Implementation of CDK4/6 Inhibitors and its Influence on the Treatment Landscape of Advanced Breast Cancer Patients - Data from the Real-World Registry PRAEGNANT

Background Comprehensive data from prospective clinical trials have led to a high level of evidence establishing CDK4/6 inhibitors in combination with endocrine treatment (CDK4/6i + ET) as a standard for the treatment of HER2-negative, hormone receptor-positive (HER2- HR+) breast cancer patients in the first-line advanced therapy setting. Data on patient populations that have been treated in the real-world setting may provide an insight into changes of patient characteristics and prognosis over time. Methods The data were extracted from the prospective real-world registry PRAEGNANT (NCT02338167). Patients had to have HER2- HR+ advanced breast cancer in the first-line metastatic setting. The chosen therapies were described as well as progression-free survival (PFS) and overall survival (OS) in relation to the given therapies and time periods during which they were indicated. Results CDK4/6 inhibitors have been rapidly implemented since their introduction in November 2016. In recent years (2018 - 2022), about 70 - 80% of the patient population have been treated with CDK4/6 inhibitors, while endocrine monotherapy was given to about 10% and chemotherapy to about 15% of all patients. The prognosis was worst in patients treated with chemotherapy. Recently, mainly patients with a good prognosis are being treated with endocrine monotherapy, and patients who are treated with chemotherapy have an unfavorable prognosis. The PFS and OS of patients treated with CDK4/6i + ET have remained similar over time despite changes in patient characteristics. Conclusion A treatment with CDK4/6i + ET has rapidly become the therapy standard for patients in the first-line advanced breast cancer setting. After the implementation of CDK4/6i + ET, endocrine monotherapy is only given to patients with a very favorable prognosis, while chemotherapy is provided to patients with a rather unfavorable prognosis. These changes in patient characteristics did not seem to influence the prognosis of patients treated with CDK4/6i + ET.

Occurrence and characteristics of patients with de novo advanced breast cancer according to patient and tumor characteristics - A retrospective analysis of a real world registry

BACKGROUND

Patients with de novo metastatic breast cancer (dnMBC) may have different clinical and pathological characteristics. In studies concerned with first-line metastatic patients, the proportion of these patients without secondary resistance mechanisms may have a large influence ont the study results. The aim of this study was to identify patient and tumor characteristics that are associated with dnMBC vs. recurrent MBC (rMBC).

METHODS

This is a retrospective analysis of data prospectively collected in the PRAEGNANT metastatic breast cancer registry (NCT02338167). Firs line treated patients were eligible. Patient and tumor characteristics were compared with common disease and tumor characteristics relative to de novo metastatic status, as well as early and late recurrences after primary disease without metastases.

RESULTS

Among the 947 patients identified, 355 were included with de novo metastatic disease (37.5%). Older age and HER2-positive disease were significantly associated with a higher frequency of dnMBC. Patients younger than 50, 50-69, or 70 years or older had dnMBC frequencies of 22.7%, 44.0%, and 57.6%, respectively. HER2-positive patients had dnMBC at initial presentation in 49.1% of cases, in comparison with 21.9%, 35.5%, and 37.6% in patients with triple-negative, luminal A-like and luminal B-like breast cancer, respectively.

CONCLUSION

Age and breast cancer subtype are associated with the frequency of first-line MBC patients. Inclusion criteria concerning age or breast cancer subtype can influence the frequency of these patients in a selected patient population and can therefore modify the number of patients with secondary resistance to specific therapies in clinical trials.

Quality of Life Effects of an Oral Fixed Combination of Netupitant and Palonosetron in Chemotherapy-Induced Nausea and Vomiting Prevention: Real-World Evidence in Patients with Breast Cancer Receiving Anthracycline-Cyclophosphamide-Based Chemotherapy

INTRODUCTION

In a prospective non-interventional study involving 2,173 patients, we showed that use of the oral fixed combination of netupitant 300 mg and palonosetron 0.5 mg (NEPA) for prevention of chemotherapy (Ctx)-induced nausea and vomiting has beneficial effects on the quality of life (QoL) of patients with various types of cancers receiving highly or moderately emetogenic Ctx. Here, we report on the effects on QoL, effectiveness, and tolerability of NEPA in patients with breast cancer exposed to anthracycline-cyclophosphamide (AC)-based Ctx.

METHODS

This is a post hoc subanalysis of a prospective non-interventional study in 1,197 patients with breast cancer receiving up to 3 cycles of doxorubicin or epirubicin plus cyclophosphamide and NEPA. NEPA administration was per the summary of product characteristics.

RESULTS

In cycle 1 of Ctx, a large proportion of patients (84%) reported "no impact on daily life" (NIDL) due to vomiting; 53% of patients reported NIDL due to nausea. The complete response rate was 86/88/81% in the acute/delayed/overall phase in cycle 1, and NEPA was well tolerated throughout the study.

CONCLUSION

The real-world beneficial effects of NEPA prophylaxis on QoL were confirmed for patients with breast cancer receiving AC. NEPA was effective with a good safety profile in this patient population in clinical practice.

Prognostic effect of low-level HER2 expression in patients with clinically negative HER2 status

PURPOSE

Assessment of HER2 overexpression using immunohistochemistry (IHC) and/or in situ hybridisation (ISH) for the detection of HER2 amplifications is standard to identify patients for established HER2-directed treatments. Patients with lower HER2 expression levels have recently also become candidates for novel therapies targeting HER2. This study aimed to assess tumour and patient characteristics and prognosis in patients with advanced breast cancer (aBC), relative to low HER2 expression levels.

METHODS

PRAEGNANT is a prospective aBC registry (NCT02338167), focusing on molecular biomarkers. Patients in all therapy lines receiving any kind of treatment are eligible. This analysis includes patients with conventionally HER2-negative aBC. Clinical outcome was compared in the groups with no (IHC score 0) or with low HER2 expression (IHC 1+, or IHC 2+/ISH negative).

RESULTS

Low HER2 expression levels in triple-negative aBC patients did not influence progression-free survival. Overall survival appeared poorer in patients with IHC 2+ compared with patients with no HER2 expression in the unadjusted analysis (hazard ratio 2.24, 95% confidence interval 0.1.12-4.47). However, this effect was not maintained in the adjusted analysis. In HER2-negative, hormone receptor-positive patients, low HER2 expression appeared to have no effect on prognosis, neither progression-free survival nor overall survival.

CONCLUSIONS

We could not demonstrate that HER2 expression at a low level and assessed in clinical routine can differentiate patients into prognostic groups. However, the prevalence of patients with a low expression makes this population interesting for clinical trials with potentially active treatments using HER2 as a target.

Abstract PS10-31: Ribecca - a phase 3b, multi-center, open label study for women with estrogen receptor positive, locally advanced or metastatic breast cancer treated with ribociclib (lee011) in combination with letrozole: Final results

Introduction: RIBECCA is a national, multi-center, open-label, single-arm phase IIIb trial assessing the efficacy and safety of ribociclib in combination with letrozole in a patient population similar to the populations of MONALEESA-2, -3 and -7, including premenopausal and postmenopausal patients without pretreatment as well as patients with up to 3 previous treatment lines for advanced disease. Here we present the final analysis for the primary endpoint. Methods:The study enrolled women or men with metastatic or locally advanced breast cancer irrespective of their menopausal status, who were not amenable to curative treatment by surgery or radiotherapy. Histological or cytological confirmation of HR+, HER2- breast cancer was required. 502 patients were enrolled in two Cohorts. Cohort A (n=319): postmenopausal women and men without pretreatment for advanced disease; Cohort B (n=183): premenopausal women without pretreatment for advanced disease and pre- or postmenopausal women and men with ≤ 1 line of chemotherapy and/or ≤ 2 lines of endocrine therapy in the advanced situation. The primary endpoint was to assess the clinical benefit rate (CBR, defined as CR, PR or SD, or NCRNPD) at 24 weeks for the overall study population. Secondary endpoints included: progression free survival (PFS), overall survival (OS), safety, and changes in quality of life as assessed by EORTC QLQ-C30 and -BR23 questionnaires. Results: The study ended 84 weeks after the enrollment of the last patient. The median observation time was 10.6 months (0.1-38 months). Baseline characteristics: of 502 pts, 5 were male, 497 were female(46 pre-or perimenopausal, 451 postmenopausal); median age: 64 yrs; ECOG 0-1: 96.8%; 71.1 % of pts had bone metastases (40.8% bone only), 30.6% liver, 27.5% lung and 30.1% other metastases. 97.3% had at least 1 metastatic site: 48.7% had 1, 35.1% had 2, 12.9% had 3 and 1.6% had 4 metastatic sites, respectively. 78.9% received at least one prior antineoplastic therapy: 4.9% received neoadjuvant, 56.8% adjuvant and 37.8% palliative treatment as last antineoplastic therapy before study start. The most common treatment emergent AEs (all grades) were neutropenia and/or neutrophil count decreased (60.6%), nausea (42%), fatigue (39.2%), alopecia (35.1%), leukopenia or WBC decreased (30.7%), nasopharyngitis (28.5%), diarrhea (25.3%), ALT increased (22.9%) and AST increased (20.7%). The CBR at week 24 for the overall study population was 69.2%. Median PFS was 16.5 [95%CI 13.7; 19.3] months in the overall study population, 21.8 [15.4; 25.3] months and 9.3 [8.1; 16.3] months in Cohort A and B, respectively. At 72 weeks, the Kaplan-Meier estimate for OS was 86.8% [83.3; 89.6]. Because of the low number of events during the study period, median OS could not be determined. Conclusion: The results of the final analysis confirmed clinical benefit of ribociclib and letrozole in this patient population. No new safety signals emerged.

Citation Format: Mattea Reinisch, Arndt Nusch, Thomas Decker, Andreas Hartkopf, Bernhard J Heinrich, Christian M Kurbacher, Roswitha Fuchs, Hans Tesch, Petra Krabisch, Sara Y Brucker, Tanja Fehm, Wolfgang Janni, Sherko Kuemmel, Diana Lüftner, Andreas Schneeweiss, Martin Schuler, Claudia Voges, Joerg Schubert, Peter A Fasching. Ribecca - a phase 3b, multi-center, open label study for women with estrogen receptor positive, locally advanced or metastatic breast cancer treated with ribociclib (lee011) in combination with letrozole: Final results [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-31.

Heregulin (HRG) assessment for clinical trial eligibility testing in a molecular registry (PRAEGNANT) in Germany

BACKGROUND

Eligibility criteria are a critical part of clinical trials, as they define the patient population under investigation. Besides certain patient characteristics, clinical trials often include biomarker testing for eligibility. However, patient-identification mostly relies on the trial site itself and is often a time-consuming procedure, which could result in missing out on potentially eligible patients. Pre-selection of those patients using a registry could facilitate the process of eligibility testing and increase the number of identified patients. One aim with the PRAEGNANT registry (NCT02338167) is to identify patients for therapies based on clinical and molecular data. Here, we report eligibility testing for the SHERBOC trial using the German PRAEGNANT registry.

METHODS

Heregulin (HRG) has been reported to identify patients with better responses to therapy with the anti-HER3 monoclonal antibody seribantumab (MM-121). The SHERBOC trial investigated adding seribantumab (MM-121) to standard therapy in patients with advanced HER2-negative, hormone receptor-positive (HR-positive) breast cancer and HRG overexpression. The PRAEGNANT registry was used for identification and tumor testing, helping to link potential HRG positive patients to the trial. Patients enrolled in PRAEGNANT have invasive and metastatic or locally advanced, inoperable breast cancer. Patients eligible for SHERBOC were identified by using the registry. Study aims were to describe the HRG positivity rate, screening procedures, and patient characteristics associated with inclusion and exclusion criteria.

RESULTS

Among 2769 unselected advanced breast cancer patients, 650 were HER2-negative, HR-positive and currently receiving first- or second-line treatment, thus potentially eligible for SHERBOC at the end of current treatment; 125 patients also met further clinical eligibility criteria (e.g. menopausal status, ECOG). In the first/second treatment lines, patients selected for SHERBOC based on further eligibility criteria had a more favorable prognosis than those not selected. HRG status was tested in 38 patients, 14 of whom (36.8%) proved to be HRG-positive.

CONCLUSION

Using a real-world breast cancer registry allowed identification of potentially eligible patients for SHERBOC focusing on patients with HER3 overexpressing, HR-positive, HER2-negative metastatic breast cancer. This approach may provide insights into differences between patients eligible or non-eligible for clinical trials.

TRIAL REGISTRATION

Clinicaltrials, NCT02338167 , Registered 14 January 2015 - retrospectively registered.

Initial experience with CDK4/6 inhibitor-based therapies compared to antihormone monotherapies in routine clinical use in patients with hormone receptor positive, HER2 negative breast cancer - Data from the PRAEGNANT research network for the first 2 years of drug availability in Germany

Purpose

Treatment with CDK4/6 inhibitors and endocrine therapy (CDK4/6i + ET) is a standard for patients with advanced hormone receptor–positive, HER2-negative (HR + HER2–) breast cancer (BC). However, real-world data on the implementation of therapy usage, efficacy, and toxicity have not yet been reported.

Methods

The PRAEGNANT registry was used to identify advanced HR + HER2– BC patients (n = 1136). The use of chemotherapy, ET, everolimus + ET, and CDK4/6i + ET was analyzed for first-line, second-line, and third-line therapy. Progression-free survival (PFS) and overall survival (OS) were also compared between patients treated with CDK4/6i + ET and ET monotherapy. Also toxicity was assessed.

Results

CDK4/6i + ET use increased from 38.5% to 62.7% in the first 2 years after CDK4/6i treatment became available (November 2016). Chemotherapy and ET monotherapy use decreased from 2015 to 2018 from 42.2% to 27.2% and from 53% to 9.5%, respectively. In this early analysis no statistically significant differences were found comparing CDK4/6i + ET and ET monotherapy patients with regard to PFS and OS. Leukopenia was was seen in 11.3% of patients under CDK4/6i + ET and 0.5% under ET monotherapy.

Conclusions

In clinical practice, CDK4/6i + ET has been rapidly implemented. A group of patients with a more unfavorable prognosis was possibly treated in the real-world setting than in the reported randomized clinical trials. The available data suggest that longer follow-up times and a larger sample size are required in order to identify differences in survival outcomes. Studies should be supported that investigate whether chemotherapy can be avoided or delayed in this patient population by using CDK4/6i + ET.

•

CDK4/6i + ET use increased from 39% to 63% after becoming available.

•

Chemotherapy and ET monotherapy use decreased from 42% to 27% and 53%–10%.

•

There was no difference between CDK4/6i + ET and ET monotherapy regarding PFS and OS.

ABC5 International Consensus Conference on Advanced Breast Cancer, Lisbon, 16 November 2019: Commentary by the German panel of experts on the ABC5 voting results

The Advanced Breast Cancer Fifth International Consensus Conference (ABC5) which focuses on the diagnosis and treatment of advanced breast cancer was held in Lisbon on November 14 - 16, 2019. The aim of the conference is to standardize the treatment of advanced breast cancer worldwide using evidence-based data and to ensure that patients with advanced breast disease anywhere in the world are treated appropriately and have access to the latest therapies. This year, the emphasis was on new developments and study results from patients with advanced breast cancer as well as precision medicine. The collaboration with patient advocates from all over the globe is also an important goal of the ABC Conference, which is why the international ABC panel also included a number of patient advocates. We present a commentary on the voting results of the ABC5 panelists in Lisbon by a working group of German breast cancer specialists together with the implications for routine clinical care in Germany. The commentary is based on the recommendations of the Breast Commission of the German Gynecological Oncology Working Group (AGO). This commentary is useful, it includes country-specific features for the ABC consensus.

International Consensus Conference for Advanced Breast Cancer, Lisbon 2019: ABC5 Consensus - Assessment by a German Group of Experts

The 5th International Consensus Conference for Advanced Breast Cancer (ABC5) took place on November 14-16, 2019, in Lisbon, Portugal. Its aim is to standardize the treatment of advanced breast cancer based on the available evidence and to ensure that all breast cancer patients worldwide receive adequate treatment and access to new therapies. This year, the conference focused on developments and study results in the treatment of patients with hormone receptor-positive/HER2-negative breast cancer as well as precision medicine. As in previous years, patient advocates from around the world were integrated into the ABC conference and had seats on the ABC consensus panel. In the present paper, a working group of German breast cancer experts comments on the results of the on-site ABC5 consensus votes by ABC panelists regarding their applicability for routine treatment in Germany. These comments take the recommendations of the Breast Committee of the Gynecological Oncology Working Group (Arbeitsgemeinschaft Gynäkologische Onkologie; AGO) into account. The report and assessment presented here pertain to the preliminary results of the ABC5 consensus. The final version of the statements will be published in Annals of Oncology and The Breast.

RIBECCA: A phase IIIb, multicenter, open label study for women with estrogen receptor-positive locally advanced or metastatic breast cancer treated with ribociclib (LEE011) in combination with letrozole—Results of the second interim analysis

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Background: RIBECCA is a national, multi-center, open-label, single-arm phase IIIb trial assessing the efficacy and safety of ribociclib in combination with letrozole in a patient population similar to the populations of MONALEESA-2, -3 and -7. Here we present the results of the second preplanned interim analysis. Methods: Main inclusion criteria allowed enrollment of men or women with metastatic or locally advanced breast cancer not amenable to curative treatment by surgery or radiotherapy, and histological or cytological confirmation of ER+, HER2- breast cancer, irrespective of their menopausal status. The primary objective is to assess the clinical benefit rate (CBR) after 6 months. Secondary objectives include: progression free survival (PFS), overall survival (OS), safety and changes in quality of life. Results: The cut-off date for this second interim analysis was 12 months after the last patient was enrolled in the pretreated and premenopausal cohort. Here we report a preliminary analysis on safety, efficacy and quality of life. We describe the baseline characteristics, safety data and the clinical benefit rate (CBR) at 24 weeks, of patients (pts) with at least 24 weeks follow up (n = 411). The median observation time for all patients in this analysis was 8.1 months. Baseline characteristics: of 411 pts, 409 were female and 2 male. Median age: 64 yrs; 46 pts pre-or perimenopausal, 363 postmenopausal; ECOG 0-1: 97.0%; median time since first recurrence: 1.6 months; 72.5 % pts had bone metastases (40.6% bone only), 30.7% liver, 27.3% lung and 29.2% other metastases. Median relative dose intensity was 0.905 for ribociclib and 1 for letrozole. The most common treatment emergent AEs (all grades) were neutropenia and/or neutrophil count decreased (54.5%), nausea (40.6%), fatigue (36.5%), alopecia (32.6%), leukopenia or WBC decreased (29%), nasopharyngitis (23.1%), diarrhea (21.4%), ALT increased (20.7%), AST increased (19%). The CBR by week 24 was 67.6%. Preliminary information on quality of life will be provided. Conclusions: The results of the second interim analysis in this additional patient population are in line with data published from the pivotal phase III studies MONALEESA-2, MONALEESA-3 and MONALEESA-7. Clinical trial information: NCT03096847.

Abstract P6-21-11: Final results from IMPROVE: A randomized, controlled, open-label, cross-over phase IV study to determine the patients' preference for either combined endocrine therapy (exemestane plus everolimus) or immunochemotherapy (capecitabine plus bevacizumab) as first line treatment for advanced HR+/HER2- breast cancer

For patients (pts) with advanced HR+/HER2- breast cancer various treatment options exist. Endocrine therapy or chemotherapy are the recommended 1st-line treatment options according to international guidelines. With comparable efficacy, it is of utmost importance to identify the treatment that has the least negative impact on the pts' quality of life (QoL). Randomized studies to determine the pts' preference (pref) for equi-effective treatment concepts, are lacking. IMPROVE compared both therapeutic concepts by assessing the pts' pref for either a combined antihormonal approach (everolimus /exemestane (E/E)) or chemotherapy (capecitabine /bevacizumab (C/B)).

In total, 77 pts were recruited from 10/14 until 04/17 at 26 sites in GER. Upon diagnosis of locally advanced, inoperable or metastatic disease, pts were randomized to receive 1st-line C/B until disease progression followed by 2nd-line E/E (Arm A) or vice versa (Arm B). Primary objective was the patient-reported pref for either treatment protocol 12 weeks after switching therapy. Key secondary endpoints include PFS, OS, safety and QoL. Descriptive statistics were used to to analyse data, PFS and OS were calculated by using the Kaplan-Meier method.

Baseline characteristics were well balanced with a slightly shorter disease-free interval after primary diagnosis and more prior treatments in Arm B.In Arm A [95% CI], 39% [13.9-68.4] vs 23% [5.0-53.8] of pts preferred E/E compared to C/B, 23% [5.0-53.8] were undecided. In Arm B, 56% [30.8-78.5] vs 11% [1.4-34.7] preferred C/B, 22% [6.4-47.6] undecided. Overall, 42% [24.5-60.9] vs 23% [9.6-41.1] of pts preferred C/B, 23% [9.6-41.1] were undecided.

Physicians' pref had a tendency for C/B treatment (Arm A, 62% [31.6-86.1] vs 39% [13.9-68.4] for C/B. Arm B, 56% [30.8-78.5] vs 28% [9.7-53.5] for C/B, no pref 17% [3.6-41.4]).

Median 1st-line PFS [months, 95% CI] was 11.1 [7.8-18.0] for C/B (Arm A) vs 3.5 [2.7-5.5] for E/E (Arm B). Median 2nd-line PFS was 3.7 [2.4-7.8] for E/E (Arm A) vs 3.6 [2.3-5.5] for C/B (Arm B). Median OS [months, 95% CI] was 28.8 [19.7-NA] (Arm A) and 24.7 [13.9-28.8] (Arm B). 73.0% and 52.6% (1st and 2nd line, C/B) vs 54.1% and 52.9% (1st and 2nd line, E/E) of pts developed grade 3/4 AEs. Most common grade 3/4 AEs (%) were hand-foot syndrome (18.9), fatigue (17.6), hypertension (13.5) for C/B and anaemia (23.5), fatigue, dyspnoea, cough (each 17.6) for E/E (either line). No treatment-related deaths occurred. Patient-reported QoL (EORTC-QLQC30) and treatment satisfaction were not significantly different between arms in either treatment phase.

In the IMPROVE study, pts had no pref for either endocrine therapy or immunochemotherapy. Overall, there was a tendency in favour of the chemotherapeutic approach (C/B), which was in line with the therapy pref reported by the physicians. C/B was found to have slightly better efficacy results but at the cost of a higher frequency of grade 3/4 AEs, bearing in mind the difference in duration of therapy between the two regimens. Patient-reported QoL, however, was similar in both arms.

Citation Format: Kurbacher CM, Söling U, Hahn A, Chiabudini M, Maintz C, Rieger L, Falkenstein J, Runkel E, Potthoff K, Decker T. Final results from IMPROVE: A randomized, controlled, open-label, cross-over phase IV study to determine the patients' preference for either combined endocrine therapy (exemestane plus everolimus) or immunochemotherapy (capecitabine plus bevacizumab) as first line treatment for advanced HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-21-11.

Efficacy and safety of everolimus plus exemestane in postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative locally advanced or metastatic breast cancer: Results of the single-arm, phase IIIB 4EVER trial

In BOLERO‐2, adding everolimus to exemestane resulted in a twofold increase in median progression‐free survival (PFS) vs exemestane in postmenopausal women with hormone receptor‐positive (HR+), human epidermal growth factor receptor 2‐negative (HER2−) advanced breast cancer (aBC) after progression on a non‐steroidal aromatase inhibitor (NSAI). Here, we report on the open‐label, single‐arm, phase IIIB 4EVER trial (NCT01626222). This trial evaluated the clinical effectiveness of everolimus plus exemestane in postmenopausal women with HR+, HER2− aBC who had progressed on or after an NSAI, but with no restrictions on the time of progression after NSAI, prior chemotherapy for advanced disease or previous exemestane. The primary endpoint was overall response rate (ORR; i.e. the percentage of patients with a best overall response of complete or partial response per RECIST 1.1) within the first 24 weeks of treatment. Secondary endpoints included PFS, overall survival, safety and health‐related quality of life. Between June 2012 and November 2013, 299 patients were enrolled at 82 German centers: 281 patients were evaluable for efficacy and 299 for safety. The ORR was 8.9% (95% confidence interval [CI]: 5.8–12.9%). Median PFS was 5.6 months (95% CI: 5.4–6.0 months). The most frequent grade 3/4 adverse events were stomatitis (8.4%), general physical health deterioration (6.7%), dyspnea (4.7%) and anemia (4.3%). The ORR in 4EVER was lower than in BOLERO‐2, likely due to inclusion of patients with more advanced disease and extensive pretreatment. These data confirm the clinical benefits and known safety profile of everolimus plus exemestane in postmenopausal women with HR+, HER2− aBC.

What's new?

Current treatment guidelines for HR+, HER2– advanced breast cancer support continued endocrine therapy after progression on first‐line treatment, including the use of everolimus and exemestane combined. Here, the authors report on the phase IIIB 4EVER trial, which evaluated the efficacy, safety and quality of life effects of everolimus plus exemestane in postmenopausal women with pretreated, HR+, HER2– advanced breast cancer. The patient population was broader than that evaluated in previous major trials, and thus more reflective of real‐world practice. Overall, the results confirm the clinical benefits and known safety profile of everolimus plus exemestane in this patient population.

The impact of mammalian target of rapamycin inhibition on bone health in postmenopausal women with hormone receptor-positive advanced breast cancer receiving everolimus plus exemestane in the phase IIIb 4EVER trial

Background

Breast cancer and its treatments are associated with a detrimental effect on bone health. Here we report the results of an exploratory analysis assessing changes in levels of biomarkers of bone metabolism in patients enrolled in the phase IIIb 4EVER study.

Methods

The 4EVER trial investigated everolimus in combination with exemestane in postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative locally advanced or metastatic breast cancer. In this prespecified exploratory analysis, changes in biomarkers of bone turnover were assessed in patients from baseline to weeks 4, 12, and 24. The serum bone markers assessed were procollagen type 1 N-terminal propeptide (P1NP), C-terminal cross-linking telopeptide of type 1 collagen (CTX), osteocalcin, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25-OH-vitamin D). On-treatment changes in bone markers over time were described per subgroup of interest and efficacy outcomes.

Results

Bone marker data were available for 241 of 299 enrolled patients. At the final assessment, P1NP, osteocalcin, PTH, 25-OH-vitamin D (all P < 0.001), and CTX (P = 0.036) were significantly decreased from baseline values per the Wilcoxon signed-rank test. At the last assessment (24 weeks or earlier), levels of serum CTX and PTH were significantly lower (P = 0.009 and P = 0.034, respectively) among patients with vs. without prior antiresorptive treatment (ART). Serum CTX levels were significantly lower (P < 0.001), and 25-OH-vitamin D concentrations significantly higher (P = 0.029), at the last postbaseline assessment in patients receiving concomitant ART vs. those without ART. Changes from baseline in PTH and 25-OH-vitamin D concentrations to the final assessment were significantly smaller in patients with prior ART. Lower baseline serum concentrations of osteocalcin and PTH were associated with clinical response (partial vs. non-response) at 24 weeks. High serum levels of CTX and P1NP at baseline were risk factors for progression at 12 weeks.

Conclusions

These exploratory analyses support use of everolimus plus exemestane for the treatment of postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer, and add to the body of evidence suggesting a potentially favorable impact of everolimus on bone turnover.

Trial registration

NCT01626222. Registered 22 June 2012, https://clinicaltrials.gov/ct2/show/NCT01626222.

A Head to Head Comparison Between SurgiMend® - Fetal Bovine Acellular Dermal Matrix and Tutomesh® - A Bovine Pericardium Collagen Membrane in Breast Reconstruction in 45 Cases

BACKGROUND/AIM

The use of acellular dermal matrices (ADM) has become a widely used option in breast reconstruction. A great deal of literature is available, totaling over 3,200 ADM reconstructions. Head-to-head comparisons between SurgiMend® and Tutomesh® are not yet reported. These are the first comparative clinical data reported on the use of Tutomesh® in breast reconstruction. Postoperative complication rates and costs for these devices were evaluated.

PATIENTS AND METHODS

This is a retrospective analysis of a 2-year experience with both SurgiMend® - fetal bovine acellular dermal matrix and Tutomesh® - a bovine pericardium collagen membrane in breast reconstruction in 45 cases from 2014-2015.

RESULTS

Forty-five patients received a total of 45 implant-based reconstructions using SurgiMend® (18 cases; 40%) or Tutomesh® (27 cases; 60%). Gross complication rates were 27.8% for SurgiMend® and 37.0% for Tutomesh® including hematoma, postoperative skin irritation, infection, red breast syndrome and revision surgery. The most common complication was postoperative red breast syndrome. Severe complications requiring revision surgery did not differ significantly in patients treated with SurgiMend® (0 cases, 0%) compared to Tutomesh® (1 case, 3.7%).

CONCLUSION

This retrospective analysis shows similar overall clinical complication rates for Tutomesh® and SurgiMend®. Severe complication rates are comparable to those reported in literature for both products. Although the retrospective nature of this work limits its clinical impact, it is possible to opt for the cheaper alternative (Tutomesh®).

Abstract P6-11-14: Safety and effectiveness of sensor-controlled scalp cooling to prevent alopecia in primary breast cancer patients receiving neoadjuvant or adjuvant epirubicin, taxanes, or both

Background: Chemotherapy (Ctx)-induced alopecia (CIA), produces a deep psychological distress in many women involved. Sensor-controlled scalp cooling (SCSC) is now approved by the FDA due to both its effectiveness and safety to prevent CIA demonstrated in two randomized trials in patients (pts) with primary breast cancer (PBC). However, SCSC is still infrequently used in many countries due to physicians´ concerns regarding both its safety and feasibility, in particular regarding anthracycline-based Ctx [Nangia et al., 2017]. This retrospective analysis was initiated to obtain more detailed information on the effectiveness and safety of SCSC using the Paxman system (Paxman, Huddersfield, UK) in PBC pts exposed to CIA-inducing neoadjuvant (NACT) or adjuvant Ctx (ACT) based on epirubicin (E), taxanes (T), or both (ET) in the clinical routine. Methods: 79 pts who underwent SCSC alongside with Ctx for PBC from 2014-2017 were identified from our database: NACT, 41 (51.9%); ACT, 38 (48.1%); dose-dense (dd) Ctx, 56 (70.9%); non-dd Ctx 23 (29.1%); premenopausal, 44 (55.7%); postmenopausal, 35 (44.3%). The following Ctx regimens were used: E, 1 (1.3%); T, 23 (29.1%); ET, 55 (69.6%). Pts were subjected to SCSC during each Ctx cycle. CIA was quantified according to the Dean score (DS) determined 3 wks after the last Ctx cycle. Data were analyzed regarding feasibility indicated by the SCSC completion rate, quality of hair preservation (success: DS 0-2, failure: DS 3-4), reasons of SCSC discontinuation, and safety. Moreover, the following parameters were investigated in regard to the success of SCSC: menopausal status (pre- vs postpenopausal), NACT vs ACT, dd Ctx vs non-dd Ctx, E- or ET-based Ctx vs T-based Ctx. Results: 55 pts (69.6%) completed SCSC, with 36 (45.6%) experiencing complete hair preservation (DS 0), and 19 (22.8%) showing partial success (DS 1-2). 24 pts (30.4%) discontinued SCSC, with CIA being the main reason in 18 pts (22.8%). Headache or earache was reported in 2 pts (1.3%) each, and local discomfort in another 4 pts (5.1%). Side effects were all not severe and resolved quickly after cessation of SCSC. SCSC was equally effective in most analyzed subgroups. The relative risk (RR) to experience CIA was 1.11 (CI: 0.82-1.54) for post- vs premenopausal pts, 1.11 (CI: 0.83-1.53) for ACT vs NACT, and 0.99 (CI: 0.72-1.43) for dd Ctx vs non-dd Ctx. Pts receiving E or ET had a significantly higher RR for SCSC failure: 1.39 (CI: 1.04-1.81, p=0.035). However, the success rate in this group was still 62.5%, thus clearly indicating a clinically meaningful benefit. Conclusions: In our study, SCSC was feasible, safe and effective in order to prevent CIA in pts with PBC. All therapeutic subgroups benefited from SCSC. Although patients on E or ET are at higher risk for CIA, the success rate in this subgroup indicates that SCSC can be reasonably offered to patients subjected to NACT or ACT with epirubicin-containing regimens.

Citation Format: Kurbacher CM, Kurbacher AT, Herz S, Kolberg G, Kettelhoit N, Schweitzer C, Kurbacher JA, Eichler C. Safety and effectiveness of sensor-controlled scalp cooling to prevent alopecia in primary breast cancer patients receiving neoadjuvant or adjuvant epirubicin, taxanes, or both [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 P6-11-14.

Panitumumab in platinum-sensitive epithelial ovarian cancer patients with KRAS wild-type: The PROVE-study, a phase II randomized multicenter study of the North-Eastern German Society of Gynaecologic Oncology

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Background: For ovarian cancer (OC) patients with platinum-sensitive recurrence the addition of new biologic agents to chemotherapy may improve survival. Panitumumab is a fully human monoclonal antibody specific to the epidermal growth factor receptor (EGFR). The purpose of this trial was to investigate the therapeutic efficacy of panitumumab in the combination with carboplatin-based chemotherapy in relation to the respective standard combination in patients with a KRAS wildtype with platinum-sensitive recurrent ovarian cancer (NCT01388621). Methods: Major eligibility criteria were pretreated platinum-sensitive epithelial ovarian/ fallopian/ peritoneal cancer and no more than 2 prior treatments for this disease. Only patients with measurable disease or elevated CA125 and with KRAS wild type were eligible. Patients were treated with Carboplatin AUC4/Gemcitabine 1000 mg/m² or Carboplatin AUC5/PLD 40 mg/m² and randomized to panitumumab 6 mg/kg day 1 and day 15, every 3 or 4 weeks. Tumor assessment was performed at baseline and at every third cycle according to CT-scan and CA-125 criteria. Results: In this multi-institutional phase II trial 102 patients were randomized and 96 enrolled for the final analysis. Progression-free survival in the intention-to-treat population (N=96) was 9.5 vs. 10.7 months (HR 0.829, 95%CI of 8.5-11.6 months vs 8.5-13.1 months) for the experimental vs. standard arm, p=0.45. Data of overall survival are not jet evaluable. The most common treatment related grade 3+ toxicities included hematologic toxicity (54%), skin reactions (18%) and gastrointestinal events (16%). Conclusions: The addition of panitumumab to platinum-based chemotherapy for recurrent ovarian cancer does not influence efficacy and progression-free survival in platinum sensitive patients, while no new additional toxicity aspects for panitumumab were evaluated. Clinical trial information: NCT01388621.

Abstract P4-10-17: Changes of bone turnover markers during perioperative anthracycline- and/or taxane-based chemotherapy in pre- and postmenopausal patients with primary breast cancer

Background: Loss of bone mineral density (BMD) is among the well known sequelae of pharmacological therapy of patients (pts) with primary breast cancer (PBC). Cancer therapy induced bone loss (CTIBL) progresses more rapidly as compared to normal age-related changes of BMD and is best known to be associated with aromatase inhibitors in postmenopausal pts. Chemotherapy (Ctx) may also lead to a deterioration of BMD but in contast to endocrine Tx, this phenomenon is by far less elucidated and, at least in younger pts, mostly interpreted as a secondary effect following Ctx induced ovarian failure. Previous investigations focused on the classical CMF scheme, whereas conclusive data regarding direct effects of more recent Ctx protocols on the bone metabolism of PBC pts are still lacking. This translational project was initiated to gain detailed insights into the influence of anthracycline (A)- and/or taxane (T)-based Ctx on bone turnover of both pre- and postmenopausal PBC pts in the clinical routine. Methods: Data of 109 pts (premenopausal: 49; postmenopausal: 60) with non-metastatic Ctx-naïve PBC exposed to neoadjuvant or adjuvant Ctx were analyzed. 84 pts (75%) had estrogen receptor-positive (ER+) disease, HER2- overexpression was found in 18 pts (17%). 16 pts (15%) received A-based Ctx, 34 pts (31%) received T-based Ctx, and 59 pts (54%) received A/T-based Ctx. Trastuzumab was given to 17 pts (16%) with HER2-positive disease. Serum bone markers including the C-telopeptide of type I collagen (ICTP) indicating osteoclast activity, the N-propeptide of type I collagen (P1NP) measuring osteoblast activity, and alkaline phosphatase (AP) were determined at baseline and prior to each subsequent Ctx cycle (C) up to C6. Changes of ICTP, P1NP, and AP over time were analyzed by repeated-measure ANOVA. Results: 600 Ctx cycles were analyzed. Baseline levels of ICTP (p = 0.0027), P1NP (p = 0.0063), and AP (p = 0.0007) were significantly higher in post- versus premenopausal pts. AP levels remained largely unchanged during Ctx. Trends showing an increase of ICTP from baseline until C6 in premenopausal pts and a decrease in postmenopausal pts did not reach statistical significance. In contrast, P1NP significantly declined in postmenopausal pts from baseline to C6 (p = 0.0152). In premenopausal pts, P1NP declined from baseline to C3 and thereafter increased to C6. These changes were highly significant (p = 0.0024). Conclusions: Our study represents one of the first systematic evaluations of bone turnover in pts exposed to modern A- and/or T-based Ctx for PBC in the clinical routine. Postmenopausal pts presented with higher baseline levels of all three markers which may be attributable to an enhanced bone turnover related to the loss of ovarian function prior to the initiation of Ctx. In postmenopausal pts, Ctx was associated with a sustained suppression of osteoblast activity whereas osteoblast suppression recovered until the end of Ctx in premenopausal pts. Whether these effects will translate into an increased risk of CTIBL remains a matter of further investigations which should clearly focus on the individual menopausal status.

Citation Format: Kurbacher CM, Rauschenbach N, Kurbacher AT, Sperling S, Herz S, Monreal K, Kurbacher JA. Changes of bone turnover markers during perioperative anthracycline- and/or taxane-based chemotherapy in pre- and postmenopausal patients with primary breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-10-17.

Abstract P4-13-22: Successful targeting HER2 in heavily pretreated HER2-negative metastatic breast cancer patients presenting with elevated serum levels of the HER2 extracellular domain and/or HER2 overexpressing circulating tumor cells

Background: A considerable proportion of patients (pts) with HER2-negative (HER2-) metastatic breast cancer (MBC) present with elevated serum levels of the soluble HER2 extracellular domain (sHER2) and/or HER2-overexpressing circulating tumor cells (CTCs) during their further clinical course. These "occult" HER2-positive (HER2+) pts may well be candidates for HER2-targeted therapy (Tx) albeit normally not subjected to such treatment. This observational study was undertaken to gain more insights into the feasibility of HER2-directed Tx in occult HER2+ MBC pts in the clinical routine. Methods: A total of 30 pts with heavily pretreated HER2- MBC (ER+, n = 26) showing sHER2 values &gt; 15 ng/mL (n = 8), HER2+ CTCs (n = 7), or both (n = 15) were included. Pts had failed 2-16 prior systemic treatments (median: 7) and did not qualify for recruitment onto a controlled clinical trial. sHER was measured by a chemiluminescence assay (Siemens Helathcare, Eschborn, Germany), CTCs were ennumerated and checked for HER2 expression by using the FDA-cleared CellSearch™ technology (Veridex, Raritan, NJ). All pts received anti-HER2 Tx with trastuzumab (H: n = 18), lapatinib (L: n = 4), H+L (n = 2), or H+pertuzumab (H+P: n = 6). HER2-targeted Tx was given alone (n = 4), or in combination with endocrine agents (n = 7), cytotoxics (n = 17), or other targeted drugs (n = 2). Responses were scored according to RECIST 1.1, OS was calculated from the start of HER2-directed Ctx until death from any reason or loss to follow-up by using Kaplan-Meier statistics. Results: Anti-HER2 Tx was generally well tolerated. Median treatment duration was 16.1 wks (range 1.0-72.9 wks). In 2 pts with L and 1 pt with H+L, Tx was prematurely stopped due to toxicity (diarrhea, fatigue). 2 pts were too early to evaluate (TE). 11 PR, 12 SD, and 5 PD accounted for an objective response rate (ORR) of 36.7% and a clinical benefit rate (CBR) of 76.7%. Median OS was 62.9 wks. In 25 pts, 9 with PR, 12 with SD, and 4 with PD, results of serial sHER2 measurements at baseline and after 3 wks of Tx were available. Most pts with PD showed increasing sHER2 levels. In the majority of pts with PR or SD, sHER2 decreased by more than 20% from baseline. However, 2 pts with PR following L-based Tx showed increasing sHER2 values. In 19 pts, 8 with PR, 7 with SD, and 4 with PD, repeated CTC counts at week 6 from baseline were available. All pts with PD showed increasing CTCs. All pts with SD and PR presented with decreasing CTC counts, most of them normalizing within 6 wks. Conclusions: Our findings indicate that anti-HER2 Tx may be a valid option in pts with heavily pretreated HER2- MBC with pathological sHER2 values and/or HER2+ CTCs in the clinical routine. Thus, determination of both sHER2 and HER2 expression on CTCs appears to be reasonable in tissue HER2-negative MBC pts. Compared to sHER2, serial CTC measurements may be the more accurate predictor of response to anti-HER2 treatment, particularly in pts receiving L as part of their Tx. Results of ongoing randomized trials in this setting are eagerly awaited.

Citation Format: Kurbacher CM, Quade A, Eichler C, Kunstmann G, Herz S, Kurbacher JA, Warm MR. Successful targeting HER2 in heavily pretreated HER2-negative metastatic breast cancer patients presenting with elevated serum levels of the HER2 extracellular domain and/or HER2 overexpressing circulating tumor cells. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-22.

NADIR: A Non-Interventional Study on the Prophylaxis of Chemotherapy-Induced Neutropenia Using Lipegfilgrastim - First Interim Analysis

BACKGROUND

The non-interventional study (NIS) NADIR was designed to assess the effectiveness and safety of lipegfilgrastim, a novel glycopegylated granulocyte-colony stimulating factor, in reducing the risk of both febrile and severe neutropenia.

METHODS

Here, the interim analysis of NIS Nadir performed under real-world conditions at 80 oncology practices across Germany is reported. For a patient to be included, lipegfilgrastim at a subcutaneous single dose of 6 mg had to be administered during at least 1 cycle of the chemotherapy under consideration.

RESULTS

The interim analysis included 224 patients. Median patient age was 61.1 years (interquartile range 51.2-70.2 years). Main tumor type was breast cancer followed by lung cancer, and non-Hodgkin's lymphoma (46.0, 13.4, and 10.7%, respectively). When lipegfilgrastim was given as primary prophylaxis, no patient developed febrile neutropenia (FN). 1.3% of patients developed FN when primary prophylaxis was withheld. Only 68.6% of patients undergoing chemotherapy and at high risk (> 20%) of developing FN were treated with lipegfilgrastim during the first cycle, exposing disparity between real-world practices and current treatment guidelines. Lipegfilgrastim was well tolerated. The only grade 3/4 treatment-related adverse event was anemia in 1 patient.

CONCLUSION

Lipegfilgrastim was effective and safe when administered for the prevention of chemotherapy-induced neutropenia under real-world conditions.

Abstract P5-19-06: 4EVER - Final efficacy analysis of the phase IIIb, multi-center, open label study for postmenopausal women with estrogen receptor positive locally advanced or metastatic breast cancer (BC) treated with everolimus (EVE) in combination with exemestane (EXE)

Introduction:

The phase III BOLERO-2 trial showed a significant doubling of PFS benefit with EVE + EXE over EXE alone in postmenopausal women with hormone receptor positive advanced BC progressing after non-steroidal aromatase inhibitor (NSAI) therapy. The 4EVER trial further evaluated the combination of EVE+EXE with regard to efficacy and safety, quality of life and health resources utilization in a broader patient population, i.e. without limitations as to the number of previous chemotherapy lines, the time point of progression after NSAI therapy, and the previous EXE therapy.

Methods:

From May 2012 to November 2012 a total of 299 postmenopausal women with metastatic or locally advanced, hormone receptor positive, HER2 negative breast cancer, refractory to NSAI were recruited to this phase IIIb study. Here we report the results of the planned analysis of the primary and secondary endpoints. The primary endpoint was the overall response rate (ORR) at week 24. The secondary endpoints included: Progression-free survival (PFS), ORR at week 48, overall survival (OS), and quality of life. This study includes a broad exploratory translational research program e.g. changes in serum bone turnover biomarkers, the correlation of Interleukin-6 with anxiety and depression, presence and molecular characteristics of circulating tumor cells, the correlation of response to EXE+EVE with pharmacogenomics.

Results:

Trial database lock will occur in late June 2014, therefore, the final data concerning the primary and secondary efficacy and safety endpoints will be presented at SACBS 2014.

The preliminary baseline analysis included 299 patients (data cut off 15 Nov 2013):

HR status: ER+/PgR+ 78.1%, ER+/PgR- 20.9%, 0.7% ER-/PgR+, 0.3% ER-/PgR-. Tissue for receptor status analysis: 71.0% primary tumor, 29.0% metastasis. The mean time since initial diagnosis was 9.6 years, the mean time since first relapse/metastasis was 4.3 years. The mean time since last relapse/metastasis was 2.8 months. 68.1% of patients had bone lesions. Last anti-neoplastic therapy had been administered in the adjuvant (23.9%) and metastatic setting (73.0%). 25.9% of patients had no prior antineoplastic therapy in the metastatic setting, 16.3% had one, 12.2% two and 47.4% three or more prior therapies.

Conclusion:

The final analysis of the 4EVER study provides more important information on disease patterns and benefits of the combined treatment with EVE and EXE.

Citation Format: Hans Tesch, Oliver J Stoetzer, Thomas Decker, Christian M Kurbacher, Romy Neumeister, Frederik Marmé, Andreas Schneeweis, Christoph Mundhenke, Andrea Distelrath, Peter A Fasching, Michael P Lux, Diana Lueftner, Peyman Hadji, Wolfgang Janni, Mathias Muth, Julia Kreuzeder, Claudia Weiss, Diethelm Wallwiener. 4EVER - Final efficacy analysis of the phase IIIb, multi-center, open label study for postmenopausal women with estrogen receptor positive locally advanced or metastatic breast cancer (BC) treated with everolimus (EVE) in combination with exemestane (EXE) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-19-06.

Updated results of neoadjuvant chemotherapy with carboplatin AUC 6 and docetaxel 75 mg/m2 in triple-negative breast cancer (TNBC)

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Background: Triple-negative breast cancer (TNBC) is associated with a poor prognosis unless a pathological complete response (pCR) is achieved or almost achieved (near-pCR). Treatment of TNBC remains a challenge as some patients fail to respond to the use of standard anthracyclin-based chemotherapy regimens. Phenotypic and molecular similarities between TNBC and BRCA1-associated breast cancer suggest that TNBC may share the same sensitivity to platinum analogues as tumors associated with BRCA1. Methods: 30 patients with primary, unilateral, non-metastasized TNBC (majority of them cT1 or cT2, two cT4) had to be unsuitable for standard anthracycline-based chemotherapy. They received 6 cycles, respectively in two case sonly 5 cycles, of carboplatin AUC 6 and docetaxel 75 mg/m² q3w. Adverse effects were recorded according to CTCAE V4.07. Primary endpoint was pathological complete response (pCR) and near-pCR, secondary endpoint toxicity. Results: 70% (21/30) of patients had either a pathological complete response (55%; 15/27) or a near-complete response (20%; 6/30) - defined as pT1mic and ypT1a - both being associated with a good prognosis. Eight remaining patients had still good partial response, leaving only low residual cancer burden, which was specified as ypT1, in contrast only one ypT4 tumor. Treatment was well tolerated - grade IV toxicities were predominantly hematological side effects (especially concerning neutropenia) and in 2 cases grade IV edema and joint pain. Carboplatin dose reduction (to an AUC of 5) was required in 5 cases (because of limited renal function, hematological side effects or patient’s age). Conclusions: Our results demonstrate a high-anti-tumour activity of docetaxel 75mg/m² in combination with carboplatin AUC 6, promising high rates of tumour regression and pathological complete remission. The omission of exposure to anthracyclines in patients with considerable heart disease risks seems to be feasible with a good pCR-rate, the latter being a surrogate-marker for long-term survival. Survival data of this trial are currently being updated and will be presented on the Breast Cancer Symposium.

Results of the CARMA study to investigate catumaxomab therapy for ascites related to peritoneal carcinomatosis in clinical practice

TPS3119^

Background: The trifunctional antibody CATU (catumaxomab) is approved in the EU for intraperitoneal (IP) treatment of malignant ascites (MA) in patients (pts) with EpCAM-positive carcinomas. Clinical data for CATU are based on 2 phase III and several phase I/II trials. However, the routine use of CATU has not been evaluated systematically. Therefore, a prospective observational study (CARMA) was started in 2010 investigating the administration of CATU in a total of 160 pts with MA under routine conditions. Participating centers were hospitals and oncologic practices in Germany and Austria. Hereby, we report on the results of the 2nd interim CARMA analysis. Methods: This analysis included 103 pts with MA due to EpCAM-positive carcinomas: ovarian, n=37; gastric, n=13; pancreatic, n=10; colorectal, n=6, miscellaneous, n=37. Pts were treated with CATU at a routine setting at 4 increasing dosages over a 2-week interval. The primary endpoint was puncture-free interval (PFI), secondary endpoints included safety and overall survival (OS). Results: The study population mainly comprised pts with advanced-stage disease. In 65% distant metastases were present. Therapy was given in 24 hospitals (73 %) and 9 outpatient facilities (27 %). Pts suffered from typical MA related symptoms such as abdominal swelling (77%), pain (56%), dyspnea (27%), anorexia (31%), constipation (13%). In 67 pts (65%), CATU was given as planned, 36 pts (35%) received <4 infusions. Most frequent adverse events (AE) were fever (20%), nausea (14%) and diarrhea (6%).The median PFI was 57 days (d), the median OS was 100 d. For the subgroups ovar/non-ovar, a median PFI of 93/41 d and a median OS of 115/72 d was observed. Conclusion: CARMA represents the first systematic evaluation of CATU therapy given for MA under routine conditions. In accordance to previous prospective trials, the presented 2nd interim-analysis was able to demonstrate a clinically meaningful benefit of CATU, particularly impressive in ovarian cancer pts. CATU showed an acceptable safety profile, thus allowing for treatment at an outpatient setting in an adequately selected group of pts. The final CARMA analysis after including 160 pts is thus eagerly awaited. Clinical trial information: DRKS00000458.

Bevacizumab-based therapy in patients with heavily pretreated ovarian and other Mullerian tract cancers

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Background: Bevacizumab (Bev) is approved for the therapy (Tx) of primary and platinum-sensitive recurrent Mullerian tract cancers (MTC) such as ovarian (OC), fallopian tube (FTC), type II endometrial (EC-II), and peritoneal papillary-serous carcinomas (PPSC). However, the role of Bev in the ≥ 3rd line Tx of MTCs is still unclear.This retrospective study summarizes our long-term experiences with Bev in patients (pts) with heavily pretreated MTC who did not qualify for recruitment into a controlled clinical trial. Methods: A total of 74 intensively pretreated MTC pts (OC, n = 65; FTC, n = 2; EC-II, n = 4; PPSC, n = 3) were included in this study with 43 (58.1%) being platinum-resistant. Pts had failed a median of 4 (range 1-10) prior chemotherapies (CTx ). Tx included Bev monotherapy (group A, n = 17), Bev + metronomic CTx (group B, n = 37), and Bev + conventionally dosed CTx (Group C, n=20). Bev was administered at either 10 mg/kg BW q2w or 15 mg/kg BW q3w. Adverse effects were classified according to CTCAE Vs 4.03. TTP was calculated from the start of Bev until progression, OS was calculated from the start of Bev until death or loss to follow up. Results: Most common Tx related toxicities were hypertension, proteinuria, headache, inflammation/infection, epistaxis, and subileus. Hypertension which often required adequate treatment was limiting in only one case as also were renal toxicity and infection. Median TTP was 27.8 wks and median OS was 53.6 wks with no significant difference between platinum-resistant and –sensitive pts. In regard to both TTP and OS, there was a non-significant trend favoring groups A (33.4/63.0 wks) and B (29.9/61.6 wks) vs group C (19.2/35.4 wks). Conclusions: Bev based Tx was active and generally well tolerated in this hard-to-treat population of pts with recurrent MTC. Both TTP and OS were equal or even superior to any conventional CTx used in this setting. Moreover, clinical platinum-resistance did not predict a worse clinical outcome. Although this is not a randomized trial, our results argue in favor that Bev should be preferably given either as single agent or combined with metronomic CTx in pts with heavily pretreated MTCs. Further clinical trials of Bev in recurrent MTCs may prove useful.

Results of the first interim analysis of the CARMA study to investigate efficacy and safety profile of catumaxomab in clinical practice

e13100^

Background: The trifunctional antibody catumaxomab is approved in the EU for intraperitoneal (i.p.) treatment of malignant ascites in patients (pts) with EpCAM-positive carcinomas. Clinical data for catumaxomab are based on the pivotal trial and several phase I/II trials. So far, the routine use of catumaxomab in clinical practice has not been evaluated systematically. Therefore, a large prospective observational study was started in 2010. The study investigates the administration of catumaxomab in a total of 160 pts with malignant ascites under routine conditions in daily clinical practice. Here we show the results of the first pre-planned interim analysis. Methods: The analysis included 49 pts with malignant ascites due to EpCAM-positive carcinomas treated with i.p. catumaxomab under routine conditions in clinical practice. Participating centres were hospitals and practices of oncologists in Germany. Primary endpoint was puncture-free interval (PFI), secondary endpoints included safety and overall survival (OS). Results: At inclusion into the study pts already had undergone a median number of 9 ascites punctures. Malignant ascites had been diagnosed for the first time 3.3 months before (median). Patients suffered from typical ascites symptoms as follows: swelling (79.6%), pain (44.9%), dyspnea (26.5%), anorexia (26.5%), obstipation (12.2%). 49 pts were treated with catumaxomab, of whom 30 pts received all 4 infusions (61.2%). Median PFI was 108 days (d), the median OS was 102 d. Most frequent adverse events were fever, nausea and diarrhoe. Conclusions: This is the first systematic report on routine use of catumaxomab in clinical practice.. Although The study population mainly comprised patients with advanced tumor diseaset a clinical benefit after catumaxomab therapy could be demonstrated. The treatment showed an acceptable safety profile Theseresults are consistent with the data of the pivotal trial. The data will be evaluated in further analyses including larger patient numbers.

Isolation and culture of ovarian cancer cells and cell lines

Ovarian carcinomas show considerable heterogeneity of origin, both in terms of site and tissue. The most important and also most frequent of these tumors arise from the coelomic epithelium and are therefore characterized as epithelial ovarian carcinomas (EOC). EOC is often large and advanced at the time of presentation, so that cells are readily obtainable from surgical specimens or effusions. While the primary tumor may be chemosensitive, they often develop resistance and may do so rapidly. Due to the easy access to tumor cells and its biological behavior, EOC is considered to be an ideal model to investigate principal mechanisms of both antineoplastic drug sensitivity and resistance. Although studies on primary EOC cells are now preferred for many of these investigations, EOC cell line studies remain important too. This chapter gives an overview over major techniques required to establish and maintain primary EOC cell cultures and to initiate and cultivate permanently growing EOC cell lines.

Activity of mevalonate pathway inhibitors against breast and ovarian cancers in the ATP-based tumour chemosensitivity assay

Previous data suggest that lipophilic statins such as fluvastatin and N-bisphosphonates such as zoledronic acid, both inhibitors of the mevalonate metabolic pathway, have anti-cancer effects in vitro and in patients. We have examined the effect of fluvastatin alone and in combination with zoledronic acid in the ATP-based tumour chemosensitivity assay (ATP-TCA) for effects on breast and ovarian cancer tumour-derived cells. Both zoledronic acid and fluvastatin showed activity in the ATP-TCA against breast and ovarian cancer, though fluvastatin alone was less active, particularly against breast cancer. The combination of zoledronic acid and fluvastatin was more active than either single agent in the ATP-TCA with some synergy against breast and ovarian cancer tumour-derived cells. Sequential drug experiments showed that pre-treatment of ovarian tumour cells with fluvastatin resulted in decreased sensitivity to zoledronic acid. Addition of mevalonate pathway components with zoledronic acid with or without fluvastatin showed little effect, while mevalonate did reduced inhibition due to fluvastatin. These data suggest that the combination of zoledronic acid and fluvastatin may have activity against breast and ovarian cancer based on direct anti-cancer cell effects. A clinical trial to test this is in preparation.

A prospective randomized controlled trial of tumour chemosensitivity assay directed chemotherapy versus physician's choice in patients with recurrent platinum-resistant ovarian cancer

The primary aim of this randomized trial was to determine response rate and progression-free survival following chemotherapy in patients with platinum-resistant recurrent ovarian cancer, who had been treated according to an ATP-based tumour chemosensitivity assay in comparison with physician's choice. A total of 180 patients were randomized to assay-directed therapy (n=94) or physician's-choice chemotherapy (n=86). Median follow-up at analysis was 18 months. Response was assessable in 147 patients: 31.5% achieved a partial or complete response in the physician's-choice group compared with 40.5% in the assay-directed group (26 versus 31% by intention-to-treat analysis respectively). Intention-to-treat analysis showed a median progression-free survival of 93 days in the physician's-choice group and 104 days in the assay-directed group (hazard ratio 0.8, 95% confidence interval 0.59-1.10, not significant). No difference was seen in overall survival between the groups, although 12/39 (41%) of patients who crossed over from the physician's-choice arm obtained a response. Increased use of combination therapy was seen in the physician's-choice arm during the study as a result of the observed effects of assay-directed therapy in patients. Patients entering the physician's-choice arm of the study during the first year did significantly worse than those who entered in the subsequent years (hazard ratio 0.44, 95% confidence interval 0.2-0.9, P<0.03). This small randomized clinical trial has documented a trend towards improved response and progression-free survival for assay-directed treatment. Chemosensitivity testing might provide useful information in some patients with ovarian cancer, although a larger trial is required to confirm this. The ATP-based tumour chemosensitivity assay remains an investigational method in this condition.

Anticancer drugs induce mdr1 gene expression in recurrent ovarian cancer

Ovarian cancer is currently the most lethal gynecologic malignancy in Europe and the US. Platin analogues and paclitaxel demonstrate high remission rates, but unfortunately the efficacy of cytostatic agents is limited by the development of multidrug resistance (mdr). Clinical paclitaxel resistance is often associated with mdr1 overexpression. In a recent study, we introduced a highly specific quantitative real-time reverse transcriptase polymerase chain reaction for the quantification of mdr1 transcripts. In the present study, we demonstrate that primary tumor cells from patients with recurrent ovarian cancer overexpress mdr1. To evaluate mdr1 expression, we collected tumor cells from 77 ovarian cancer patients (13 chemotherapy-naive ovarian cancer, 64 recurrent ovarian cancer). Cancer cells were aspirated from 49 solid specimens (63%) and 28 ascitic fluids (37%). Subsequently, cancer cells were exposed in 221 short-term cultures either to blank medium (control) or to a single anticancer drug, cisplatin, doxorubicin or paclitaxel. The drug concentrations applied referred to clinical relevant doses. mdr1 mRNA expression was significantly higher in specimens from recurrent ovarian cancer incubated in paclitaxel than in specimens from chemotherapy-naive ovarian cancer. No significant differences were detectable between the mean value of mdr1 mRNA expression in tumor specimens from recurrent ovarian cancer incubated in cisplatin or doxorubicin. Differences within the untreated patients group were also not statistically significant. The result of this study confirms clinical observations, as well as in-vitro studies based on tumor cell lines, that paclitaxel resistance is correlated with mdr1 overexpression.

Pilot studies of the effect of zoledronic acid (Zometa) on tumor-derived cells ex vivo in the ATP-based tumor chemosensitivity assay

There is debate regarding the direct effect of bisphosphonates against visceral metastases from solid tumors, despite their proven efficacy against the skeletal complications of metastasis. The aim of this study was to determine whether zoledronic acid showed direct activity against five ovarian cell lines and tumor-derived cells, and whether addition of zoledronic acid to cytotoxic agents increased their cytotoxicity. In this study we used a standardized ATP-based tumor chemosensitivity assay (ATP-TCA) to measure the activity of alendronate, clodronate and zoledronic acid in five ovarian carcinoma cell lines and human solid tumors (breast, lung, ovarian, unknown primary carcinoma, and cutaneous and uveal melanoma) (n=34). We also tested the combination of zoledronic acid with paclitaxel and cisplatin in tumor-derived cells. All five cell lines exhibited greater sensitivity to bisphosphonates than the tumor-derived cells and in all five the IC50 for zoledronic acid was less than 4 muM. In the tumor-derived cells, zoledronic acid showed concentration-dependent inhibition with a median IC50 for all tumors tested of 17 muM and evidence of apoptosis (caspase activation). Simultaneous addition of zoledronic acid to cisplatin or paclitaxel showed no major increase in cytotoxicity. We conclude that the activity of bisphosphonates was greater in cell lines than in tumor-derived cells. However, the pattern of activity of bisphosphonates was the same in cell lines and tumor derived cells. This study suggests a direct, or possibly an indirect, effect of zoledronic acid and other nitrogen-containing bisphosphonates against neoplastic cells, but simultaneous addition with cisplatin or paclitaxel does not substantially increase the activity of the cytotoxic agent.

Chemosensitivity testing using microplate adenosine triphosphate-based luminescence measurements

During the last two decades, novel nonclonogenic methods for pretherapeutic chemosensitivity testing have been developed that are likely to overcome major technical limitations of older assays such as low evaluability rates, low degree of standardization and reproducibility, lack of technical robustness, and poor methodological efficacy. Among these, the microplate adenosine triphosphate (ATP)-based tumor chemosensitivity assay (ATP-TCA) has gained particular merits for ex vivo chemosensitivity testing of native nonhematological tumors including cancers of the breast, ovary, gastrointestinal tract, cervix and corpus uteri, and lung; malignant melanomas; gliomas; sarcomas; and mesotheliomas. For this indication, the ATP-TCA can now be considered the best documented and validated technology. This assay, which is now commercially available, provides a highly reproducible, easy-to-handle kit technique; low technical failure rates; and a high methodological efficacy requiring only 1 x 106 tumor cells to test four to six different drugs or combinations. In ovarian and breast carcinomas, the predictive accuracy is > 90%, with a positive predictive value of 85-90% and a negative predictive value near 100%, respectively. In primary ovarian cancers, the ATP-TCA has been found to accurately predict both clinical response and survival. In two prospective clinical trials in patients with heavily pretreated ovarian cancer, chemotherapy individually selected by the ATP-TCA has been found to triple the response rates and nearly double the survival compared to empirically chosen regimens. Consequently, this assay, which is now under phase III evaluation, has successfully been used in new agent development to screen for novel chemotherapy regimens for the treatment of patients with breast and ovarian carcinoma and melanoma, respectively. This chapter highlights the recent preclinical and clinical experience with this promising technology and gives a detailed description of all the technical aspects of the ATP-TCA.

Continuous low-dose GM-CSF as salvage therapy in refractory recurrent breast or female genital tract carcinoma

Granulocyte-macrophage colony-stimulating factor (GM-CSF, sargramostim [Leukine]) is a powerful cytokine that is able to stimulate the generation of dendritic cells. Adjuvant treatment with continuous low-dose GM-CSF has been shown to prolong survival of stage III/IV melanoma patients. Data on continuous low-dose GM-CSF therapy in tumors other than prostate cancer are still lacking. This pilot trial was initiated in order to evaluate the efficacy and tolerability of continuous low-dose GM-CSF as salvage in various chemotherapy-refractory carcinomas. A total of 19 patients who had failed a median of 4 prior chemotherapies were included. Their malignancies included metastatic breast cancer, recurrent ovarian carcinoma, metastatic endometrial carcinoma, and recurrent squamous cell cancer of the cervix uteri. Continuous low-dose GM-CSF was delivered subcutaneously at a daily starting dose of 125 microg. GM-CSF was increased at 25-microg increments until a maximum of 250 microg was reached or when mild leukocytosis (10-20 g/L) was achieved, providing that the relative eosinophil count did not exceed 15%. Therapy was continued until progression or refusal by the patient. Toxicity was generally mild. Only one patient was withdrawn due to grade 3 fatigue. In three additional patients, temporary dose reduction was necessary because of grade 1 injection site reactions, which recovered spontaneously. Mild to moderate leukocytosis was obvious in 10 patients. Systemic hypersensitivity-like reactions did not occur and no patient required hospitalization for other life-threatening side effects. The objective response rate was 37%: 1 complete and 6 partial responses, 4 disease stabilizations, 8 progression of disease. Median response duration was 6 months. Notably, 6 of 7 responders but only 1 of 8 patients with disease progression developed leukocytosis during therapy. Therefore, we conclude that continuous low-dose GM-CSF has substantial activity in heavily pretreated patients with either metastatic breast cancer or female genital tract cancer. Achievement of mild leukocytosis seems to be a predictor of response.