Diversity of US participants in AstraZeneca-sponsored clinical trials

BACKGROUND

To develop medicines that are safe and efficacious to all patients, clinical trials must enroll appropriate target populations, but imbalances related to race, ethnicity and sex have been reported. A comprehensive analysis and improvement in understanding representativeness of patient enrollment in industry-sponsored trials are key public health needs.

METHODS

We assessed race/ethnicity and sex representation in AstraZeneca (AZ)-sponsored clinical trials in the United States (US) from 2010 to 2022, compared with the 2019 US Census.

RESULTS

In total, 246 trials representing 95,372 patients with complete race/ethnicity and sex records were analyzed. The proportions of different race/ethnicity subgroups in AZ-sponsored clinical trials and the US Census were similar (White: 69.5% vs 60.1%, Black or African American: 13.3% vs 12.5%, Asian: 1.8% vs 5.8%, Hispanic: 14.4% vs 18.5%). We also observed parity in the proportions of males and females between AZ clinical trials and US Census (males: 52.4% vs 49.2%, females: 47.6% vs 50.8%). Comparisons of four distinct therapy areas within AZ (Respiratory and Immunology [R&I]; Cardiovascular, Renal, and Metabolism [CVRM]; Solid Tumors; and Hematological Malignancies), including by trial phases, revealed greater variability, with proportions observed above and below US Census levels.

CONCLUSION

This analysis provides the first detailed insights into the representativeness of AZ trials. Overall, the proportions of different race/ethnicity and sex subgroups in AZ-sponsored clinical trials were broadly aligned with the US Census. We outline some of AZ's planned health equity initiatives that are intended to continue to improve equitable patient enrollment.

P130 A RARE CASE OF LARGE POST INFARCTION LEFT VENTRICULAR PSEUDOANEURYSM UNDERGOING CONSERVATIVE MANAGEMENT

Introduction

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction and its natural history is still unclear. Non invasive imaging improves detection ability and differential diagnosis with aneurysm. We present the case of large post infarction left ventricular pseudoaneurysm undergoing conservative management.

Case Report

A 81–years–old woman presented to emergency room complaining dyspnea and epigastric and right hemithoracic pain. Her past medical history included: chronic coronary syndrome, already undergoing CABG; recent inferior STEMI complicated with complete AVB, with ineffective RCA reperfusion attempt and bicameral pacemaker implantation; Paroxysmal AF in antithrombotic prophylaxis with DOAC. The ECG showed sinus tachycardia, HR 114 bpm, electro–induced ventricular complexes. Objectively, fine bilateral basal crackles were detected. Chest x–ray showed pulmonary congestion. The echocardiographic examination revealed: left ventricle with eccentric remodeling and severe depression of the contractile function (EF 35%), coarse neochamber in communication with the basal segment of the lower wall (D: 6.4 cm x 4.9 cm). The narrow neck, with a ratio <0.5 between inlet orifice diameter / neochamber diameter, suggested pseudoaneurysm. Working diagnosis of NSTEMI–ACS was made (usTnT peak: 344 pg / mL, NV: 0–15 pg / mL) complicated by heart failure. Progressive improvement in compensation was achieved through diuretic therapy. To improve diagnostic definition, cardio–synchronized chest CT with contrast medium was performed. The examination confirmed the voluminous neochamber, consistent with pseudoaneurysm, in correspondence with the mid–basal segments of the lower and inferior septal wall, with thinned walls and mass effect on the great cardiac vein, and highlighted the patency of the bypasses. The venous graft to OM was 5 mm distant from the posterior sternal surface. The case was discussed collectively in Heart Team, due to the high operative risk, the surgical option was rejected and a decision was made for conservative therapy. It was titled beta–blocker, ranolazine was introduced, heart failure therapy was implemented, introducing ARNI. The patient was discharged at home and is in follow–up at the outpatient clinic for heart failure. One month after discharge, she is in NYHA functional class II and she is asymptomatic for angor. The pseudoaneurysmatic dimensions are unchanged on echocardiographic control.

P13 COMPLETE ATRIOVENTRICULAR BLOCK IN A 52–YEAR–OLD MAN ASSOCIATED WITH LYMPHATIC CANCER WITH CARDIAC INVOLVEMENT

A 52–year–old man arrived at the local emergency room for worsening dyspnea and asthenia, present for about a month, but significantly worsening during the night of the access. The ECG (Figure 1) revealed complete AtrioVentricular Block (ABV) with a narrow–QRS junctional escape rhythm, with a heart rate of about 30 beats per minute (bpm). The other vital parameters were within the normal limits and no anomalies were detected on the physical examination. Medium–dose intravenous isoprenaline infusion was immediately started, with an increase in the junctional escape rate up to 50 bpm. The patient also underwent chest x–ray, which showed interstitial thickening in the pulmonary hilus, which was judged to be nonspecific. The blood chemistry was normal and the echocardiogram (Figure 2) did not show any abnormalities. Since there were no apparent reversible causes of the complete AV block, on the next day, a bicameral pacemaker was implanted via the left cephalic vein. The procedure was uneventful and the patient was discharged home two days later, in good general condition. Eight days after the discharge, surgical wound control and pacemaker control were performed, with completely normal parameters. About 15 days after the discharge the patient went back to the local emergency room for dyspnea and fever. Chest Computed Tomography (CT) without contrast medium was performed, which revealed the presence of widespread pathological mediastinal lymphadenopathy. Therefore, the patient was admitted to the internal medicine ward. An in–depth diagnostic was performed first with thoraco–abdominal angio–CT, then with Positron Emission Tomography (PET)–CT (see Figure 3), which revealed the presence of diffuse areas of fixation of the radio–drug (18F–Fluorodeoxyglucose –FDG–), at the ilo–mediastinal, hepatic, pulmonary, retrocrural, retrocaval, iliac, supra and subclavicular, and also cardiac area (activation of interatrial brown fat and between aortic root and the superior vena cava). The patient was therefore transferred to another hospital for diagnostic investigations and lymphoma therapy. In the light of the picture that emerged, the arrhythmological disease was considered to be referred to the cardiac involvement of the oncological disease; to date there are few similar cases described in the literature. Legend of the figures: Figure 1: ECG at the admission Figura 2: Echocardiogram at the admission Figura 3: PET / CT with myocardial areas of 18F–FDG fixation.

Curative-Intent Treatment with Durvalumab in Early-Stage Cancers

The introduction of immunotherapy has fundamentally transformed the treatment landscape in cancer, providing long-term survival benefit for patients with advanced disease across multiple tumor types, including non-small cell lung cancer (NSCLC). In the placebo-controlled phase 3 PACIFIC trial, the PD-L1 inhibitor durvalumab demonstrated significant improvements in progression-free survival and overall survival in patients with unresectable, stage III NSCLC who had not progressed after platinum-based chemoradiotherapy (CRT). These findings have led to the widespread acceptance of the 'PACIFIC regimen' (durvalumab after CRT) as the standard of care in this setting. Moreover, the PACIFIC trial is the first study to demonstrate a proven survival advantage with an immunotherapy in a curative-intent setting, thereby providing a strong rationale for further investigation of durvalumab in early-stage cancers. Herein, we describe the extensive clinical development program for durvalumab across multiple tumor types in curative-intent settings, outlining the scientific rationale(s) for its use and highlighting the innovative research (e.g., personalized cancer monitoring) advanced by these trials.

Starting the fight in the tumor: expert recommendations for the development of human intratumoral immunotherapy (HIT-IT)

A European Society for Medical Oncology (ESMO)-sponsored expert meeting was held in Paris on 8 March 2018 which comprised 11 experts from academia, 11 experts from the pharmaceutical industry and 2 clinicians who were representatives of ESMO. The focus of the meeting was exclusively on the intratumoral injection/delivery of immunostimulatory agents with the aim of harmonizing the standard terms and methodologies used in the reporting of human intratumoral immunotherapy (HIT-IT) clinical trials to ensure quality assurance and avoid a blurring of the data reported from different studies. The goal was to provide a reference document, endorsed by the panel members that could provide guidance to clinical investigators, pharmaceutical companies, ethics committees, independent review boards, patient advocates and the regulatory authorities and promote an increase in the number and quality of HIT-IT clinical trials in the future. Particular emphasis was placed not only on the development of precise definitions to facilitate a better understanding between investigators but also on the importance of systematic serial biopsies as a driver for translational research and the need for the recording and reporting of data, to facilitate a better understanding of the key processes involved.

Serum Tumor Markers may Precede Instrumental Response to Chemotherapy in Patients with Metastatic Cancer

Purpose

Although serum tumor markers (STMs) are widely used in clinical practice, their predictive role for the response to anticancer treatment is still controversial. The correlation of CEA, CA 15.3, CA 19.9, CA 125 (only with peritoneal involvement) and NSE levels with imaging response and clinical benefit was investigated in 60 non-selected patients with metastatic epithelial cancers treated by single-agent docetaxel chemotherapy.

Methods

STM measurement was performed at baseline and subsequently every three to four weeks. We applied the WHO criteria to evaluate both STM and instrumental responses. Concordance analysis was performed by the Cohen Kw index, and the significance of the results was established using the Fleiss, Cohen & Everitt test. Qualitative interpretation of data was obtained with the Landis & Koch scale. Correlations of STM response with clinical benefit (PS or pain improvement) were evaluated by the chi-square test.

Results

The primary tumors included breast cancers (38 patients), gastrointestinal non-colorectal cancers (12 patients), and lung cancers (10 patients). An overall significant good degree of agreement was observed between STM and instrumental response (p<0.0005). The degree of agreement for each marker was as follows: excellent for CEA (p<0.0005) and CA 125 (p=0.006), good for CA 15.3 (p<0.0005) and CA 19.9 (p=0.011). Restricted analysis for the correlation of each marker with primary tumor origin showed good prediction of radiological response for CA 15.3 and CEA in breast cancer patients (p<0.0005 for both), for CEA and CA 19.9 in gastrointestinal cancer patients (p=0.01 and 0.04, respectively), and for CEA+NSE in lung cancer patients (p=0.01). Conversely, STM response did not correlate significantly with the clinical benefit for the patients, both in terms of PS and pain improvement (p=0.24 and p=0.42, respectively).

Conclusion

This study showed STMs to be good predictors of tumor response. Although STMs cannot replace diagnostic imaging, in metastatic cancer they might be useful to optimize the timing of radiological re-evaluation in the palliative setting.

A randomized adaptive phase II/III study of buparlisib, a pan-class I PI3K inhibitor, combined with paclitaxel for the treatment of HER2- advanced breast cancer (BELLE-4)

Background

Phosphatidylinositol 3-kinase (PI3K) pathway activation in preclinical models of breast cancer is associated with tumor growth and resistance to anticancer therapies, including paclitaxel. Effects of the pan-Class I PI3K inhibitor buparlisib (BKM120) appear synergistic with paclitaxel in preclinical and clinical models.

Patients and methods

BELLE-4 was a 1:1 randomized, double-blind, placebo-controlled, adaptive phase II/III study investigating the combination of buparlisib or placebo with paclitaxel in women with human epidermal growth factor receptor 2-negative locally advanced or metastatic breast cancer with no prior chemotherapy for advanced disease. Patients were stratified by PI3K pathway activation and hormone receptor status. The primary endpoint was progression-free survival (PFS) in the full and PI3K pathway-activated populations. An adaptive interim analysis was planned following the phase II part of the study, after ≥125 PFS events had occurred in the full population, to decide whether the study would enter phase III (in the full or PI3K pathway-activated population) or be stopped for futility.

Results

As of August 2014, 416 patients were randomized to receive buparlisib (207) or placebo (209) with paclitaxel. At adaptive interim analysis, there was no improvement in PFS with buparlisib versus placebo in the full (median PFS 8.0 versus 9.2 months, hazard ratio [HR] 1.18), or PI3K pathway-activated population (median PFS 9.1 versus 9.2 months, HR 1.17). The study met protocol-specified criteria for futility in both populations, and phase III was not initiated. Median duration of study treatment exposure was 3.5 months in the buparlisib arm versus 4.6 months in the placebo arm. The most frequent adverse events with buparlisib plus paclitaxel (≥40% of patients) were diarrhea, alopecia, rash, nausea, and hyperglycemia.

Conclusions

Addition of buparlisib to paclitaxel did not improve PFS in the full or PI3K pathway-activated study population. Consequently, the trial was stopped for futility at the end of phase II.

Phase II study of buparlisib (BKM120) and trastuzumab in patients with HER2+ locally advanced or metastatic breast cancer resistant to trastuzumab-based therapy

PURPOSE

A Phase Ib study in patients with trastuzumab-resistant, human epidermal growth factor receptor-2- (HER2)-positive advanced breast cancer defined the recommended Phase II dose of buparlisib as 100 mg/day in combination with 2 mg/kg weekly trastuzumab, and reported preliminary signs of clinical activity. Here we present results from the Phase II portion.

METHODS

Patients with trastuzumab-resistant, HER2-positive advanced breast cancer received buparlisib plus trastuzumab. Study endpoints included safety/tolerability and antitumour activity. The study was extended to include a Phase Ib dose-escalation phase, in which patients with progressive brain metastases also received capecitabine.

RESULTS

In the Phase II portion, of 50 patients treated with buparlisib and trastuzumab, the most common (≥ 30%) all-grade adverse events (AEs) were diarrhoea (54%), nausea (48%), decreased appetite, increased alanine aminotransferase (36% each), increased aspartate aminotransferase (34%), fatigue, rash (32% each), cough and hyperglycemia (30% each). One (2%) patient achieved complete response and four (8%) patients had confirmed partial responses [PR; including two patients with phosphatidylinositol 3-kinase (PI3 K) pathway-activated tumours]. Overall response rate (ORR) was 10%: the primary endpoint (ORR ≥ 25%) was therefore not met. In the Phase Ib portion, all patients with measurable brain lesions at baseline showed tumour shrinkage to some degree; due to low enrollment, maximum tolerated dose of buparlisib in combination with trastuzumab and capecitabine was not determined.

CONCLUSION

Buparlisib plus trastuzumab, as a chemotherapy-free regimen, demonstrated an acceptable safety profile but limited efficacy in patients with heavily pretreated, trastuzumab-resistant HER2-positive breast cancer, and in patients with progressive brain metastases also receiving capecitabine.

Ceritinib versus chemotherapy in patients with ALK-rearranged non-small-cell lung cancer previously given chemotherapy and crizotinib (ASCEND-5): a randomised, controlled, open-label, phase 3 trial

BACKGROUND

Ceritinib is a next-generation anaplastic lymphoma kinase (ALK) inhibitor, which has shown robust anti-tumour efficacy, along with intracranial activity, in patients with ALK-rearranged non-small-cell lung cancer. In phase 1 and 2 studies, ceritinib has been shown to be highly active in both ALK inhibitor-naive and ALK inhibitor-pretreated patients who had progressed after chemotherapy (mostly multiple lines). In this study, we compared the efficacy and safety of ceritinib versus single-agent chemotherapy in patients with advanced ALK-rearranged non-small-cell lung cancer who had previously progressed following crizotinib and platinum-based doublet chemotherapy.

METHODS

In this randomised, controlled, open-label, phase 3 trial, we recruited patients aged at least 18 years with ALK-rearranged stage IIIB or IV non-small-cell lung cancer (with at least one measurable lesion) who had received previous chemotherapy (one or two lines, including a platinum doublet) and crizotinib and had subsequent disease progression, from 99 centres across 20 countries. Other inclusion criteria were a WHO performance status of 0-2, adequate organ function and laboratory test results, a life expectancy of at least 12 weeks, and having recovered from previous anticancer treatment-related toxicities. We randomly allocated patients (1:1; with blocking [block size of four]; stratified by WHO performance status [0 vs 1-2] and presence or absence of brain metastases) to oral ceritinib 750 mg per day fasted (in 21 day treatment cycles) or chemotherapy (intravenous pemetrexed 500 mg/m² or docetaxel 75 mg/m² [investigator choice], every 21 days). Patients who discontinued chemotherapy because of progressive disease could cross over to the ceritinib group. The primary endpoint was progression-free survival, assessed by a masked independent review committee using Response Evaluation Criteria in Solid Tumors 1.1 in the intention-to-treat population, assessed every 6 weeks until month 18 and every 9 weeks thereafter. This trial is registered with ClinicalTrials.gov, number NCT01828112, and is ongoing but no longer recruiting patients.

FINDINGS

Between June 28, 2013, and Nov 2, 2015, we randomly allocated 231 patients; 115 (50%) to ceritinib and 116 (50%) to chemotherapy (40 [34%] to pemetrexed, 73 [63%] to docetaxel, and three [3%] discontinued before receiving treatment). Median follow-up was 16·5 months (IQR 11·5-21·4). Ceritinib showed a significant improvement in median progression-free survival compared with chemotherapy (5·4 months [95% CI 4·1-6·9] for ceritinib vs 1·6 months [1·4-2·8] for chemotherapy; hazard ratio 0·49 [0·36-0·67]; p<0·0001). Serious adverse events were reported in 49 (43%) of 115 patients in the ceritinib group and 36 (32%) of 113 in the chemotherapy group. Treatment-related serious adverse events were similar between groups (13 [11%] in the ceritinib group vs 12 [11%] in the chemotherapy group). The most frequent grade 3-4 adverse events in the ceritinib group were increased alanine aminotransferase concentration (24 [21%] of 115 vs two [2%] of 113 in the chemotherapy group), increased γ glutamyltransferase concentration (24 [21%] vs one [1%]), and increased aspartate aminotransferase concentration (16 [14%] vs one [1%] in the chemotherapy group). Six (5%) of 115 patients in the ceritinib group discontinued because of adverse events compared with eight (7%) of 116 in the chemotherapy group. 15 (13%) of 115 patients in the ceritinib group and five (4%) of 113 in the chemotherapy group died during the treatment period (from the day of the first dose of study treatment to 30 days after the final dose). 13 (87%) of the 15 patients who died in the ceritinib group died because of disease progression and two (13%) died because of an adverse event (one [7%] cerebrovascular accident and one [7%] respiratory failure); neither of these deaths were considered by the investigator to be treatment related. The five (4%) deaths in the chemotherapy group were all due to disease progression.

INTERPRETATION

These findings show that patients derive significant clinical benefit from a more potent ALK inhibitor after failure of crizotinib, and establish ceritinib as a more efficacious treatment option compared with chemotherapy in this patient population.

FUNDING

Novartis Pharmaceuticals Corporation.

Buparlisib plus fulvestrant versus placebo plus fulvestrant in postmenopausal, hormone receptor-positive, HER2-negative, advanced breast cancer (BELLE-2): a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

Phosphatidylinositol 3-kinase (PI3K) pathway activation is a hallmark of endocrine therapy-resistant, hormone receptor-positive breast cancer. This phase 3 study assessed the efficacy of the pan-PI3K inhibitor buparlisib plus fulvestrant in patients with advanced breast cancer, including an evaluation of the PI3K pathway activation status as a biomarker for clinical benefit.

METHODS

The BELLE-2 trial was a randomised, double-blind, placebo-controlled, multicentre study. Postmenopausal women aged 18 years or older with histologically confirmed, hormone receptor-positive and human epidermal growth factor (HER2)-negative inoperable locally advanced or metastatic breast cancer whose disease had progressed on or after aromatase inhibitor treatment and had received up to one previous line of chemotherapy for advanced disease were included. Eligible patients were randomly assigned (1:1) using interactive voice response technology (block size of 6) on day 15 of cycle 1 to receive oral buparlisib (100 mg/day) or matching placebo, starting on day 15 of cycle 1, plus intramuscular fulvestrant (500 mg) on days 1 and 15 of cycle 1, and on day 1 of subsequent 28-day cycles. Patients were assigned randomisation numbers with a validated interactive response technology; these numbers were linked to different treatment groups which in turn were linked to treatment numbers. PI3K status in tumour tissue was determined via central laboratory during a 14-day run-in phase. Randomisation was stratified by PI3K pathway activation status (activated vs non-activated vs and unknown) and visceral disease status (present vs absent). Patients, investigators, local radiologists, study team, and anyone involved in the study were masked to the identity of the treatment until unblinding. The primary endpoints were progression-free survival by local investigator assessment per Response Evaluation Criteria In Solid Tumors (version 1.1) in the total population, in patients with known (activated or non-activated) PI3K pathway status, and in PI3K pathway-activated patients. Efficacy analyses were done in the intention-to-treat population. Safety was analysed in all patients who received at least one dose of study drug and had at least one post-baseline safety assessment according to the treatment they received. This trial is registered with ClinicalTrials.gov, number NCT01610284, and is currently ongoing but not recruiting participants.

FINDINGS

Between Sept 7, 2012, and Sept 10, 2014, 1147 patients from 267 centres in 29 countries were randomly assigned to receive buparlisib (n=576) or placebo plus fulvestrant (n=571). In the total patient population (n=1147), median progression-free survival was 6·9 months (95% CI 6·8-7·8) in the buparlisib group versus 5·0 months (4·0-5·2) in the placebo group (hazard ratio [HR] 0·78 [95% CI 0·67-0·89]; one-sided p=0·00021). In patients with known PI3K status (n=851), median progression-free survival was 6·8 months (95% CI 5·0-7·0) in the buparlisib group vs 4·5 months (3·3-5·0) in the placebo group (HR 0·80 [95% CI 0·68-0·94]; one-sided p=0·0033). In PI3K pathway-activated patients (n=372), median progression-free survival was 6·8 months (95% CI 4·9-7·1) in the buparlisib group versus 4·0 months (3·1-5·2) in the placebo group (HR 0·76 [0·60-0·97], one-sided p=0·014). The most common grade 3-4 adverse events in the buparlisib group versus the placebo group were increased alanine aminotransferase (146 [25%] of 573 patients vs six [1%] of 570), increased aspartate aminotransferase (103 [18%] vs 16 [3%]), hyperglycaemia (88 [15%] vs one [<1%]), and rash (45 [8%] vs none). Serious adverse events were reported in 134 (23%) of 573 patients in the buparlisib group compared with 90 [16%] of 570 patients in the placebo group; the most common serious adverse events (affecting ≥2% of patients) were increased alanine aminotransferase (17 [3%] of 573 vs one [<1%] of 570) and increased aspartate aminotransferase (14 [2%] vs one [<1%]). No treatment-related deaths occurred.

INTERPRETATION

The results from this study show that PI3K inhibition combined with endocrine therapy is effective in postmenopausal women with endocrine-resistant, hormone receptor-positive and HER2-negative advanced breast cancer. Use of more selective PI3K inhibitors, such as α-specific PI3K inhibitor, is warranted to further improve safety and benefit in this setting. No further studies are being pursued because of the toxicity associated with this combination.

FUNDING

Novartis Pharmaceuticals Corporation.

First-line ceritinib versus platinum-based chemotherapy in advanced ALK-rearranged non-small-cell lung cancer (ASCEND-4): a randomised, open-label, phase 3 study

BACKGROUND

The efficacy of ceritinib in patients with untreated anaplastic lymphoma kinase (ALK)-rearranged non-small-cell lung cancer (NSCLC) is not known. We assessed the efficacy and safety of ceritinib versus platinum-based chemotherapy in these patients.

METHODS

This randomised, open-label, phase 3 study in untreated patients with stage IIIB/IV ALK-rearranged non-squamous NSCLC was done in 134 centres across 28 countries. Eligible patients were assigned via interactive response technology to oral ceritinib 750 mg/day or platinum-based chemotherapy ([cisplatin 75 mg/m² or carboplatin AUC 5-6 plus pemetrexed 500 mg/m²] every 3 weeks for four cycles followed by maintenance pemetrexed); randomisation was stratified by World Health Organization performance status (0 vs 1-2), previous neoadjuvant or adjuvant chemotherapy, and presence of brain metastases as per investigator's assessment at screening. Investigators and patients were not masked to treatment assignment. The primary endpoint was blinded independent review committee assessed progression-free survival, based on all randomly assigned patients (the full analysis set). Efficacy analyses were done based on the full analysis set. All safety analyses were done based on the safety set, which included all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT01828099.

FINDINGS

Between Aug 19, 2013, and May 11, 2015, 376 patients were randomly assigned to ceritinib (n=189) or chemotherapy (n=187). Median progression-free survival (as assessed by blinded independent review committee) was 16·6 months (95% CI 12·6-27·2) in the ceritinib group and 8·1 months (5·8-11·1) in the chemotherapy group (hazard ratio 0·55 [95% CI 0·42-0·73]; p<0·00001). The most common adverse events were diarrhoea (in 160 [85%] of 189 patients), nausea (130 [69%]), vomiting (125 [66%]), and an increase in alanine aminotransferase (114 [60%]) in the ceritinib group and nausea (in 97 [55%] of 175 patients), vomiting (63 [36%]), and anaemia (62 [35%]) in the chemotherapy group.

INTERPRETATION

First-line ceritinib showed a statistically significant and clinically meaningful improvement in progression-free survival versus chemotherapy in patients with advanced ALK-rearranged NSCLC.

FUNDING

Novartis Pharmaceuticals Corporation.

A Phase II Study of BEZ235 in Patients with Everolimus-resistant, Advanced Pancreatic Neuroendocrine Tumours

BACKGROUND

This was a two-stage, phase II trial of the dual phosphatidylinositol 3-kinase/mammalian target of rapamycin inhibitor BEZ235 in patients with everolimus-resistant pancreatic neuroendocrine tumours (pNETs) (NCT01658436).

PATIENTS AND METHODS

In stage 1, 11 patients received 400 mg BEZ235 orally twice daily (bid). Due to tolerability concerns, a further 20 patients received BEZ235 300 mg bid. Stage 2 would be triggered by a 16-week progression-free survival (PFS) rate of ≥60% in stage 1.

RESULTS

As of 30 June, 2014, 29/31 patients had discontinued treatment. Treatment-related grade 3/4 adverse events were reported in eight (72.7%) patients at 400 mg and eight (40.0%) patients at 300 mg, including hyperglycaemia, diarrhoea, nausea, and vomiting. The estimated 16-week PFS rate was 51.6% (90% confidence interval=35.7-67.3%).

CONCLUSION

BEZ235 was poorly tolerated by patients with everolimus-resistant pNETs at 400 and 300 mg bid doses. Although evidence of disease stability was observed, the study did not proceed to stage 2.

PI3K inhibitors as new cancer therapeutics: implications for clinical trial design

The PI3K–AKT–mTOR pathway is frequently activated in cancer. PI3K inhibitors, including the pan-PI3K inhibitor buparlisib (BKM120) and the PI3Kα-selective inhibitor alpelisib (BYL719), currently in clinical development by Novartis Oncology, may therefore be effective as anticancer agents. Early clinical studies with PI3K inhibitors have demonstrated preliminary antitumor activity and acceptable safety profiles. However, a number of unanswered questions regarding PI3K inhibition in cancer remain, including: what is the best approach for different tumor types, and which biomarkers will accurately identify the patient populations most likely to benefit from specific PI3K inhibitors? This review summarizes the strategies being employed by Novartis Oncology to help maximize the benefits of clinical studies with buparlisib and alpelisib, including stratification according to PI3K pathway activation status, selective enrollment/target enrichment (where patients with PI3K pathway-activated tumors are specifically recruited), nonselective enrollment with mandatory tissue collection, and enrollment of patients who have progressed on previous targeted agents, such as mTOR inhibitors or endocrine therapy. An overview of Novartis-sponsored and Novartis-supported trials that are utilizing these approaches in a range of cancer types, including breast cancer, head and neck squamous cell carcinoma, non-small cell lung carcinoma, lymphoma, and glioblastoma multiforme, is also described.

Abstract LB-A05: Profiling cell free DNA in breast cancer and non-small cell lung cancer using broad NGS assessment

Introduction: Cell free DNA (cfDNA) has become a promising approach for non-invasive assessment of the tumor genome. Many cfDNA assays target hotspot alterations in a focused set of genes, but do not provide a broad characterization of the cancer. We have developed and optimized a large next generation sequencing (NGS) panel covering the coding regions of over 500 genes. Using this panel, we sequenced cell free DNA from plasma and matched tumor DNA in patients with early stage breast cancer, late stage breast cancer and late stage lung cancer.

Methods: Plasma was collected from patients with cancer using a double spin protocol and, when available, matched archival tumor tissue (representing different time interval with blood collection) was obtained. Next generation sequencing libraries were generated from cell free DNA isolated from 70 plasma samples and genomic DNA from 58 matched tumor samples. The NGS libraries were enriched for the gene panel of interest and were sequenced to a targeted depth of 1,000X for plasma and 300X for matched tumors. We optimized parameters of standard bioinformatics tools to robustly call low allelic fraction events, detecting single nucleotide variants down to 1%, as well as indels and copy number alterations.

Results: We identified 8 PIK3CA hotspot alterations in plasma from late stage breast and lung cancers, in addition to many alterations across driver genes such as AKT1, EGFR, IDH2, NRAS, PTEN and TP53. In plasma samples from patients with late stage breast cancer, we found 4 ESR1 mutations exclusive to the plasma samples, of which 3 are known resistance mutations to endocrine therapy. Copy number alterations in EGFR, CCND1 and KRAS were also identified in patient plasma. When comparing the number of alterations across tumor stages, we found that late stage breast (mean = 12.5 variants) and lung cancers (mean = 12.5 variants) had a larger number of alterations present in plasma than early stage breast cancers (mean = 4.5 variants). We compared somatic mutations calls in plasma and matched tumor samples and found a concordance of 53%-67% at the variant level across patients with late stage cancers (N = 37 pairs). Higher variant level concordance was observed among plasma-tumor pairs collected less than a year apart (N = 11 pairs; 76%-84%) versus more than 5 years apart (N = 8 pairs; 41%-50%).

Conclusion: We have developed and optimized a 500+ gene panel for direct sequencing of cfDNA, and we demonstrate that this broad assessment of circulating tumor DNA can be used for non-invasive characterization of the cancer genome landscape. The number of alterations identified in patient plasma is consistent with higher levels of ctDNA being present in late stage disease than in early stage disease. The time dependent degree of concordance between plasma and tumor collection suggests that cell free DNA assays may provide a more accurate characterization of the current tumor mutational landscape than an archival tumor sample. The identification of plasma specific ESR1 alterations highlights the importance of cfDNA in the context of identifying mechanisms of resistance, particularly for metastatic disease when tumor tissue collection may not be feasible. In addition, a broad NGS panel provides the opportunity to identify lesions unevaluated by targeted assays and to discover resistance mutations.

Citation Format: Nadia Solovieff, Matt Hims, Rebecca Leary, Derek Chiang, Caroline Germa, Cristian Massacesi, Samit Hirawat, Stefan J. Scherer, Michael Morrissey, Wendy Winckler, Emmanuelle di Tomaso. Profiling cell free DNA in breast cancer and non-small cell lung cancer using broad NGS assessment. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr LB-A05.

Abstract A166: BELLE-4: A Phase II study of buparlisib and paclitaxel in women with HER2- advanced breast cancer, with or without PI3K pathway activation

Introduction: Phosphatidylinositol 3-kinase (PI3K) pathway activation in breast cancer (BC) is associated with tumor growth and resistance to anticancer therapies, including paclitaxel (PAC). Combined treatment with the pan-Class I PI3K inhibitor buparlisib (BKM120) + PAC has shown signs of activity in a Phase Ib study in advanced solid tumors, and may delay chemoresistance and progression on PAC therapy in BC.

Study design: BELLE-4 (NCT01572727) is a randomized, double-blind, placebo-controlled, adaptive, Phase II/III seamless study of buparlisib + PAC in women with HER2- locally advanced or metastatic BC with no prior systemic chemotherapy for advanced BC (ABC).

Patients were randomized (1:1) to receive buparlisib (100 mg/day) or placebo with PAC (80 mg/m2/week). Randomization was stratified by PI3K pathway status (activated vs non-activated) and hormone receptor status.

The primary endpoint was progression-free survival (PFS; locally assessed per RECIST v1.1) in the full and PI3K pathway-activated populations. Secondary endpoints included overall survival, overall response rate (ORR), clinical benefit rate, and safety (CTCAE v4.03).

An adaptive interim analysis was planned at the end of Phase II after ≥125 PFS events had occurred. Decision rules based on predefined thresholds of PFS predictive probabilities of success in the full and PI3K pathway-activated populations were used to decide whether the study would enter Phase III (in the full population or restricted to the PI3K pathway-activated population), or be stopped for futility.

Results: As of June 7, 2014, 338 women were randomized to receive buparlisib + PAC (n = 168) or placebo + PAC (n = 170). In total, 125 (37%) patients had PI3K pathway-activated tumors, and 248 (73%) tumors were hormone receptor-positive.

At data cut-off, 112 (67%) vs 93 (55%) patients (buparlisib vs placebo arm) had discontinued treatment, most commonly for disease progression (30% vs 35%) and adverse events (AEs; 22% vs 8%). Median duration of study treatment exposure was 3.4 months (range: 0.2-16.2) vs 4.6 months (range: 0.2-20.1). The most frequent AEs (≥35% of patients) were diarrhea (55% vs 34%), alopecia (49% vs 52%), nausea (45% vs 27%), hyperglycemia (45% vs 11%), rash (40% vs 24%), fatigue (37% vs 34%), and neutropenia (35% vs 30%). Grade 3/4 AEs occurred in 79% vs 52% of patients.

At the interim analysis (based on 131 PFS events), the study met the futility criteria in the full and PI3K pathway-activated populations as per the predefined decision rules. Primary efficacy results (buparlisib vs placebo arm) are as follows: In the full population, hazard ratio (HR) was 1.18 (95% CI: 0.82-1.68) with median PFS 8.0 vs 9.2 months. In the PI3K pathway-activated population, HR was 1.17 (95% CI: 0.63-2.17) with median PFS 9.1 vs 9.2 months. In the PI3K pathway non-activated population, HR was 1.18 (95% CI: 0.76-1.83) with median PFS 7.3 vs 9.2 months. ORR in the full population was 23% vs 27%, with similar trends in the PI3K pathway-activated and non-activated populations.

Conclusions: At the interim analysis, the predefined futility criteria were met and Phase III was not initiated. No PFS benefit was conferred by addition of buparlisib to PAC in either the full or PI3K pathway-activated populations, possibly due to limited treatment exposure; the PI3K pathway may not drive PAC resistance in untreated HER2- ABC.

Citation Format: Miguel Martín, Arlene Chan, Luc Dirix, Joyce O'Shaughnessy, Roberto Hegg, Alexey Manikhas, Mikhail Shtivelband, Petr Krivorotko, Norberto Batista López, Mario Campone, Manuel Ruiz Borrego, Qamar J. Khan, J. Thaddeus Beck, Manuel Ramos Vasquez, Patrick Urban, Pantelia Roussou, Emmanuelle Di Tomaso, Cristian Massacesi, Suzette Delaloge. BELLE-4: A Phase II study of buparlisib and paclitaxel in women with HER2- advanced breast cancer, with or without PI3K pathway activation. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr A166.

Abstract 4698: Combination of ceritinib (LDK378) with PI3K inhibitors (buparlisib [BKM120] and alpelisib [BYL719]) demonstrates synergistic preclinical antitumor activity in ALK-rearranged non-small cell lung cancer (NSCLC)

Introduction: NSCLCs harboring rearrangements of the anaplastic lymphoma kinase (ALK) gene are highly sensitive to ALK inhibition. Ceritinib is a novel ALK inhibitor that demonstrates significant preclinical and clinical antitumor potency, including in tumors that have developed resistance to the approved ALK inhibitor crizotinib. Upregulation of the phosphatidylinositol 3-kinase (PI3K) pathway may be involved in ALK inhibitor resistance, suggesting that combining ceritinib with a PI3K inhibitor may provide synergistic antitumor activity in ALK-rearranged NSCLC. Here, we assess the synergy and antiproliferative activity of PI3K inhibitor/ceritinib combinations in crizotinib-naïve primary preclinical models of NSCLC.

Methods: In vitro experiments used the EML4−ALK-translocated lung cancer cell line H2228 to screen for synergistic combinations of ceritinib with 18 other compounds (PI3K, MEK, and CDK4/6 inhibitors, among others). In vivo experiments used a human-mouse primary xenograft lung cancer model with similar EML4−ALK translocation (LUF1656). Tumor fragments (diameter 2−3 mm) from stock mice inoculated with LUF1656 lung cancer tissue were harvested and used for inoculation into nu/nu mice for tumor development. Once mean tumor size had reached ∼150 mm3, treatment was initiated with single-agent or combination regimens of buparlisib (pan-PI3K inhibitor; 35 mg/kg QD), alpelisib (PI3Kα inhibitor; 30 mg/kg QD), or ceritinib (25 mg/kg [low dose] or 50 mg/kg [full dose] QD). All doses used were equivalent to known therapeutic doses in patients.

Results: In vitro experiments revealed the strongest antiproliferative activity when ceritinib was combined with either buparlisib or alpelisib versus the other compounds tested. In vivo, low-dose ceritinib in combination with buparlisib improved tumor growth delay over single-agent, full-dose ceritinib. Full-dose ceritinib plus alpelisib showed no significant difference in tumor growth delay versus full-dose ceritinib alone. Low-dose ceritinib plus alpelisib appeared to be better tolerated than full-dose ceritinib plus alpelisib, but with similar efficacy to low-dose ceritinib alone. A delayed tumor growth rate after treatment interruption was noted in all ceritinib combinations.

Conclusion: Synergy was observed between ceritinib and PI3K inhibitors in a crizotinib-naïve ALK-translocated lung model in vitro. In the in vivo EML4−ALK lung preclinical cancer models, low-dose ceritinib (25 mg/kg) combined with buparlisib showed improved efficacy versus full-dose ceritinib (50 mg/kg) alone. Preclinical experiments exploring combinations of PI3K- and ALK-targeted therapies in crizotinib-resistant ALK-rearranged tumors are also ongoing.

Citation Format: Emmanuelle Di Tomaso, Ronald Linnartz, Fang Li, Cristian Massacesi, Samit Hirawat. Combination of ceritinib (LDK378) with PI3K inhibitors (buparlisib [BKM120] and alpelisib [BYL719]) demonstrates synergistic preclinical antitumor activity in ALK-rearranged non-small cell lung cancer (NSCLC). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4698. doi:10.1158/1538-7445.AM2015-4698

Abstract A26: Detecting PIK3CA mutations in circulating cell-free DNA from patients with metastatic cancer: An exploratory analysis in patients with endometrial and lung cancer

Background: Personalized therapy relies on the ability to characterize the tumor at the time of treatment. Circulating cell-free DNA (cfDNA) may offer the potential for representative mutation analysis in patients with cancer irrespective of tumor tissue availability. Recent publications have started to establish the feasibility of this approach. For example, 72.5% concordance of PIK3CA mutations was reported between temporally unmatched cfDNA and archival tumor tissue from patients with metastatic breast cancer (Higgins et al. Clin Cancer Res 2012). Here, we present a retrospective analysis evaluating the reliability of detecting PIK3CA mutations in plasma samples from patients with endometrial and lung cancer – two malignancies known to harbor alterations in the PI3K pathway.

Methods: Baseline plasma DNA samples were available from 61 patients with advanced endometrial cancer (NCT01289041) and 37 patients with advanced non-small cell lung cancer (NSCLC; NCT01297491). BEAMing technology (Richardson & Iglehart. Clin Cancer Res 2012) and Sanger analysis were used in all samples. Sanger analysis was able to detect any mutation in exons 1, 5, 7, 9, and 20, whereas only selected mutations (14 in total) known to affect PI3K function in exons 1, 4, 7, 9, and 20 could be detected in cfDNA. Plasma samples were all temporally unmatched to the archival tissue specimen. Concordance analysis was performed by comparing the mutation status of samples (i.e. the proportion of samples that were detected as either wildtype or mutant consistently) between Sanger and cfDNA sequencing.

Results: 54 of 61 patients with endometrial cancer had interpretable mutation results by both Sanger and cfDNA analysis. Concordance of PIK3CA mutation was 74% between plasma and tissue. The PIK3CA mutations detected in cfDNA were distributed over exons 1, 7, 9, and 20 (29%, 19%, 33%, and 19%, respectively). Among the 37 patients with NSCLC, overall concordance was 54%. Variant distribution of PIK3CA mutations in this small number of lung tumors appeared to differ from the usual “hotspots” as two-thirds of mutations detected by Sanger analysis were not available on the BEAMing panel.

Conclusion: Concordance for PIK3CA mutation between temporally unmatched archival specimens and blood samples in this endometrial cancer patient population was in line with the published rate for metastatic breast cancer. The different mutations identified in samples from patients with NSCLC indicate a need for better understanding of the potential role of the PI3K pathway in this tumor type.

Overall these results support the feasibility of assessing PIK3CA mutations in plasma samples. The outcomes show a similar trend to multiple recent publications, thus warranting rapid further exploration of the clinical utility of cfDNA in metastatic cancer.

Citation Format: Emmanuelle di Tomaso, Bradley Monk, Grace Dy, Douglas Robinson, Paola Aimone, Lucia Trandafir, Cristian Massacesi, Samit Hirawat. Detecting PIK3CA mutations in circulating cell-free DNA from patients with metastatic cancer: An exploratory analysis in patients with endometrial and lung cancer. [abstract]. In: Proceedings of the AACR Special Conference: Targeting the PI3K-mTOR Network in Cancer; Sep 14-17, 2014; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(7 Suppl):Abstract nr A26.

Abstract A02: Biomarkers of drug response to buparlisib: Results of next-generation sequencing in a phase II trial of advanced endometrial carcinoma

Background: Genetic alterations in the phosphatidylinositol 3-kinase (PI3K) pathway are frequent in endometrial carcinoma (EC; 59% PIK3CA and 66% PTEN alterations; Kandoth C et al., Nature 2013), thus providing a rationale for testing PI3K inhibitors in this tumor type. A Phase II, single-arm clinical trial of buparlisib, an oral pan-PI3K inhibitor that inhibits all four class I PI3K isoforms (α, β, δ, γ), as second-line therapy, was conducted in advanced EC (N=70). All patients (pts) received buparlisib 100 mg/day until disease progression or discontinuation due to an adverse event. The primary objective was objective response rate (RECIST v1.1) in pts with PI3K-activated tumors (PIK3CA and/or PTEN alteration) or in all pts. The activity of single-agent buparlisib was marginal and PI3K pathway activation was not associated with a better outcome in this pt population (Teneriello MG et al., ICACT 2013). Retrospective molecular characterization was undertaken to assess a potential alternate contribution to PI3K pathway activation in EC and the impact on response to treatment.

Methods: Next-generation sequencing data were generated for 51 pts (serous n=17, endometrioid n=28, unknown n=6) and targeted coding regions of approximately 400 genes. Using standard bioinformatics tools, short nucleotide variants (SNVs) were called. To generate signatures of PI3K pathway activation, data from the TCGA endometrial cohort (Kandoth C et al., Nature 2013) were first leveraged. Levels of pAKT (pT308 and pS473) and pS6 (pS235 and pS240), proxies for PI3K pathway activation, were modeled using SNVs in the TCGA endometrial cohort. Specifically, elastic net models predicting pAKT and pS6 were optimized using somatic SNVs for endometrioid (6-gene model) and serous (3-gene model) subtypes separately. The TCGA models were then used to create pathway activation scores for each pt based on their molecular profile.

Results: No significant relationships were found for pts with the serous subtype, hence the results focus on the endometrioid subtype. Subgroup analysis was performed to assess trends in progression-free survival (PFS) using Cox proportional hazards regression. Pts with the lowest PI3K pathway activation scores, based on the pAKT TCGA model, including pts with PTEN wildtype (n=5), trended towards a lower risk of PFS event compared with pts with moderate or high activation (n=23). In addition, pts with the highest pathway activation scores, based on the pS6 TCGA model, including pts with alterations in mTOR (n=5), trended towards a higher risk of PFS event compared with pts with moderate or low activation (n=23). When combining the two signatures, pts with high pS6 activation (n=5) had a higher risk of PFS event followed by pts with low pS6 and high pAKT scores (n=19) compared with pts with low pS6 and low pAKT scores (n=4). PIK3CA mutations were unrelated to pAKT in the TCGA model for the endometrioid subtype, but PIK3CA-mutated tumors in the TCGA model had slightly higher levels of pS6.

Conclusion: In both models, pts with the lowest levels of PI3K pathway activation trended towards a lower risk of PFS event compared with pts with moderate or high levels of PI3K activation. A possible explanation is that the high levels of PI3K pathway activation observed in EC may represent a challenge for single-agent inhibition. Alternatively, for this single-arm study in EC, we can only elucidate the prognostic value of the biomarker and not the contribution of the treatment per se. Further validation with larger sample sizes is warranted to support this hypothesis further.

Citation Format: Nadia Solovieff, Angad Pal Singh, Hans Bitter, Markus Riester, Michael Teneriello, Amit Oza, Bradley Monk, Douglas Robinson, Lucia Trandafir, Cristian Massacesi, Emmanuelle di Tomaso, R. Wendel Naumann. Biomarkers of drug response to buparlisib: Results of next-generation sequencing in a phase II trial of advanced endometrial carcinoma. [abstract]. In: Proceedings of the AACR Special Conference: Targeting the PI3K-mTOR Network in Cancer; Sep 14-17, 2014; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(7 Suppl):Abstract nr A02.

Present and future breast cancer management--bench to bedside and back: a positioning paper of academia, regulatory authorities and pharmaceutical industry

Insights into tumour biology of breast cancer have led the path towards the introduction of targeted treatment approaches; still, breast cancer-related mortality remains relatively high. Efforts in the field of basic research revealed new druggable targets which now await validation within the context of clinical trials. Therefore, questions concerning the optimal design of future studies are becoming even more pertinent. Aspects such as the ideal end point, availability of predictive markers to identify the optimal cohort for drug testing, or potential mechanisms of resistance need to be resolved. An expert panel representing the academic community, the pharmaceutical industry, as well as European Regulatory Authorities met in Vienna, Austria, in November 2012, in order to discuss breast cancer biology, identification of novel biological targets and optimal drug development with the aim of treatment individualization. This article summarizes statements and perspectives provided by the meeting participants.

Phase I dose-escalation and -expansion study of buparlisib (BKM120), an oral pan-Class I PI3K inhibitor, in patients with advanced solid tumors

PURPOSE

The pan-Class I PI3K inhibitor buparlisib (BKM120) has shown activity in a range of preclinical cancer models. This first-in-man study was initiated to identify the maximum tolerated dose (MTD) of buparlisib (100 mg/day) and to assess safety and preliminary efficacy.

METHODS

Patients with advanced solid tumors (N = 83) enrolled in a Phase I dose-escalation and -expansion study of single-agent buparlisib. Patients in the dose-expansion arm (n = 43) had tumor samples with PIK3CA and/or PTEN alterations.

RESULTS

The most common cancers were colorectal (n = 31) and breast cancer (n = 21). Median number of prior antineoplastic regimens was four (range: 1-12). Grade 3/4 adverse events (AEs) included asthenia (12.0 %) and performance status decrease (9.6 %). Treatment-related AEs (all grades) included decreased appetite, diarrhea, nausea (each in 33 % of patients), hyperglycemia (31 %) and rash (29 %). One confirmed partial response (PR; triple-negative breast cancer) and three unconfirmed PRs (parotid gland carcinoma, epithelioid hemangiothelioma, ER + breast cancer) were reported. Tumor molecular status did not predict clinical benefit in the full study cohort, or among the colorectal or breast cancer subpopulations. Pharmacodynamic biomarkers ((18)F-FDG-PET, C-peptide, pS6) demonstrated dose-dependent changes; however, tumor heterogeneity precluded a clear correlation with clinical benefit.

CONCLUSION

Buparlisib was well tolerated up to the 100 mg/day dose and showed preliminary activity in patients with advanced cancers. Future studies in more homogeneous patient populations will evaluate buparlisib in combination with other agents and further investigate the use of predictive biomarkers.

Challenges in the clinical development of PI3K inhibitors

The PI3K/Akt/mTOR pathway is one of the most frequently dysregulated signaling pathways in cancer and an important target for drug development. PI3K signaling plays a fundamental role in tumorigenesis, governing cell proliferation, survival, motility, and angiogenesis. Activation of the pathway is frequently observed in a variety of tumor types and can occur through several mechanisms. These mechanisms include (but are not limited to) upregulated signaling via the aberrant activation of receptors upstream of PI3K, amplification or gain-of-function mutations in the PIK3CA gene encoding the p110α catalytic subunit of PI3K, and inactivation of PTEN through mutation, deletion, or epigenetic silencing. PI3K pathway activation may occur as part of primary tumorigenesis, or as an adaptive response (via molecular alterations or increased phosphorylation of pathway components) that may lead to resistance to anticancer therapies. A range of PI3K inhibitors are being investigated for the treatment of different types of cancer; broad clinical development plans require a flexible yet well-structured approach to clinical trial design.

Phase II trial of the phosphatidyinositol-3 kinase (PI3K) inhibitor BKM120 in recurrent glioblastoma (GBM)

2015

Background: The PI3K pathway is activated in most GBMs and represents a potential therapeutic target. BKM120 is an oral, pan-Class I PI3K inhibitor that enters the brain at therapeutic concentrations demonstrated to inhibit PI3K pathway, and potently inhibits the growth of U87 GBM tumors and human glioma tumor spheres in vitro and in vivo. Methods: The Ivy Foundation Early Phase Clinical Trials Consortium is conducting a phase II study of BKM120 in recurrent GBM patients with activation of the PI3K pathway (mutation, homozygous deletion or loss of IHC of PTEN, PIK3CA or PIK3RI mutations, or detectable pAKT). Additional eligibility criteria included radiologic progression, 1st or 2nd relapse, > 18 yrs, KPS > 60, adequate bone marrow and organ function, controlled blood glucose, and no enzyme-inducing antiepileptic drugs. Patients received BKM120 100mg daily. The study consisted of 2 parts conducted concurrently. Part 1 involved up to 15 patients who received BKM120 daily for 8-12 days prior to surgery for recurrent disease. Patients underwent FDG PET, pharmacokinetic (PK) studies, and tumor was obtained for drug concentrations and pharmacodynamic effects. Part 2 consisted of up to 50 patients with unresectable GBM treated with BKM120. The primary endpoint for Part 2 was 6-month progression-free survival (p0 =15%; p1= 32%). Results: To date 7 patients have been enrolled into Part 1, 33 into part 2. There were 5 women and 35 men. Median age was 54 yrs (29-68). Treatment was fairly well-tolerated. Major grades 3/4 toxicities were asymptomatic lipase elevation (5), fatigue (3), hyperglycemia (3), rash (3) elevated AST (1), and depression (1). Analysis of tumor from Part 1 showed reduction of pAkt by IHC. Genotyping of tumor specimens is ongoing. To date 33 patients had positive pAkt, 21 had PTEN loss by IHC. Of the first 19 patients who underwent whole exome sequencing, 3 had PIK3Ca mutations and 6 had PTEN mutations. Conclusions: BKM120 is generally well tolerated in patients with recurrent GBM and achieves adequate tumor concentration to inhibit pAkt. Updated PK and efficacy data and correlation of the latter with tumor genotype will be presented. Clinical trial information: NCT01339052.

BOLERO-1: A randomized, phase III, double-blind, placebo-controlled multicenter trial of everolimus in combination with trastuzumab and paclitaxel as first-line therapy in women with HER2-positive (HER2+), locally advanced or metastatic breast cancer (BC)

TPS648

Background: Up to 25% of BCs overexpress human epidermal growth factor receptor 2 (HER2). Patients with HER2+ disease have a higher rate of relapse and shorter overall survival (OS). Trastuzumab, a monoclonal antibody targeting HER2, is the standard of care and improves OS for HER2+ BC, but acquired resistance is common. The combination of trastuzumab and paclitaxel has shown good tolerability and excellent objective response rates (ORR) in up to 84% of patients with HER2+ metastatic BC (MBC) (Gasparini G, et al. BCRT. 2007;101:355-65). Everolimus is an orally bioavailable inhibitor of mammalian target of rapamycin (mTOR), a protein kinase central to multiple protein synthesis pathways and implicated in trastuzumab resistance. Everolimus-containing regimens have shown promising results in patients with ER+, HER2– advanced BC in phase II/III trials; everolimus plus trastuzumab/paclitaxel or vinorelbine has shown encouraging ORR with an acceptable safety profile in phase I/II trials in patients with HER2+ MBC. The present phase III study was undertaken to assess the effectiveness of adding everolimus to first-line standard therapy in HER2+ advanced BC. Methods: Women with HER2+, locally advanced or metastatic BC who have received no prior systemic therapy (except endocrine) are eligible. Local disease must not be amenable to resection with curative intent. Women with a history of central nervous system metastasis are excluded. Patients are randomized 2:1 (everolimus vs control) to receive standard therapy (paclitaxel and trastuzumab) plus everolimus (10 mg daily) or placebo. The primary endpoint is progression-free survival. Secondary endpoints include OS, ORR, and clinical benefit rate. Additional endpoints are safety, performance status, and biomarkers. This trial is sponsored by Novartis Pharmaceuticals and is registered (ClinicalTrials.gov: NCT00876395). Enrollment began September 2009, with a planned accrual of 717. The current accrual is 719, and the estimated primary completion date is October 2012.

P3-16-01: Safety Profile and Clinical Activity of Single-Agent BKM120, a Pan-Class I PI3K Inhibitor, for the Treatment of Patients with Metastatic Breast Carcinoma

Background

Phosphatidylinositol 3-kinase (PI3K) is critical to cancer cell growth, survival, and metabolism. BKM120 is an oral pan-class I (α, β, γ, δ) PI3K inhibitor that has demonstrated in vitro and in vivo tumor cell growth inhibition in a range of cancer types including breast cancer.

Materials and methods: The Phase I study CBKM120X2101 investigating single-agent daily BKM120 in patients (pts) with advanced solid tumors has been recently completed with the maximum tolerated dose established at 100 mg/day. Here, we report the analysis of metastatic breast carcinoma (MBC) pts enrolled in this study.

Results: Overall, 83 pts have enrolled, 21 of whom have MBC. At the cut-off date of 25th February 2011, 20 MBC pts were evaluable: 1 pt at 80 mg, 1 pt at 150 mg and 18 pts at 100 mg. Patient characteristics were as follows: median age 55 years (range 37–71); performance status ECOG 0/1/2 for 7/12/1 pts, respectively; visceral disease was reported in 16 pts, including liver, 10 pts (50%); lung, 9 pts (45%); and pleura, 5 pts (25%); all pts had &gt;3 lines of systemic therapy (3-12). The median time from last treatment and study entry was 46 days (29-235). The median duration of BKM120 treatment administered was 7.5 weeks (1.0−96.4). The most frequent grade 3 drug-related adverse events (AEs) were: transaminases increase, 4 pts; psychiatric disorders, 3 pts, consisting of anxiety, affective disorder, and mood alteration (1 pt each); diarrhea, 2 pts; fatigue, 2 pts; and hyperglycemia, 1 pt. The only grade 4 drug-related AE was hyperglycemia, reported in 1 pt at 150 mg. Most AEs were manageable with treatment interruption and dose reductions. Eighteen pts were evaluable for objective tumor response by RECIST. Two pts (11%) exhibited partial responses, which were confirmed in a triple-negative MBC pt, and unconfirmed in an ER+ HER2− MBC pt. For these 2 pts, the treatment duration was 29+ (ongoing) and 6 months, respectively. An additional 9 pts (50%) had stable disease, lasting &gt;4 months in 7 pts (35%).

Conclusions: This preliminary analysis showed that BKM120 has single-agent activity in heavily pretreated pts with MBC, and an acceptable safety profile. Molecular profiling and updated pharmacokinetic results will be presented at the meeting.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-16-01.

Phase I study of everolimus plus weekly paclitaxel and trastuzumab in patients with metastatic breast cancer pretreated with trastuzumab

PURPOSE

To determine the recommended dose of everolimus, a mammalian target of rapamycin inhibitor, combined with paclitaxel and trastuzumab in patients with human epidermal growth factor receptor 2 (HER2)-overexpressing metastatic breast cancer pretreated with trastuzumab.

METHODS

In this phase Ib, multicenter, dose-escalation study, patients were treated with everolimus 5 mg/d, 10 mg/d, or 30 mg/wk in combination with paclitaxel (80 mg/m(2) days 1, 8, and 15 every 4 weeks) and trastuzumab (2 mg/kg weekly). End points included end-of-cycle 1 dose-limiting toxicity (DLT) rate (primary end point), safety, relative dose intensity of study drugs, overall response rate (ORR), and pharmacokinetics.

RESULTS

Of 33 patients enrolled, 31 were pretreated with taxanes, and 32 were resistant to trastuzumab. Patients received a median of two lines of chemotherapy in the metastatic setting (range, 0 to 17 lines). Three patients experienced cycle 1 DLTs: febrile neutropenia (5 mg/d), stomatitis (10 mg/d), and confusion (30 mg/wk). Grade 3 to 4 neutropenia was the most common toxicity observed (n = 17 patients [52%]). On the basis of observed DLTs and overall safety, 10 mg/d was recommended for additional development. Twenty-seven patients had measurable disease and were evaluable for efficacy. Among these patients, ORR was 44%. Overall disease was controlled for 6 months or more in 74%. Median progression-free survival was 34 weeks (95% CI, 29.1 to 40.7 weeks). Among 11 patients who were resistant to both trastuzumab and taxane, a similar level of antitumor activity was observed (ORR, 55%).

CONCLUSION

Everolimus combined with weekly paclitaxel and trastuzumab was generally well tolerated and had encouraging antitumor activity in patients with trastuzumab-pretreated and -resistant metastatic HER2-overexpressing breast cancer.

First clinical experience of orally active epidermal growth factor receptor inhibitor combined with simplified FOLFOX6 as first-line treatment for metastatic colorectal cancer

BACKGROUND

Gefitinib, an orally active inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase, combined with chemotherapy, has shown efficacy as second-line treatment for advanced colorectal cancer (CRC). Gefitinib combined with FOLFOX6 (oxaliplatin plus folinic acid and 5-fluorouracil) was tested as a first-line therapy.

METHODS

Patients with metastatic EGFR-positive CRC received gefitinib at a dose of 250 mg/day combined with simplified FOLFOX6. Gefitinib was continued as maintenance treatment in nonprogressing patients. Responses were assessed by Response Evaluation Criteria in Solid Tumors (RECIST) criteria and adverse events were assessed with the National Cancer Institute Common Toxicity Criteria (NCI-CTC) scale.

RESULTS

A total of 56 patients were recruited. There were 26 men and 30 women, with a median age of 57.5 years. The Eastern Cooperative Oncology Group (ECOG) performance status was as follows: 0 in 39 patients, 1 in 12 patients, and 2 in 5 patients. Thirty-nine patients (69.6%) had stage IV disease at diagnosis, 92.9% had liver involvement, and 46.4% had > or =2 metastatic sites. All patients were evaluated for safety, and 53 were evaluated for response: 40 patients (71.4%; 95% confidence interval [95% CI], 57.8%-82.6%) had complete or partial responses, and 11 patients (19.6%) had stable disease. Median time to progression was 7 months (range, 2.1-33.0 months; 95% CI, 6.2-9.0 months). Radical surgery or thermoablation of metastatic sites was performed in 14 patients (25%). NCI-CTC grade 3-4 events occurred in 36 patients (64.3%): diarrhea in 9 patients (16.1%), and hematologic toxicity in 13 patients (23.2%). Four patients (7.1%) were withdrawn for drug-related adverse events.

CONCLUSIONS

The regimen has shown promising efficacy with manageable toxicity as a first-line treatment for patients with advanced CRC.

Epidermal growth factor receptor (EGFR) serum level may predict response in patients with advanced colorectal cancer (ACC) treated with gefitinib

4119

Background: EGFR-overexpression reported in colorectal cancer, justifies use of EGFR inhibitors. We conducted a phase II study (ESMO 2005) in ACC with the aim to assess efficacy of gefitinib plus oxaliplatin containing regimen. Main biological objective was to assess serum EGFR extra-cellular binding domain as surrogate marker of tyrosine-kinase inhibition and as predictor of outcome. Methods: 57 patients with EGFR-positive ACC,received gefitinib 250 mg/day combined with simplified FOLFOX-6 for at least 4 cycles,for a maximum of 10 courses.In not progressive disease, gefitinib was continued as maintenance treatment. Tumour assessment by RECIST criteria was performed at baseline and every 4 cycles.Serum EGFR extracellular binding-domain was evaluated by quantitative enzyme-linked immunoadsorbent.Serum EGFR as predictive factor was evaluated both taking into account the basal value only,and the whole EGFR pattern over time.The analyses were performed by logistic and Cox’s regression model with time-dependent covariate respectively;both models included centre, gender,age and site of primary tumours as adjusting factors. Results: Serum samples for EGFR were obtained at baseline and at every assessment.During mono-therapy phase the patients with serum samples decreased. Over treatment,34 patients reported a CR or PR as best objective response (BOR),while 9 patients showed SD or PD. Higher serum EGFR was associated to BOR both at baseline and over time.This result was confirmed by a similar analysis,which considered the whole EGFR profile,instead of the basal value only. Conclusions: Serum EGFR at baseline can be considered a significant predictor for the BOR.This observation is in line with data reported on lung cancer (Gregorc V, 2004).Although the EGFR trend over time seems to confirm the basal difference,this result should be taken with caution,due to the little number of cases reporting EGFR values besides the basal one.

[Table: see text]

No significant financial relationships to disclose.

Capecitabine and mitomycin C is an effective combination for anthracycline- and taxane-resistant metastatic breast cancer

Capecitabine is converted to 5-fluorouracil by thymidine phosphorylase, and mitomycin C is capable of upregulating the expression of thymidine phosphorylase suggesting a synergistic effect. Fifty-three patients (median age 62 years) with anthracycline- and taxane-resistant, metastatic breast cancer received mitomycin C 6 mg/m(2) on day 1, and capecitabine (Xeloda) 2,000 mg/m(2)/day from day 1 to day 14 with cycles repeated every 4 weeks. Overall, 77.4% had visceral metastases and 33 were pretreated with >/=3 chemotherapy lines. A median of 6 cycles were given (range 1-19) with a complete response observed in 2 patients (3.9%), partial response in 17 (33.3%) and stable disease in 19 (37.2%). Overall response rate was 37.2% (95% CI, 24.0-50.5%), with a median duration of 10.4 months. Median time to progression was 8.1 months and median survival was 17.4 months (1- and 2-year survival rates of 60 and 28%, respectively). Toxicity was mild. The most frequent grade 3/4 events were neutropenia (5.7% of patients), diarrhea (3.8%), and deep venous thrombosis (3.8%). Capecitabine plus mitomycin C may represent an effective and manageable treatment option for advanced breast cancer patients resistant to anthracyclines and taxanes. This approach provides an alternative for pretreated patients with advanced breast cancer.

Sustained release octreotide may have a role in the treatment of malignant bowel obstruction

Daily or continuous infusion octreotide is effective in relieving the gastrointestinal symptoms associated with inoperable malignant bowel obstruction (MBO). The sustained release (LAR) formulation of octreotide provides sustained exposure of the drug. This preliminary study aimed to investigate the efficacy of octreotide LAR (20 mg) for reducing gastrointestinal symptoms or nasogastric tube (NGT) secretions in patients with MBO. In patients with NGT (n = 8), octreotide LAR reduced NGT secretions from day one onwards, and NGT was removed in one patient. In patients without NGT (n = 4), octreotide LAR reduced episodes of vomiting and the severity of nausea, and this reduction was maintained throughout the study. Tolerability was good. In conclusion, the more convenient dosing schedule and potential activity of octreotide LAR may have a role in controlling MBO symptoms, and, therefore, it deserves further studies.

Paclitaxel and epirubicin followed by cyclophosphamide, methotrexate and 5-fluorouracil for patients with stage IIIC breast cancer with ten or more involved axillary lymph nodes

OBJECTIVE

The aim of this study was to evaluate the feasibility of a combination of epirubicin and paclitaxel followed by intravenous (iv) cyclophosphamide, methotrexate, and 5-fluorouracile (CMF) as adjuvant treatment of breast cancer patients with 10 or more metastatic axillary lymph nodes.

METHODS

Forty-four patients entered this multicenter study and received 4 cycles of epirubicin (E 120 mg/m2 day 1, q3 weeks) and paclitaxel (T 135 mg/m2 day 1, q3 weeks), followed by 4 cycles of iv CMF (days 1 and 8, q4 weeks). Patients with positive hormonal receptors received sequentially tamoxifen associated with LH-RH analogue if premenopausal. The endpoints were the evaluation of the feasibility of this schedule and disease free survival (DFS).

RESULTS

Median age of patients was 55; median number of positive axillary nodes was 14 (range, 10-47). Hormonal receptor status was positive in 57% of patients. The combination of epirubicin and paclitaxel was well tolerated; NCI grade 3/4 events were: leucopenia in 27% of patients, neutropenic fever in 5 patients, anemia in 7%, thrombocytopenia in 7%, nausea in 18%, vomiting in 14%, and neurotoxicity in 4%. CMF regimen caused a few cases of grade 3/4 hematologic toxicity. No cardiac toxicity was recorded. With a median follow-up of 59 months, 18 (41%) patients relapsed. Sites of relapse were mainly bone, skin/soft tissues, liver, and lung. Median DFS was 78 months, with a 5-year rate of 60%.

CONCLUSIONS

The combination of paclitaxel at low dose and epirubicin followed by CMF is a feasible regimen, which seems to be effective in high-risk node positive breast cancer patients and requires further investigations.

Tamoxifen-related endocrine symptoms in early breast cancer patients are relieved when it is switched to anastrozole

10597

Background: To determine how menopausal symptoms and quality of life changed when adjuvant tamoxifen has been suspended for any reason in favor of anastrozole in early breast cancer (BC) patients (pts). Methods: Major inclusion criteria: severe side effects or serious potential diseases caused by tamoxifen (20 mg die) that switched to anastrozole (1 mg die); confirmed early BC radically resected and with positive hormonal receptors; postmenopausal status; adjuvant chemo and/or radiotherapy suspended at least 4 wks before the hormonal switch. Exclusion criteria: discontinuation of tamoxifen for endocrine symptoms. Menopausal symptoms and health-related quality of life were assessed by the series of Functional Assessment of Cancer Therapy-Breast (FACT-B) plus endocrine subscale (ES) questionnaires at the switch and 3, 6, 9, and 12 months later. Sample size was decided by the effect size method (SD fixed as 0.5, effect of medium value). Score modifications were evaluated by one-way ANOVAS. Results: From Feb 2002 to Jun 2003, a total of 44 women were enrolled into the study. Discontinuation of tamoxifen was for: asymptomatic uterine problems (endometrium thickening or fibromatosis) in 56% of pts; cardiovascular disorders (mainly leg thrombosis and phlebitis) in 18%; patient’s refusal in 9%; GI persistent side effects in 5%; other reasons in 12% of pts. Endocrine symptoms ameliorated between baseline and 3 months, and stabilized thereafter. Mean ES scores improvement from baseline test was +3 (95% CI, 1 to 5), +4 (95% CI, 3 to 6), +5 (95% CI, 3 to 7), and +4 (95% CI, 3 to 6) at 3, 6, 9 and 12 months, respectively. FACT-ES global score had a mean improvement during 1-yr period of 9 points (95% CI 6 to 13, p < .0005), with 22 patients (50%) ever reaching an increase ≥ 5% of the baseline score. There also was a significant improvement in TOI score (+4 points, 95% CI 2 to 6, p < .0005), and physical and breast cancer subscales (+2, 95% CI 1 to 2, p < .001, and +1, 95% CI, 1 to 2, p < .001, respectively). Pts receiving anastrozole reported higher rate of mild arthritic and bone pain (27% vs 7%, p = .021). Conclusion: When a patient develops an endocrine symptom while on tamoxifen, a change in favor of anastrozole should be considered to minimize those symptoms and to improve quality of patient’s life.

No significant financial relationships to disclose.

Innovative schedule of oral idarubicin in elderly patients with metastatic breast cancer: comprehensive results of a phase II multi-institutional study with pharmacokinetic drug monitoring

BACKGROUND

To determine if protracted low-dose oral idarubicin (IDA), feasible in a previous dose-finding study, would result in similar activity and a better toxicity profile in patients with metastatic breast cancer.

PATIENTS AND METHODS

Elderly women (> or=65 years) with metastatic breast carcinoma were treated with 7.5 mg/day for 21 consecutive days, every 4 weeks. After the first fourteen patients, due to excessive toxicity, the protocol was amended to 5 mg/day. IDA and Idarubicinol (IDOL) plasma concentrations (C(trough)) were investigated in all patients.

RESULTS

Between April 1999 and June 2004, 47 elderly patients were accrued in this two-part study (14 and 33 patients respectively). The median age was 74 and 75 years respectively. Visceral involvement was present in most patients. A partial response was noted in 7/31 patients (22%; 95% CI, 9.6-41.1%). Eleven patients had stable disease (33%). At the dose of 5 mg/day the treatment was well tolerated. Neutropenia grade 4 was present in only 6% of patients; alopecia > grade 1 and cardiotoxicity did not occur. The median time to progression was 3 months and the median overall survival was 17 months. IDA C(trough) and IDOL C(trough) levels were significantly associated with haematologic toxicity.

CONCLUSION

This study shows that idarubicin at the dose of 5 mg/day for 21 consecutive days is feasible and effective in elderly breast cancer patients but do not demonstrate an improvement in efficacy. A determination of the IDA and IDOL plasma levels (C(trough)) is predictive for toxicity.

Uridine diphosphate glucuronosyl transferase 1A1 promoter polymorphism predicts the risk of gastrointestinal toxicity and fatigue induced by irinotecan-based chemotherapy

BACKGROUND

In the current Phase II study, the authors evaluated the association between genomic polymorphic variants in uridine diphosphate glucuronosyl transferase (UGT1A1), methylenetetrahydrofolate reductase (MTHFR), and thymidylate synthase (TS) genes, and the incidence of the adverse effects of irinotecan and raltitrexed in previously heavily treated patients with metastatic colorectal carcinoma.

METHODS

Fifty-six patients received irinotecan (at a dose of 80 mg/m(2) on Days 1, 8, 15, and 22 every 5 wks), combined with raltitrexed (at a dose of 3 mg/m(2) every 3 wks). Genotyping for the MTHFR C677T polymorphism, the TATA box region in the UGT1A1 promoter, and tandem repeats in the TS promoter was performed on genomic DNA extracted from blood. Nineteen variables related to patient, disease, and treatment characteristics, together with genotypes, were analyzed using a binary logistic regression model with stepwise selection to evaluate their correlation with adverse reactions.

RESULTS

Toxicities (determined according to the National Cancer Institute Common Toxicity Criteria) were evaluated in 169 cycles. Grade 3/4 neutropenia was reported to occur in 2% of cycles, Grade 2-4 nausea was reported to occur in 19% of cycles, Grade 2-4 emesis was reported to occur in 9% of cycles, Grade 2-4 diarrhea was reported to occur in 20% of cycles, Grade 2/3 fatigue was reported to occur in 11% of cycles, and Grade 3/4 hepatic toxicity was reported to occur in 7% of cycles. Homozygosis for six TA repeats in the promoter region of the UGT1A1 gene was found to be the main predictive factor for diarrhea (P < 0.00005), emesis (P = 0.0001), and fatigue (P = 0.007). Homozygosis for two tandem repeats in the TS promoter was found to be predictive of a reduced incidence of fatigue (P = 0.044). MTHFR C677T polymorphism was not found to be associated with any adverse reaction.

CONCLUSIONS

In the current study, UGT1A1 promoter polymorphism was found to be predictive of the risk of diarrhea, emesis, and fatigue caused by chemotherapy with irinotecan and raltitrexed. Screening for UGT1A1 promoter polymorphism may be clinically useful for identifying patients at a higher risk of developing a severe or potentially life-threatening toxicity after irinotecan-based chemotherapy.

High activity and reduced neurotoxicity of bi-fractionated oxaliplatin plus 5-fluorouracil/leucovorin for elderly patients with advanced colorectal cancer

BACKGROUND

The proportion of elderly within the general population is increasing and the incidence of colorectal cancer increases with age. Oxaliplatin and 5-fluorouracil (FU) combination is active in this disease.

PATIENTS AND METHODS

This multicenter phase II study was designed to investigate feasibility, efficacy, activity of daily living (ADL) and instrumental activity of daily living (IADL) in elderly patients with metastatic colorectal cancer treated, as first-line chemotherapy, with a bi-fractionated oxaliplatin/5-FU based regimen. Treatment was oxaliplatin 45 mg/m2, leucovorin 200 mg/m2, 5-FU 400 mg/m2 and 22 h continuous infusion of 5-FU 600 mg/m2, all given intravenously on days 1 and 2, every 2 weeks.

RESULTS

Seventy-eight patients were enrolled; median age was 75 years (range 70-85). Among 77 evaluable patients, we observed seven complete responses and 32 partial responses, for an overall response rate of 51% (95% confidence interval 40% to 62%). A stabilization of disease was observed in 25% of patients while 19 patients progressed. Canadian NCI grade 3/4 toxicities were: neutropenia in 32% of patients (febrile in two), diarrhea in 10%, mucositis in 4%, and fatigue in 4%. Sensory neuropathy was mild and occurred as grade 3 in 6% of patients. ADL and IADL scores did not change significantly during treatment.

CONCLUSIONS

The bi-fractionated delivery of oxaliplatin plus 5-FU/leucovorin demonstrated high antitumor activity in elderly patients with advanced colorectal cancer. Splitting oxaliplatin administration might reduce incidence of severe neuropathy, although this has to be confirmed by further studies.