline pretreated advanced breast cancer patients were enrolled. Oxaliplatin was given at 130 mg/m2 on day 1 and repeated every three weeks. Analysis of toxicity, response rate and survival was performed.

RESULTS

The median number of courses per patient was four (range 2 6). The median administered dose-intensity was 43.3 mg/m2/week (range 32.5-43.3) which represents 100% of projected dose-intensity. No severe toxicity was encountered. Three patients developed acute transient laryngeal symptoms. Three patients displayed a partial response (21%), (95% confidence interval (CI): 0%-43%), two stable disease (14%) and nine progressed (64%). Response lasted five, four and five months respectively. Median survival was 12 months.

CONCLUSIONS

In this limited experience, oxaliplatin appeared to be well tolerated and moderately active in advanced anthracycline-pretreated breast cancer patients. Combination chemotherapy with other active drugs such as 5-fluorouracil (5-FU), anthracyclines and taxanes should represent the next step of development of this new drug.

Role of P53 and BCL-2 in high-risk breast cancer patients treated with adjuvant anthracycline-based chemotherapy

PURPOSE

Adjuvant therapy has become an integral component of the managment of primary high-risk breast cancer patients. However, a considerable fraction of women receive no benefit from this treatment. This study investigates whether a number of biopathological factors can influence the outcome of patients submitted to adjuvant chemotherapy involving the use of high-dose epirubicin and cyclophosphamide.

METHODS

One hundred and fifty-seven primary breast cancer patients, considered at high risk according to the St. Gallen Meeting Consensus Conference, were evaluated immunohistochemically for estrogen, progesterone receptors, p53, bcl-2, HER-2/neu, and Ki-67, of which the results were correlated with patient outcome.

RESULTS

Results obtained demonstrated that p53 is a significant predictor of disease-free survival (DFS P < 0.0001) and overall survival (OS P = 0.0002) both in ductal and lobular carcinomas, whereas bcl-2 expression seems to be of prognostic value only in lobular carcinomas (DFS P = 0.01; OS P = 0.02).

CONCLUSIONS

This data indicates that in high-risk breast cancer patients the immunohistochemical evaluation of p53 and bcl-2 may be of clinical value in distinguishing different responses to adjuvant anthracycline-based chemotherapy.

Overcoming resistance to chronomodulated 5-fluorouracil and folinic acid by the addition of chronomodulated oxaliplatin in advanced colorectal cancer patients

The addition of oxaliplatin (L-OHP) to a 5-fluorouracil (5-FU)/ leucovorin (FA) regimen was retrospectively evaluated in 35 consecutive advanced colorectal cancer patients after progression of disease. L-OHP, 25 mg/m2/day, was infused from 10.00-22.00 with a peak flow at 16.00 while 5-FU, 700 mg/m2/day and FA, 150 mg/m2/day of the I-form or 300 mg/m2/day of the racemic form, from 22.00 to 10.00 with a nocturnal peak at 4.00, for 5 days every 3 weeks in 24 patients and for 4 days every 2 weeks in the other 11. Diarrhea and sensitive neuropathy were the most relevant types of toxicity (17% of patients). An objective response was achieved in 8/35 patients (23%) [95% CL 9-37], stabilization in 15 patients (43%) which included five minor responses, and progression in 12. There was no relevant difference in quality of life assessed with the EORTC QLQ C30+3 questionnaire before and after treatment. Median duration of response and median progression-free survival were 6 months; median overall survival was 11 months. This retrospective study showed that it is possible to reverse resistance to chronomodulated 5-FU by adding chronomodulated L-OHP to the previous regimen; comparison with different schedules of this combination should be performed in order to identify the best tolerated and active regimen as second-line treatment of advanced colorectal cancer.

Toxicity and activity of docetaxel in anthracycline-pretreated breast cancer patients: a phase II study

Docetaxel has proven effective in advanced breast cancer. Myelosuppression and cumulative fluid retention syndrome are troublesome, potentially avoidable toxicities. In this consecutive cohort study, docetaxel (100 mg/m2 by 1 hour i.v. infusion, q3 weeks) activity and toxicity was explored in 56 anthracycline-pretreated patients (eligible: 55: median age: 51 years [range: 28-68 years]; median performance status: 0 [range: 0-3]) with metastatic breast cancer, using two different granulocyte colony-stimulating factor and steroid pre- and postmedication schedules. Twenty-nine patients (group A) received a 5-day oral prednisone premedication, and 26 (group B) received 4-day low-dose i.m. dexamethasone; group B patients also received prophylactic granulocyte colony-stimulating factor. All patients were evaluable for toxicity and 53 for response. Prophylactic granulocyte colony-stimulating factor significantly lowered the incidence of grade III-IV neutropenia and neutropenic fever (p = 0.0001 and 0.01, respectively). The incidence of moderate-severe fluid retention syndrome was lower in patients receiving i.m. dexamethasone (p = 0.08). Overall response rate was 53% (4 complete responses/24 partial responses, 95% confidence interval 39.4-66.2%); 32% have stable disease and 15% progressive disease. In 21 anthracycline-refractory/resistant patients, as well as in 10 paclitaxel-pretreated patients, the overall response rate was 50%. Docetaxel is highly active in anthracycline- and paclitaxel-pretreated metastatic breast cancer, with manageable toxicity. Optimal use of both granulocyte colony-stimulating factor support and steroid premedication deserves further investigation.

Weekly schedule of vinorelbine in pretreated breast cancer patients

PURPOSE

In this phase II study, we explored tolerability and activity of vinorelbine administered according to a dose-dense weekly schedule with hematopoietic growth factor support in pretreated, advanced breast cancer patients.

PATIENTS AND METHODS

From January 1994 to March 1996, 40 patients with metastatic breast cancer, pretreated with at least one prior anthracycline-containing regimen, were entered into the study.

PATIENT CHARACTERISTICS

median age 53 years (range 32-70); ECOG performance status 0-1: 34 patients, 2: 6 patients; dominant visceral metastatic disease: 15 patients, dominant non-visceral: 25; anthracycline-refractory/resistant: 2 patients, sensitive: 38 patients. Six patients were treated as first-line therapy for metastatic disease and 34 in second- or subsequent lines. All patients received vinorelbine at the dose of 25 mg/m2/week as a short intravenous infusion, together with routine antiemetic medication. Granulocyte-colony stimulating factor (Lenograstim) at the dose of 150 microg/m2 subcutaneously on day 3 was included in the treatment schedule.

RESULTS

The median number of treatment weeks was 23 (range: 4-24), with a delivered dose-intensity (DDI) of 23.8 mg/m2/week (range: 18.7-25, 95.2% of projected dose-intensity). Toxicity was mild, with non-complicated neutropenia being the main toxicity observed (grade 3-4 in 25% of the patients but only 2% of treatment weeks). Overall response rate was 52.5%, with complete responses in 12.5% of patients. Median duration of the response and median time to progression were 10 and 9 months, respectively. Median overall survival was 19 months.

CONCLUSION

Dose-dense weekly vinorelbine is safe and effective with minimal toxicity in pretreated advanced breast cancer patients.

Phase II study of epirubicin and vinorelbine with granulocyte colony-stimulating factor: a high-activity, dose-dense weekly regimen for advanced breast cancer

BACKGROUND

This study was designed to explore the effectiveness and tolerability of a weekly regimen of epirubicin and vinorelbine plus granulocyte colony-stimulating factor (G-CSF).

PATIENTS AND METHODS

Fifty-two patients with previously untreated advanced breast cancer were treated with epirubicin (25 mg/m2/week) and vinorelbine (25 mg/m2/week) with G-CSF support, for 24 consecutive weeks.

RESULTS

The median number of courses per patient was 22 (range 10-24). The administered dose intensity was 23 mg/m2 for both epirubicin and vinorelbine. Ten complete responses (19%) and 30 partial responses (58%) were obtained, for an overall response rate of 77%. None of the patients progressed during treatment. The median response duration and time to progression were both 10 months. A total of 1065 courses were assessed for toxicity. Grade 3 neutropenia was the most common toxic manifestation, (39% of patients), without febrile neutropenia or neutropenic sepsis. Two patients had grade 3 cardiac toxicity, which regressed without sequelae. Median survival was 31 months, with a median follow-up of 24 months (range 9-40).

CONCLUSIONS

Owing to its effectiveness and tolerability, the weekly regimen of epirubicin and vinorelbine plus G-CSF may represent an acceptable alternative for patients with untreated metastatic breast cancer. It could be tested in the adjuvant and neoadjuvant setting.

Weekly epirubicin plus lonidamine in advanced breast carcinoma

Lonidamine has been demonstrated to potentiate the cytotoxic activity of several antineoplastic drugs, for example anthracyclines. Moreover, epirubicin is considered one of the most active drugs in advanced breast cancer, although optimal dose and schedule remains to be defined. In the present study we have treated 51 patients with advanced breast cancer with a combination of lonidamine (450 mg/day orally from day 1 throughout treatment) and epirubicin (25 mg/m2 i.v.) administered according to a weekly schedule for 24 weeks. Objective responses were observed in 29 out of 51 patients (57%; CR 16%, PR 41%). Liver metastases responded in eight out of 12 evaluable patients (67%). Average response duration was 12.4 months and median overall survival was 23 months (range 1-90+). Toxicity was negligible. The combination of weekly epirubicin and lonidamine is feasible and active in advanced breast cancer patients.

Breast cancer and timing of surgery during menstrual cycle: a 5-year analysis of 248 premenopausal women

In the present report, we retrospectively analyzed the impact of the timing of surgery during menstrual cycle on disease-free and overall survival of 248 premenopausal patients with stage I/II breast cancer who underwent surgery followed by anthracycline-containing adjuvant chemotherapy. With a median follow-up of 5 years, no statistically significant differences were observed in disease-free or overall survival between women operated upon during the follicular (days 0-14) and the luteal (days 15-32) phase of the menstrual cycle. The impact on disease-free and overall survival of lymph-node status, tumor size and hormone receptor expression, but not of the phase of the menstrual cycle at the time of surgery, was confirmed by univariate and multivariate analysis. However, when combined with hormone receptor status, the phase of the menstrual cycle at the time of surgery proved useful to better define the prognosis of primary breast cancer patients, with significantly longer disease-free and overall survival for patients operated upon during the follicular phase and with positive hormone receptors.

Bladder-vaginal fistulas: Technical notes

Bladder vaginal fistulas are one of the most common urological pathologies. They are mostly of iatrogenic origin and are a great handicap, especially with regard to the quality of life of the patients. The authors report on the experience gained by working together with gynaecology departments, giving some case reports and the therapeutic strategies used.