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Kovač MB, Pavlin T, Čavka L, Ribnikar D, Spazzapan S, Templeton AJ, Šeruga B. The trajectory of sarcopenia following diagnosis of prostate cancer: A systematic review and meta-analysis. J Geriatr Oncol 2023; 14:101594. [PMID: 37482497 DOI: 10.1016/j.jgo.2023.101594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Sarcopenia is a common skeletal muscle disorder in older people. Here we explore the prevalence of sarcopenia and its impact on men with prostate cancer. MATERIALS AND METHODS We searched PubMed, Embase, and Web of Science databases for relevant studies with an explicit definition of sarcopenia in men with prostate cancer which were published between years 2000 and 2022. Prevalence of sarcopenia and its association with time to biochemical recurrence (BCR), progression-free survival (PFS), non-cancer mortality, overall survival (OS), and treatment-related complications in men with prostate cancer were explored. The summary prevalence, hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated. RESULTS A total of 24 studies comprising 3,616 patients with early and advanced prostate cancer were included. The prevalence of sarcopenia and sarcopenic obesity was 43.8% (95% CI 19.2%-68.5%) and 24.0% (95% CI 5.0%-43.1%), respectively. Sarcopenia was not associated with a shorter time to BCR (HR 0.89, 95% CI 0.64-1.23, p = 0.48), a shorter PFS (HR 1.20, 95% CI 0.73-1.97, p = 0.48), or a shorter OS (HR 1.29, 95% CI 0.90-1.85, p = 0.16). In contrast, sarcopenia was significantly associated with a higher non-cancer mortality (HR 1.85, 95% CI 1.23-2.80, p = 0.003). In four out of five studies eligible for assessment, sarcopenia was not associated with an increased risk of treatment-related complications. DISCUSSION Sarcopenia increases the risk of death from other causes in men with prostate cancer. Patients with prostate cancer should be assessed and managed for sarcopenia in everyday clinical practice.
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Affiliation(s)
- Milena Blaž Kovač
- Ljubljana Community Health Centre, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tina Pavlin
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Luka Čavka
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Department of Oncology, University Medical Center Maribor, Maribor, Slovenia
| | - Domen Ribnikar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Simon Spazzapan
- S.O.C. Oncologia Medica e Prevenzione Oncologica, Centro di Riferimento Oncologico IRCCS, Aviano, Italy
| | - Arnoud J Templeton
- St. Clara Research, St. Claraspital Basel and Faculty of Medicine, University of Basel, Switzerland
| | - Boštjan Šeruga
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia.
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Alexandraki A, Papageorgiou E, Zacharia M, Keramida K, Papakonstantinou A, Cipolla CM, Tsekoura D, Naka K, Mazzocco K, Mauri D, Tsiknakis M, Manikis GC, Marias K, Marcou Y, Kakouri E, Konstantinou I, Daniel M, Galazi M, Kampouroglou E, Ribnikar D, Brown C, Karanasiou G, Antoniades A, Fotiadis D, Filippatos G, Constantinidou A. New Insights in the Era of Clinical Biomarkers as Potential Predictors of Systemic Therapy-Induced Cardiotoxicity in Women with Breast Cancer: A Systematic Review. Cancers (Basel) 2023; 15:3290. [PMID: 37444400 PMCID: PMC10340234 DOI: 10.3390/cancers15133290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Cardiotoxicity induced by breast cancer therapies is a potentially serious complication associated with the use of various breast cancer therapies. Prediction and better management of cardiotoxicity in patients receiving chemotherapy is of critical importance. However, the management of cancer therapy-related cardiac dysfunction (CTRCD) lacks clinical evidence and is based on limited clinical studies. AIM To provide an overview of existing and potentially novel biomarkers that possess a promising predictive value for the early and late onset of CTRCD in the clinical setting. METHODS A systematic review of published studies searching for promising biomarkers for the prediction of CTRCD in patients with breast cancer was undertaken according to PRISMA guidelines. A search strategy was performed using PubMed, Google Scholar, and Scopus for the period 2013-2023. All subjects were >18 years old, diagnosed with breast cancer, and received breast cancer therapies. RESULTS The most promising biomarkers that can be used for the development of an alternative risk cardiac stratification plan for the prediction and/or early detection of CTRCD in patients with breast cancer were identified. CONCLUSIONS We highlighted the new insights associated with the use of currently available biomarkers as a standard of care for the management of CTRCD and identified potentially novel clinical biomarkers that could be further investigated as promising predictors of CTRCD.
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Affiliation(s)
- Alexia Alexandraki
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Elisavet Papageorgiou
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Marina Zacharia
- A.G. Leventis Clinical Trials Unit, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (E.P.); (M.Z.)
| | - Kalliopi Keramida
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
- Cardiology Department, General Anti-Cancer Oncological Hospital, Agios Savvas, 11522 Athens, Greece
| | - Andri Papakonstantinou
- Department of Oncology-Pathology, Karolinska Institute, 17176 Stockholm, Sweden;
- Department for Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Carlo M. Cipolla
- Cardioncology and Second Opinion Division, European Institute of Oncology (IEO), IRCCS, Via Ripamonti 435, 20141 Milan, Italy;
| | - Dorothea Tsekoura
- 2nd Department of Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens, 76 Vas. Sofias Av., 11528 Athens, Greece; (D.T.); (E.K.)
| | - Katerina Naka
- 2nd Cardiology Department, University of Ioannina Medical School, 45110 Ioannina, Greece;
| | - Ketti Mazzocco
- Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology IRCCS, 20139 Milan, Italy;
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Davide Mauri
- Department of Medical Oncology, University of Ioannina, 45110 Ioannina, Greece;
| | - Manolis Tsiknakis
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, 71410 Heraklion, Greece; (M.T.); (K.M.)
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Georgios C. Manikis
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Kostas Marias
- Department of Electrical and Computer Engineering, Hellenic Mediterranean University, 71410 Heraklion, Greece; (M.T.); (K.M.)
- Computational BioMedicine Laboratory (CBML), Institute of Computer Science, Foundation for Research and Technology Hellas (FORTH), 70013 Heraklion, Greece;
| | - Yiola Marcou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Eleni Kakouri
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Ifigenia Konstantinou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Maria Daniel
- Department of Radiation Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus;
| | - Myria Galazi
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
| | - Effrosyni Kampouroglou
- 2nd Department of Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens, 76 Vas. Sofias Av., 11528 Athens, Greece; (D.T.); (E.K.)
| | - Domen Ribnikar
- Division of Medical Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Zaloska Cesta 2, 1000 Ljubljana, Slovenia;
| | - Cameron Brown
- Translational Medicine, Stremble Ventures Ltd., 59 Christaki Kranou, Limassol 4042, Cyprus;
| | - Georgia Karanasiou
- Biomedical Research Institute, Foundation for Research and Technology, Hellas, 45500 Ioannina, Greece;
| | - Athos Antoniades
- Research and Development, Stremble Ventures Ltd., 59 Christaki Kranou, Limassol 4042, Cyprus;
| | - Dimitrios Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, 45110 Ioannina, Greece;
| | - Gerasimos Filippatos
- Cardio-Oncology Clinic, Heart Failure Unit, Department of Cardiology, National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, 11527 Athens, Greece;
| | - Anastasia Constantinidou
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Nicosia 2006, Cyprus; (Y.M.); (E.K.); (I.K.); (M.G.)
- School of Medicine, University of Cyprus, Panepistimiou 1, Aglantzia, Nicosia 2408, Cyprus
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Ribnikar D, Horvat VJ, Ratosa I, Veitch ZW, Grcar Kuzmanov B, Novakovic S, Langerholc E, Amir E, Seruga B. Association between PIK3CA activating mutations and outcomes in early-stage invasive lobular breast carcinoma treated with adjuvant systemic therapy. Radiol Oncol 2023; 57:220-228. [PMID: 37341201 DOI: 10.2478/raon-2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/18/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The aim of the study was to evaluate the independent prognostic role of PIK3CA activating mutations and an association between PIK3CA activating mutations and efficacy of adjuvant endocrine therapy (ET) in patients with operable invasive lobular carcinoma (ILC). PATIENTS AND METHODS A single institution study of patients with early-stage ILC treated between 2003 and 2008 was performed. Clinicopathological parameters, systemic therapy exposure and outcomes (distant metastasis-free survival [DMFS] and overall survival [OS]) were collected based on presence or absence of PIK3CA activating mutation in the primary tumor determined using a quantitative polymerase chain reaction (PCR)-based assay. An association between PIK3CA mutation status and prognosis in all patient cohort was analyzed by Kaplan-Meier survival analysis, whereas an association between PIK3CA mutation and ET was analyzed in estrogen receptors (ER) and/or progesterone receptors (PR)-positive group of our patients by the Cox proportional hazards model. RESULTS Median age at diagnosis of all patients was 62.8 years and median follow-up time was 10.8 years. Among 365 patients, PIK3CA activating mutations were identified in 45%. PIK3CA activating mutations were not associated with differential DMFS and OS (p = 0.36 and p = 0.42, respectively). In patients with PIK3CA mutation each year of tamoxifen (TAM) or aromatase inhibitor (AI) decreased the risk of death by 27% and 21% in comparison to no ET, respectively. The type and duration of ET did not have significant impact on DMFS, however longer duration of ET had a favourable impact on OS. CONCLUSIONS PIK3CA activating mutations are not associated with an impact on DMFS and OS in early-stage ILC. Patients with PIK3CA mutation had a statistically significantly decreased risk of death irrespective of whether they received TAM or an AI.
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Affiliation(s)
- Domen Ribnikar
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | | | - Ivica Ratosa
- Faculty of Medicine Ljubljana, University of Ljubljana, Ljubljana, Slovenia
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Zachary W Veitch
- Division of Medical Oncology and Hematology, Royal Victoria Hospital, Bariie, Ontario, USA
| | | | - Srdjan Novakovic
- Department of Molecular Diagnostics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Erik Langerholc
- Institute of Biostatistics and informatics, Faculty of Medicine Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Eitan Amir
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
| | - Bostjan Seruga
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine Ljubljana, University of Ljubljana, Ljubljana, Slovenia
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4
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Visani L, Livi L, Ratosa I, Orazem M, Ribnikar D, Saieva C, Becherini C, Salvestrini V, Scoccimarro E, Valzano M, Cerbai C, Desideri I, Bernini M, Orzalesi L, Nori J, Bianchi S, Morandi A, Meattini I. Safety of CDK4/6 inhibitors and concomitant radiation therapy in patients affected by metastatic breast cancer. Radiother Oncol 2022; 177:40-45. [PMID: 36349599 DOI: 10.1016/j.radonc.2022.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) currently represent the standard of care for the initial treatment of patients with metastatic hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer. The aim of our study is to evaluate the safety of the use of concomitant radiation therapy (RT) in a consecutive series of HR+/HER2- patients treated in two academic institutions with CDK4/6i in the metastatic setting. METHODS AND MATERIALS From September 2017 to February 2020, we retrospectively collected and analysed data on a sequential series of patients treated with CDK4/6i, receiving RT or not, at two European institutions. Primary outcome of the study was the association between RT and any adverse events (AEs) ≥ G3. Secondary outcomes were the association between RT and any AEs (any grade), CDK4/6i dose reduction rate, and CDK4/6i treatment discontinuation rate. RESULTS We analysed a total of 132 consecutive women; RT was prescribed in 57 (43.2%) patients (70 irradiated lesions). The median age of the series was 52.1 years (range 32.3-78.2). Concomitant RT administration was not significantly related to higher AEs ≥ G3 (p = 0.19) and any grade AEs (p = 1.0); there was no association with RT and CDK4/6i dose reduction (p = 0.49) and discontinuation rates (p = 0.14). At a median follow-up of 18.8 months, the progression-free survival (PFS) rate was 35% and the overall survival (OS) rate was 38.7% in the whole group. The use of concomitant RT did not affect both PFS (p = 0.71) and OS rates (p = 0.55). CONCLUSIONS Our data are encouraging regarding the safety of this combination, showing that concurrent RT did not increase severe toxicity and did not have an impact on systemic treatment conduction.
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Affiliation(s)
- Luca Visani
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Orazem
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Domen Ribnikar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Calogero Saieva
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research Prevention and Clinical Network, Florence, Italy
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Viola Salvestrini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Erika Scoccimarro
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marianna Valzano
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Cecilia Cerbai
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marco Bernini
- Breast Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Lorenzo Orzalesi
- Breast Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Jacopo Nori
- Diagnostic Senology Unit, Careggi University Hospital, Florence, Italy
| | - Simonetta Bianchi
- Division of Pathological Anatomy, Department of Health Sciences, University of Florence, Florence, Italy
| | - Andrea Morandi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
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5
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Karanasiou G, Grigoriadis G, Alexandraki A, Antoniades A, Brown C, Bucur A, Cipolla C, Economopoulou P, Foukakis T, Goossens J, Keramida K, Lakkas L, Marias K, Naka K, Papakonstantinou A, Pravettoni G, Ribnikar D, Šeruga B, Zacharia M, Tsiknakis M, Fotiadis D. A multimodal approach for the management of co-morbid cardiotoxicity in the elderly breast cancer patients. Eur J Cancer 2022. [DOI: 10.1016/s0959-8049(22)01456-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ratosa I, Dobnikar N, Bottosso M, Dieci MV, Jacot W, Pouderoux S, Ribnikar D, Sinoquet L, Guarneri V, Znidaric T, Darlix A, Griguolo G. Leptomeningeal metastases in patients with human epidermal growth factor receptor 2 positive breast cancer: real-world data from a multicentric European cohort. Int J Cancer 2022; 151:1355-1366. [PMID: 35666525 PMCID: PMC9540903 DOI: 10.1002/ijc.34135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/20/2022] [Accepted: 05/10/2022] [Indexed: 11/29/2022]
Abstract
In patients with human epidermal growth factor receptor 2 positive (HER2+) breast cancer, leptomeningeal metastases (LM) are a rare but often a fatal clinical scenario. In this multicentric study, clinical and pathologic characteristics of patients with HER2+ breast cancer developing LM were described, as well as survival outcomes. Data were gathered retrospectively from medical records of 82 patients with advanced HER2+ breast cancer and LM treated between August 2005 and July 2020. Following LM diagnosis, 79 (96.3%) patients received at least one line of anti‐HER2 therapy, 25 (30.5%) patients received intrathecal therapy and 58 (70.7%) patients received radiotherapy. Overall survival (OS) was 8.3 months (95% confidence interval [CI] 5.7‐11), 1‐year OS was 42%, and 2‐year OS was 21%. At univariate analysis, patients who were treated after 2010, had better Karnofsky performance status, were free of neurological symptoms, had better prognostic, received chemotherapy (OS difference 9.4 months, P = .024), or monoclonal antibodies (trastuzumab ± pertuzumab; OS difference 6.1 months; P = .013) after LM diagnosis, had a statistically significantly longer OS. Presence of neurological symptoms (hazard ratio 3.32, 95% CI 1.26‐8.73; P = .015) and not having received radiotherapy (hazard ratio 2.02, 95% CI 1.09‐3.72; P = .024) were all associated with poorer OS at multivariate analysis. To summarize, not having neurological symptoms and receiving RT at LM diagnosis were associated with prolonged OS in our cohort. Survival seemed to be prolonged with multimodality treatment, which included targeted therapy, chemotherapy, and RT to the LM sites.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Nika Dobnikar
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Michele Bottosso
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy.,Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Maria Vittoria Dieci
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy.,Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - William Jacot
- Department of Medical Oncology, Institut régional du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - Stéphane Pouderoux
- Department of Medical Oncology, Institut régional du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - Domen Ribnikar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Léa Sinoquet
- Department of Medical Oncology, Institut régional du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - Valentina Guarneri
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy.,Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Tanja Znidaric
- Department of Oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Amélie Darlix
- Department of Medical Oncology, Institut régional du Cancer de Montpellier, University of Montpellier, Montpellier, France.,Institut de Génomique Fonctionnelle, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Gaia Griguolo
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy.,Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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7
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Jeric Horvat V, Manevski D, Gazic B, Drev P, Matos E, Ribnikar D, Seruga B. Prognostic role of the stromal tumor-infiltrating lymphocytes (TILs) in women with early ER+/HER2+ breast cancer (BC) in whom adjuvant chemotherapy (ChT) was omitted. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e12526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12526 Background: Adjuvant systemic therapy in women with early ER+/HER2+ BC usually includes ChT, trastuzumab (T) and endocrine therapy (ET). High level of TILs is associated with better outcome in HER2+ disease. Here we explore the outcome and prognostic role of TILs in women with early ER+/HER2+ BC in whom ChT was omitted. Methods: Women with ER+ (IHC ≥ 1%) and HER2+ (IHC3+ and/or FISH ratio ≥ 2.0) early BC who underwent surgery between years 2006 and 2016 at the Institute of Oncology Ljubljana and did not receive adjuvant ChT were eligible for this study. Hematoxilin and eosin slides of primary tumors were retrieved and evaluated for the percentage of stromal TILs. Distant disease-free survival (DDFS) was estimated by the Kaplan-Meier method. The association between DDFS and TILs level was explored in the Cox proportional hazard model. Relative survival was used for estimating the probability of dying due to the breast cancer or other causes. Results: During the 10-year period 86 (29.4%) out of 292 women with early ER+/HER2+ BC who underwent surgery did not receive adjuvant ChT. ChT was omitted due to the stage I disease (n=30), comorbidities (n=25), older age (n=19), refusal of treatment (n=9) and other causes (n=3). Five (5.8%) and 81 (94.1%) women received T and ET, respectively. Their median age was 65.8 yrs (IQR 55.7, 75.6 yrs) and 45 (52.3%) had stage I disease. There were 53 (61.6%), 24 (27.9%) and 9 (10.4%) women with low (<10%), intermediate (≤10% to <40%) and high (≥ 40%) level of TILs, respectively. After median follow-up of 10 years 28 events (distant recurrence or death) occurred. The 10-year DDFS for those who did not receive ChT due to the stage I disease, comorbidities and older age was 91% (95% CI, 0.79 to 1.00), 38% (95% CI, 0.18 to 0.75]) and 26% (95% CI, 0.10 to 0.66) (p˂0.0001), respectively. After excluding women with stage I disease the estimated probability of dying due to the breast cancer and due to other causes was 26.7% and 26.5%, respectively. Overall, for every 10% increase in TILs the risk of distant recurrence or death was reduced for 18% (HR=0.82; 95% CI, 0.64 to 1.05) (p=0.11). In the multivariable Cox model, higher TILs level was a significant predictor of better DDFS (HR 0.75; 95% CI, 0.57 to 0.98) (p=0.041) (Table). Conclusions: Women with stage I ER+/HER2+ BC who do not receive adjuvant ChT and T but do receive adjuvant ET may still have a very good outcome. In contrast, survival of women who do not receive adjuvant ChT and T for other reasons is poor; however, only a half of those deaths are related to BC. TIL is a favourable prognostic biomarker which might be helpful when de-escalation of systemic therapy in women with ER+/HER2+ BC is considered.[Table: see text]
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Affiliation(s)
| | - Damjan Manevski
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Barbara Gazic
- Department of Pathology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Primoz Drev
- Department of Pathology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Erika Matos
- Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Domen Ribnikar
- Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Bostjan Seruga
- Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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8
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Horvat VJ, Manevski D, Perme MP, Gazić B, Drev P, Ribnikar D, Matos E, Šeruga B. 143P The impact of de-escalation of adjuvant systemic therapy on the outcome of women with early ER+/HER2+ breast cancer. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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9
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Meattini I, Visani L, Ratosa I, Saieva C, Ribnikar D, Scoccimarro E, Becherini C, Orazem M, Stocchi G, Bellini C, Lorenzetti V, Orsatti C, Angelini L, Desideri I, Scotti V, Morandi A, Marinko T, Livi L. 242P Impact of metastases directed radiation therapy on CDK4/6 inhibitors treatment for metastatic breast cancer. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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10
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Visani L, Ratosa I, Scoccimarro E, Becherini C, Saieva C, Desideri I, Scotti V, Ozarem M, Ribnikar D, Aquilano M, Cerbai C, Orzalesi L, Bernini M, Sanchez L, Nori J, Bianchi S, Meattini I, Livi L. OC-0071 Safety and efficacy of concomitant radiation and CDK4/6 inhibitors in breast cancer patients. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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11
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Ribnikar D, Goldvaser H, Veitch ZW, Ocana A, Templeton AJ, Šeruga B, Amir E. Efficacy, safety and tolerability of drugs studied in phase 3 randomized controlled trials in solid tumors over the last decade. Sci Rep 2021; 11:10843. [PMID: 34035370 PMCID: PMC8149406 DOI: 10.1038/s41598-021-90403-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/30/2021] [Indexed: 01/08/2023] Open
Abstract
Data suggest that for newly approved cancer drugs safety and tolerability are worse than in control arms of registration trials. Less is known about the balance between efficacy and toxicity of drugs studied in unselected phase 3 randomized controlled trials (RCTs) including those not resulting in regulatory approval. We searched Clinicaltrials.gov to identify phase 3 RCTs in patients with advanced breast, colorectal, lung, or prostate cancer completed between January 2005 and October 2016. We extracted efficacy and safety data from publications. For efficacy hazard ratios (HRs) for progression-free survival (PFS) and overall survival (OS) were extracted. For safety, we computed odds ratios (ORs) and 95% confidence intervals (CIs) for toxic death, treatment discontinuation without progression and commonly reported grade 3/4 adverse events (AEs). Data were then pooled in a meta-analysis. Of 377 RCTs identified initially, 143 RCTs comprising 88,603 patients were included in the analysis. Of these, 79 (57%) trials met their primary endpoint. Compared to control groups, both PFS (HR 0.80; 95% CI 0.78–0.82) and OS (HR 0.87; 95% CI 0.85–0.89) were improved with experimental drugs. Toxic death (OR 1.14; 95% CI 1.03–1.27), treatment discontinuation without progression (OR 1.64; 95% CI 1.56–1.71) and grade 3/4 AEs were also more common with experimental drugs compared to respective control group therapy. Just over half of phase 3 RCTs in common solid tumors met their primary endpoint and in nearly half, experimental therapy had worse safety compared to control arms.
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Affiliation(s)
- Domen Ribnikar
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia.,Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, 700U, 7-721, Toronto, ON, M5G 2M9, Canada
| | - Hadar Goldvaser
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, 700U, 7-721, Toronto, ON, M5G 2M9, Canada.,Rabin Medical Center, Davidoff Cancer Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zachary W Veitch
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, 700U, 7-721, Toronto, ON, M5G 2M9, Canada
| | - Alberto Ocana
- Drug Development Program, Hospital Clinico San Carlos and CIBERONC, Madrid, Spain.,Translational Oncology Laboratory. Regional Center for Biomedical Research (CRIB), Castilla La Mancha University, Albacete, Spain
| | - Arnoud J Templeton
- Department of Oncology, St. Claraspital Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Boštjan Šeruga
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Eitan Amir
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, 700U, 7-721, Toronto, ON, M5G 2M9, Canada.
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12
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Lohmann AE, Soldera SV, Pimentel I, Ribnikar D, Ennis M, Amir E, Goodwin PJ. Association of Obesity with Breast Cancer Outcome in Relation to Cancer Subtypes: A Meta-Analysis. J Natl Cancer Inst 2021; 113:1465-1475. [PMID: 33620467 PMCID: PMC8562970 DOI: 10.1093/jnci/djab023] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background Obesity at breast cancer (BC) diagnosis has been associated with poor outcome, although the magnitude of effect in different BC subtypes is uncertain. We report on the association of obesity or overweight at diagnosis of nonmetastatic BC with disease-free (DFS) and overall survival (OS) in the following defined subtypes: hormone receptor positive/HER2 negative (HR+HER2−), HER2 positive (HER2+), and triple negative (TNBC). Methods We searched MEDLINE, EMBASE, and COCHRANE databases up to January 1, 2019. Study eligibility was performed independently by 2 authors. Studies reporting hazard ratios (HRs) of OS and/or DFS for obesity or overweight in BC subtypes were included. The pooled hazard ratio was computed and weighted using generic inverse variance and random effects models. Results Twenty-seven studies were included. Obese compared with nonobese women had worse DFS in all subtypes: the hazard ratios were 1.26 (95% confidence interval [CI] = 1.13 to 1.41, P < .001) for HR+HER2− BC, 1.16 (95% CI = 1.06 to 1.26, P < .001) for HER2+ BC, and 1.17 (95% CI = 1.06 to 1.29, P = .001) for TNBC. OS was also worse in obese vs nonobese women (HR+HER2− BC HR = 1.39, 95% CI = 1.20 to 1.62, P < .001; HER2+ BC HR = 1.18, 95% CI = 1.05 to 1.33, P = .006; and TNBC HR = 1.32, 95% CI = 1.13 to 1.53, P < .001). As opposed to obesity, overweight was not associated with either DFS or OS in HER2+ BC (HR = 1.02, 95% CI = 0.81 to 1.28, P = .85; and HR = 0.96, 95% CI = 0.76 to 1.21, P = .99, respectively) or TNBC (HR = 1.04, 95% CI = 0.93 to 1.18, P = .49; and HR = 1.08, 95% CI = 0.81 to 1.44, P = .17), respectively. In HR+HER2− BC, being overweight was associated with worse OS (HR = 1.14, 95% CI = 1.07 to 1.22, P < .001). Conclusions Obesity was associated with modestly worse DFS and OS in all BC subtypes.
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Affiliation(s)
- Ana Elisa Lohmann
- Department of Oncology, University of Western Ontario, Ontario, Canada
| | - Sara V Soldera
- Department of Hematology and Oncology, CISSS Montérégie Centre/Hôpital Charles-Lemoyne, Centre Affilié de l'Université de Sherbrooke, Quebec, Canada
| | | | - Domen Ribnikar
- Institute of Oncology Ljubljana, Department of Medical Oncology, Ljubljana, Slovenia
| | | | - Eitan Amir
- Institute of Health Policy Management and Evaluation, University of Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network, Division of Medical Oncology and Hematology, Department of Medicine University of Toronto, Ontario, Canada
| | - Pamela J Goodwin
- Institute of Health Policy Management and Evaluation, University of Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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13
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Ribnikar D, Stukalin I, Bedard PL, Hamilton RJ, Jewett M, Warde P, Chung P, Anson-Cartwright L, Templeton AJ, Amir E, Hansen AR, Heng DYC, Lewin J. The Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Metastatic Testicular Cancer. ACTA ACUST UNITED AC 2020; 28:107-114. [PMID: 33622996 PMCID: PMC7816171 DOI: 10.3390/curroncol28010014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/03/2020] [Accepted: 12/15/2020] [Indexed: 01/04/2023]
Abstract
We investigated the prognostic utility of pre-chemotherapy neutrophil-to-lymphocyte ratio (NLR) in patients with metastatic germ cell tumors (GCTs) undergoing first-line chemotherapy. We utilized two institutional databases to analyze the pretreatment-derived NLR (dNLR). Predictive accuracy was evaluated using the Cox proportional hazard model adjusted for the international germ cell cancer collaborative group (IGCCCG) risk classification. Discriminatory accuracy was evaluated by determining the area under the receiver operating characteristic curve (AUROC). In total, 569 of 690 patients had available dNLR (IGCCCG: good, 64%; intermediate, 21%; poor, 16%). The 5-year and 10-year overall survivals (OSs) for good, intermediate, and poor risk groups were 96.2%, 92.8%, and 62.7% and 93.9%, 90.3%, and 62.7%, respectively. A dNLR of 2 provided the best discriminatory accuracy with an AUROC of 0.58 (95% CI: 0.52-0.65, p = 0.01) for progression-free survival (PFS), whereas for OS, a dNLR of 3 provided the best discriminatory accuracy with an AUROC of 0.62 (95% CI: 0.53-0.70, p < 0.01). A dNLR > 2 was associated with a hazard ratio (HR) of 1.99 (95% CI: 1.27-3.12, p < 0.01) for PFS, which lost its effect after adjustment for IGCCCG (HR: 1.44, 95% CI: 0.90-2.30, p = 0.13). For OS, a dNLR >3 was associated with an HR of 3.00 (95% CI: 1.79-5.01, p < 0.01), but lost its effect after adjustment for IGCCCG. Systemic inflammation plays a role in metastatic GCT, but its prognostic utility beyond established algorithms is limited. The general prognostic value of NLR can be seen across a number of tumors, although the consistency and magnitude of the effect differ according to cancer type, disease stage, and treatment received. We identified that an elevated NLR was associated with an adverse PFS and OS, but not independent of the IGCCCG risk classification. dNLRs >2 and >3 were associated with an adverse PFS and OS, respectively, in patients with metastatic GCT receiving first-line chemotherapy, but not independent of the IGCCCG risk classification.
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Affiliation(s)
- Domen Ribnikar
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (D.R.); (P.L.B.); (E.A.); (A.R.H.)
| | - Igor Stukalin
- Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (I.S.); (D.Y.C.H.)
| | - Philippe L. Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (D.R.); (P.L.B.); (E.A.); (A.R.H.)
| | - Robert J. Hamilton
- Princess Margaret Cancer Centre, Department of Surgery, University Health Network, 610 University Ave 3-130, Toronto, ON M5G 2C1, Canada; (R.J.H.); (M.J.)
| | - Michael Jewett
- Princess Margaret Cancer Centre, Department of Surgery, University Health Network, 610 University Ave 3-130, Toronto, ON M5G 2C1, Canada; (R.J.H.); (M.J.)
| | - Padraig Warde
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (P.W.); (P.C.); (L.A.-C.)
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (P.W.); (P.C.); (L.A.-C.)
| | - Lynn Anson-Cartwright
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (P.W.); (P.C.); (L.A.-C.)
| | - Arnoud J. Templeton
- Department of Oncology, St. Claraspital Basel, and Faculty of Medicine, University of Basel, CH-4058 Basel, Switzerland;
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (D.R.); (P.L.B.); (E.A.); (A.R.H.)
| | - Aaron R. Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (D.R.); (P.L.B.); (E.A.); (A.R.H.)
| | - Daniel Y. C. Heng
- Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (I.S.); (D.Y.C.H.)
| | - Jeremy Lewin
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; (D.R.); (P.L.B.); (E.A.); (A.R.H.)
- Correspondence: ; Tel.: +61-3-8559-5000
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14
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Saleh RR, Meti N, Ribnikar D, Goldvaser H, Ocana A, Templeton AJ, Seruga B, Amir E. Associations between safety, tolerability, and toxicity and the reporting of health-related quality of life in phase III randomized trials in common solid tumors. Cancer Med 2020; 9:7888-7895. [PMID: 32886422 PMCID: PMC7643655 DOI: 10.1002/cam4.3390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 01/09/2023] Open
Abstract
Background Anti‐cancer drugs are approved typically on the basis of efficacy and safety as evaluated in phase III randomized trials (RCTs). Health‐related quality of life (HRQoL) is a direct measure of patient benefit, but is under‐reported. Here we explore associations with reporting of HRQoL data in phase III RCTs in common solid tumors. Methods We searched ClinicalTrials.gov to identify phase III RCTs evaluating new drugs in adults with advanced cancers that completed accrual between January 2005 and October 2016. Data on HRQoL, safety, and tolerability comprising treatment‐related death, treatment discontinuation and commonly reported grade 3 or 4 adverse events (AEs) were extracted. Associations between these measures and reporting of HRQoL data were explored using logistic regression. Results Of 377 phase III RCTs identified initially, 143 studies were analysed and comprised 55% positive trials and 90% industry sponsored trials. HRQoL was listed as an endpoint in 59% trials; and of these, only 65% reported HRQoL data. There were higher odds of reporting HRQoL data for positive trials (OR 2.05, P = .04) and trials published in journals with higher impact factor (OR 1.35, P = .01). Reporting of HRQoL was not associated with treatment‐related death (OR 1.25, P = .40) or treatment discontinuation (OR 1.12, P = .61), but was positively associated with dyspnea and dermatological adverse events. Conclusions HRQoL is reported in only two‐thirds of RCTs that describe collecting such data. Reporting of HRQoL is associated with positive trial outcome and higher journal impact factor, but not associated with overall safety and tolerability of anti‐cancer drugs.
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Affiliation(s)
- Ramy R Saleh
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Nicholas Meti
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Domen Ribnikar
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Hadar Goldvaser
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alberto Ocana
- Experimental Therapeutics Unit, Medical Oncology Department, Hospital Clínico San Carlos, and IdISSC, Madrid, Spain.,Centro de Investigación Biomédica en Red Cáncer (CIBERONC), Madrid, Spain.,Centro Regional de Investigaciones Biomédicas, Castilla-La Mancha University, Ciudad Real, Spain
| | - Arnoud J Templeton
- Department of Oncology, St. Claraspital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Bostjan Seruga
- Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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15
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Veitch Z, Khan OF, Tilley D, Tang PA, Ribnikar D, Stewart DA, Kostaras X, King K, Lupichuk S. Impact of Cumulative Chemotherapy Dose on Survival With Adjuvant FEC-D Chemotherapy for Breast Cancer. J Natl Compr Canc Netw 2020; 17:957-967. [PMID: 31390594 DOI: 10.6004/jnccn.2019.7286] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/21/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Reductions in adjuvant chemotherapy dose <85% for historical regimens (ie, cyclophosphamide/methotrexate/fluorouracil) are known to affect breast cancer survival. This threshold, in addition to early versus late dose reductions, are poorly defined for third-generation anthracycline/taxane-based chemotherapy. In patients with breast cancer receiving adjuvant 5-fluorouracil/epirubicin/cyclophosphamide followed by docetaxel (FEC-D), we evaluated the impact of chemotherapy total cumulative dose (TCD), and early (FEC) versus late (D only) dose reductions, on survival outcomes. PATIENTS AND METHODS Women with stage I-III, hormone receptor-positive/negative, HER2-negative breast cancer treated with adjuvant FEC-D chemotherapy from 2007 through 2014 in Alberta, Canada, were included. TCD for cycles 1 to 6 of <85% or ≥85% was calculated. Average cumulative dose was also calculated for early (cycles 1-3) and late (cycles 4-6) chemotherapy. Survival outcomes (disease-free survival [DFS] and overall survival [OS]) were estimated using Kaplan-Meier and multivariate analysis. Cohorts were evaluated for uniformity. RESULTS Characteristics were reasonably balanced for all cohorts. Overall, 1,302 patients were evaluated for dose reductions, with 16% being reduced <85% (n=202) relative to ≥85% (n=1,100; 84%). Patients who received TCD ≥85% relative to <85% had superior 5-year DFS (P=.025) and OS (P<.001) according to Kaplan-Meier analysis, which remained significant on univariate and multivariate analyses. In stratified late and early dose reduction cohorts, DFS and OS showed a significant inferior survival trend for dose reduction early in treatment administration in 5-year Kaplan-Meier (P=.002 and P<.001, respectively) and multivariate analyses (hazard ratio [HR], 1.46; P=.073, and HR, 1.77; P=.011, respectively). Dose delays of <14 or ≥14 days and granulocyte colony-stimulating factor use did not affect outcomes. CONCLUSIONS Chemotherapy TCD <85% for adjuvant FEC-D affects breast cancer survival. Late reductions (D only) were not shown to adversely affect DFS or OS. Conversely, early reductions (FEC±D) negatively affected patient outcomes.
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Affiliation(s)
- Zachary Veitch
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta.,Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario
| | - Omar F Khan
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
| | - Derek Tilley
- CancerControl Alberta, Alberta Health Services, Calgary, Alberta; and
| | - Patricia A Tang
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
| | - Domen Ribnikar
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario
| | - Douglas A Stewart
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
| | | | - Karen King
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Sasha Lupichuk
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
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16
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Ratosa I, Orazem M, Scoccimarro E, Steinacher M, Dominici L, Aquilano M, Cerbai C, Desideri I, Ribnikar D, Marinko T, Livi L, Meattini I. Cyclin-Dependent Kinase 4/6 Inhibitors Combined With Radiotherapy for Patients With Metastatic Breast Cancer. Clin Breast Cancer 2020; 20:495-502. [PMID: 32622736 DOI: 10.1016/j.clbc.2020.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) represent the standard treatment for hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer. Data about the balance between efficacy and toxicity of combined palliative radiotherapy (RT) and CDK4/6 inhibition are lacking. PATIENTS AND METHODS We undertook a review of 46 patients with metastatic breast cancer on systemic treatment with CDK4/6i who underwent 62 metastases-directed RT. Clinical, laboratory, and RT treatment planning data were collected. Statistical analyses included Student t test, paired sample t test, and logistic regression modeling. RESULTS Thirty patients (65.2%) received palbociclib, 15 (32.6%) received ribociclib, and one patient received abemaciclib (2.2%). Median total prescribed RT dose was 20 Gy (range, 8-63 Gy). Sites of RT were bone (n = 50; 80.7%), visceral (n = 7; 11.3%), or brain metastases (n = 3; 4.8%), as well as primary tumor of the breast (n = 2; 3.2%). Overall, the rates of grade 3 or higher adverse events (AEs) were 6.5%, 4.3%, 15.2%, and 23.9% before the start of RT, during RT, 2 and 6 weeks after RT completion, respectively. We found no correlation between dose distribution to organs at risk and the development of AEs. The local control rates for the entire cohort were 98% at 6 months and 90% at 12 months. Overall, pain relief (complete or partial) was experienced by 80% (24/30) of patients who initially reported pain at the treated metastatic site. CONCLUSION We observed a modest increase in the rates of grade 3 or higher AEs after combined RT and CDK4/6i, with maintained efficacy of concomitant RT.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia.
| | - Miha Orazem
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Erika Scoccimarro
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mateja Steinacher
- Department of Oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Luca Dominici
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Michele Aquilano
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Cecilia Cerbai
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Domen Ribnikar
- Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Tanja Marinko
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy; Oncology Department, Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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17
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Saleh R, Meti N, Ribnikar D, Goldvaser H, Ocana A, Templeton AJ, Seruga B, Amir E. Associations between safety and tolerability and reporting of health-related quality of life in phase III randomized trials in common solid tumors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19206 Background: Anti-cancer drugs are approved typically on the basis of efficacy and safety as evaluated in phase III randomized trials (RCTs). Health related quality of life (HRQoL) is a direct measure of patient benefit from drugs. Despite this, HRQoL is not reported universally for all anti-cancer drugs. Here we explore associations with reporting of HRQoL data in phase III RCTs in common solid tumors. Methods: We searched ClinicalTrials.gov to identify phase III oncology RCTs evaluating new drugs in adult patients with breast, colorectal, lung, or prostate cancers. We included all completed or active trials that completed accrual between January 1, 2005 and October 31, 2016. Data were extracted from published trials including HRQoL data and toxicity data on toxic death, treatment discontinuation and commonly reported grade 3 or 4 adverse events (AEs). Then, we explored associations between these safety and tolerability measures and the odds of reporting HRQoL data and whether HRQoL were favourable or not. Analysis comprised logistic regression and was performed in SPSS version 25. Results: A total of 377 phase III RCTs were initially identified. After excluding ineligible studies, a total of 143 studies were analysed. All trials (100%) were in the metastatic setting with 79 (55%) being positive trials. 40 (28%) were breast cancer trials, 38 (26%) were focused on evaluating chemotherapy, and 128 (90%) of trials were industry sponsored. 84 (59%) trials reported measuring HRQoL data, however of these, only 47 (56%) reported HRQoL data. In 14 (30%) HRQoL was improved with experimental therapy. There was no association between treatment related death (OR 1.25, 95%CI 0.74-2.12, p = 0.398) or treatment discontinuation (OR 1.12, 95%CI 0.73-1.72, p = 0.61) with reporting of HRQoL data. Associations with grade 3 or 4 AEs are shown in the Table. Conclusions: HRQoL is reported for only around a half of RCTs that collect such data. Reporting of HRQoL is not associated with safety and tolerability of anti-cancer drugs. [Table: see text]
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Affiliation(s)
- Ramy Saleh
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | | | | | - Hadar Goldvaser
- Rabin Medical Center, Beilinson Hospital, Davidoff Center, Kyriat Ono, Israel
| | | | - Arnoud J. Templeton
- Department of Medical Oncology, St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Eitan Amir
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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Lohmann AE, Soldera SV, Pimentel I, Ribnikar D, Ennis M, Amir E, Goodwin PJ. Association of obesity with breast cancer outcome in relation to cancer subtypes. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11557 Background: Obesity at breast cancer (BC) diagnosis is associated with poor outcome, although the magnitude of effect in different BC subtypes is uncertain. Here we report on the association of obesity at BC diagnosis with disease-free (DFS) and overall survival (OS) in the following subtypes: (i) hormone receptor (ER/PgR) +ve, HER2-ve, (ii) HER2+ve, any ER/PgR and (iii) triple negative (TN). Methods: We searched MEDLINE, EMBASE and COCHRANE databases to December 31, 2018 and meeting presentations (past 5 years) using predefined search terms. Study eligibility, data abstraction were performed independently by two authors; those reporting hazard ratios (HR) for obesity and DFS/OS in BC subtypes were included. Using Review Manager pooled HRs were computed and weighted using generic inverse variance in fixed and random effects models (results were similar, random effects are presented). Results: Of 10,702 titles, 26 studies (108,793 patients) were included. Pooled HR for DFS for obese vs non-obese were (i) ER/PgR+ve HER2-ve 1.21 (95% Confidence interval, CI; 1.12-1.31, p < 0.00001), (ii) HER2+ve, any ER/PgR 1.16 (95%CI, 1.06-1.26; p = 0.0006) and (iii) TN, 1.13 (95%CI; 1.05-1.22 p = 0.002). Pooled HRs for OS were (i) ER/PgR+ve, HER2-ve 1.45 (95%CI; 1.30-1.62 p < 0.00001), (ii) HER2+ve any ER/PgR 1.21 (95%CI; 1.10-1.34 p = 0.0001) and (iii) TN 1.13 (95%CI, 1.04-1.23, p = 0.003).PooledHR for OS (but not DFS) were somewhat higher in observational vs interventional studies in (i) ER/PgR+ve, HER2-ve 1.57 vs 1.36, HER2+ve any ER/PgR (ii) 1.37 vs 1.09 but not (iii) TN 1.12 vs 1.22 (p = 0.21, 0.03 and 0.48, respectively). Conclusions: Obesity was associated with a worse outcome in all BC subtypes. Higher HR for OS in observational studies in (i) ER/PgR+ve, HER2- and (ii) HER2+ve any ER/PgR BC may reflect selection of healthier patients for intervention trials.
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Affiliation(s)
- Ana Elisa Lohmann
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Isabel Pimentel
- Mount Sinai Hospital- University of Toronto, Toronto, ON, Canada
| | | | | | - Eitan Amir
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Pamela Jean Goodwin
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
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Goldvaser H, Yasmin KC, Shepshelovich D, Yerushalmi R, Sarfaty M, Ribnikar D, Thavendiranathan P, Amir E. De-escalating adjuvant trastuzumab in human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer: A systemic review and meta-analysis. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
524 Background: One year of adjuvant trastuzumab in combination with chemotherapy is the standard of care in early-stage HER2 positive breast cancer. Existing data on shortening trastuzumab treatment show conflicting results. Methods: A search of PubMed and conferences identified randomized trials that compared abbreviated trastuzumab therapy to one year of treatment in early-stage HER2 positive breast cancer. Hazard ratios (HRs) and 95% confidence intervals (CI) were extracted for disease free survival (DFS) and overall survival (OS). Data on the number of DFS and distant relapse events were also collected as were the number of patients at risk in each group. Subgroup analyses evaluated the effect of nodal involvement, estrogen receptor (ER) expression and the duration of abbreviated trastuzumab (9-12 weeks versus 6 months). Odds ratios (ORs) and 95% CI were computed for pre-specified cardiotoxicity events including cardiac dysfunction and congestive heart failure (CHF). Results: Analysis included 6 trials comprising 11603 patients. In most studies adjuvant chemotherapy included anthracyclines and taxanes. Shorter trastuzumab treatment was associated with worse DFS (HR = 1.14, 95% CI 1.05-1.25, p = 0.002) and OS (HR = 1.15, 95% CI 1.02-1.29. p = 0.02). The effect on DFS was not influenced by ER status (p for the subgroup difference = 0.23), nodal involvement (p = 0.44) or the different duration of trastuzumab in the experimental arm (p = 0.08). In absolute terms, after an estimated median follow-up of 71 months, shorter treatment with trastuzumab was associated with an absolute increase in DFS events of 2.3%. Shorter trastuzumab treatment was associated with lower odds of cardiac dysfunction (OR = 0.67, 95% CI 0.55-0.81, p < 0.001) and CHF (OR = 0.66, 95% CI 0.50-0.86, p = 0.003). Conclusions: Compared to one year, shorter duration of adjuvant trastuzumab is associated with significantly worse DFS and OS, despite favorable cardiotoxicity profile. One year of trastuzumab should remain the standard adjuvant treatment in early-stage HER2 positive breast cancer with appropriate cardiac monitoring.
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Affiliation(s)
- Hadar Goldvaser
- Rabin Medical Center, Beilinson Hospital, Davidoff Center, Kyriat Ono, Israel
| | | | | | - Rinat Yerushalmi
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | | | | | | | - Eitan Amir
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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Veitch ZWN, Bedard PL, Tang PA, Conway JL, Ribnikar D, Albaba H, King KM, Lupichuk SM, Cescon DW. Clinical characteristics of patients with no evidence of disease (NED) versus residual disease (RES) to anti-HER2 therapy in metastatic breast cancer (MBC): A multi-institutional analysis. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.1034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1034 Background: Anti-HER2 therapy has improved survival in HER2+ MBC. Yet, large patient cohorts with no evidence of disease (NED) with long-term follow up are incompletely described in the literature. We evaluated the clinical characteristics of patients with HER2+ MBC and prolonged response to anti-HER2 therapy, exhibiting NED vs Residual disease (RES). Methods: Patients treated with chemotherapy plus trastuzumab (CT) from 2005-2013, or taxane plus trastuzumab-pertuzumab (TTP), or trastuzumab-emtansine (TDM1) from 2012-2016 for HER2+ MBC at Princess Margaret Cancer Centre in Toronto, Ontario or in Alberta, Canada were included. Duration on anti-HER2 therapy (without switch) was collected. Patients with median duration of response (MDR; months) 2x higher than phase II/III trials for each regimen (CT = 18.2; TTP = 40.4; TDM1 = 25.2) were included to select for prolonged response. Clinical features (ie: stage at diagnosis, survival, etc) and oncologist/radiologist reported best response were collected. Responses were grouped as NED (including sclerotic bone metastases) or RES. Clinical variables were evaluated by Chi-square and survival by Kaplan-Meier (log-rank). Results: 2403 patients (CT = 1830; TTP = 394; TDM1 = 179) were evaluated. After cut-off, 119 patients (5%) were included, with NED in 41% (49/119) and RES in 59% (70/119). More women aged < 50 vs ≥50 (p = 0.015) had NED (61%) than RES (39%). No breast surgery (curative or metastatic) showed higher (p = 0.015) rates of NED (49%) relative to RES (27%). More women having NED (92%) than RES (37%) were still alive (p < 0.0001) at data cut-off, with improved mPFS (years; p < 0.0001) for NED (11.2, 95%CI: 11.2-NR) vs RES (3.0, 2.7-3.6), and mOS (years; p < 0.0001) for NED (NR) vs RES (3.4, 95%CI: 2.8-4.2). Significance persisted with TDM1 patients excluded. Treatment type (p = 0.053) and number of organs with metastases (p = 0.067) were of borderline significance. Conclusions: Patients with NED have improved survival compared to RES. Younger age and avoiding breast surgery correlates with NED. Evaluation of genomic factors influencing NED are planned.
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Affiliation(s)
| | | | - Patricia A. Tang
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | | | | | - Hamzeh Albaba
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - David W. Cescon
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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21
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Goldvaser H, Korzets Y, Shepshelovich D, Yerushalmi R, Sarfaty M, Ribnikar D, Thavendiranathan P, Amir E. Deescalating Adjuvant Trastuzumab in HER2-Positive Early-Stage Breast Cancer: A Systemic Review and Meta-Analysis. JNCI Cancer Spectr 2019; 3:pkz033. [PMID: 31360906 PMCID: PMC6649709 DOI: 10.1093/jncics/pkz033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/18/2019] [Accepted: 04/26/2019] [Indexed: 12/30/2022] Open
Abstract
Background One year of adjuvant trastuzumab in combination with chemotherapy is the standard of care in early-stage human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Existing data on shortening trastuzumab treatment show conflicting results. Methods A search of PubMed and abstracts from key conferences identified randomized trials that compared abbreviated trastuzumab therapy to 1 year of treatment in early-stage HER2-positive breast cancer. Hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted for disease-free survival (DFS) and overall survival (OS). Subgroup analyses evaluated the effect of nodal involvement, estrogen receptor expression, and the duration of abbreviated trastuzumab (9–12 weeks vs 6 months). Odds ratios (ORs) and 95% confidence intervals were computed for prespecified cardiotoxicity events including cardiac dysfunction and congestive heart failure. P values were two-sided. Results Analysis included six trials comprising 11 603 patients. Shorter trastuzumab treatment was associated with worse DFS (HR = 1.14, 95% CI = 1.05 to 1.25, P = .002) and OS (HR = 1.15, 95% CI = 1.02 to 1.29. P = .02). The effect on DFS was not influenced by estrogen receptor status (P for the subgroup difference = .23), nodal involvement (P = .44), or the different duration of trastuzumab in the experimental arm (P = .09). Shorter trastuzumab treatment was associated with lower odds of cardiac dysfunction (OR = 0.67, 95% CI = 0.55 to 0.81, P < .001) and congestive heart failure (OR = 0.66, 95% CI = 0.50 to 0.86, P = .003). Conclusions Compared with 1 year, shorter duration of adjuvant trastuzumab is associated with statistically significantly worse DFS and OS despite favorable cardiotoxicity profile. One year of targeted HER2 treatment should remain the standard adjuvant treatment in early-stage HER2-positive disease with appropriate cardiac monitoring.
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Affiliation(s)
- Hadar Goldvaser
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada.,Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yasmin Korzets
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Radiation Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
| | - Daniel Shepshelovich
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada.,Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Rinat Yerushalmi
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Michal Sarfaty
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Domen Ribnikar
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, Peter Munk Cardiac Center, University of Toronto, Toronto, Canada
| | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
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22
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Veitch ZW, Bedard P, Tang PA, Conway JL, Ribnikar D, Albaba H, King K, Lupichuk S, Cescon D. Abstract P6-17-29: Withdrawn. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p6-17-29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
This abstract was withdrawn by the authors.
Citation Format: Veitch ZW, Bedard P, Tang PA, Conway JL, Ribnikar D, Albaba H, King K, Lupichuk S, Cescon D. Withdrawn [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 P6-17-29.
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Affiliation(s)
- ZW Veitch
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - P Bedard
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - PA Tang
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - JL Conway
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - D Ribnikar
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - H Albaba
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - K King
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - S Lupichuk
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - D Cescon
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada; Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada; Princess Margaret Cancer Centre, University of Toronto, Edmonton, AB, Canada; Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
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23
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Veitch Z, Khan OF, Tilley D, Ribnikar D, Kostaras X, King K, Tang P, Lupichuk S. Real-World Outcomes of Adjuvant Chemotherapy for Node-Negative and Node-Positive HER2-Positive Breast Cancer. J Natl Compr Canc Netw 2019; 17:47-56. [PMID: 30659129 DOI: 10.6004/jnccn.2018.7066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/30/2018] [Indexed: 11/17/2022]
Abstract
Background: Comparative real-world outcomes for patients with HER2-positive (HER2+) breast cancer receiving adjuvant trastuzumab outside of clinical trials are lacking. This study sought to retrospectively characterize outcomes for patients with node-negative and node-positive breast cancer receiving adjuvant trastuzumab in combination with docetaxel/cyclophosphamide (DCH), docetaxel/carboplatin/trastuzumab (TCH), or fluorouracil/epirubicin/cyclophosphamide followed by docetaxel/trastuzumab (FEC-DH) chemotherapy in Alberta, Canada, from 2007 through 2014. Methods: Disease-free survival and overall survival (OS) analyses for node-negative cohorts receiving DCH (n=111) or TCH (n=371) and node-positive cohorts receiving FEC-DH (n=146) or TCH (n=315) were compared using chi-square, Kaplan-Meier, or Cox multivariable analysis where appropriate. Results: Median follow-up was similar in node-negative (63.9 months) and node-positive (69.0 months) cohorts. The 5-year OS rates in patients with node-negative disease receiving DCH or TCH were similar (95.2% vs 96.9%; P=.268), whereas 5-year OS rates were higher but nonsignificant for patients with node-positive disease treated with FEC-DH compared with TCH (95.2% vs 91.4%; P=.160). Subgroup analysis of node-positive cohorts showed significantly improved OS with FEC-DH versus TCH in patients with estrogen receptor (ER)/progesterone receptor (PR)-positive breast cancer (98.3% vs 91.6%, respectively; P=.014). Conversely, patients with ER/PR-negative disease showed a nonsignificant trend toward higher OS rates with TCH versus FEC-DH (91.6% vs 83.3%, respectively; P=.298). Given the retrospective design, we were unable to capture all potential covariates that may have impacted treatment assignment and/or outcomes. Furthermore, cardiac toxicity data were unavailable. Conclusions: Survival rates of patients with HER2+ breast cancer in our study are comparable to those seen in clinical trials. Our findings support chemotherapy de-escalation in patients with node-negative disease and validate the efficacy of FEC-DH in those with node-positive disease.
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Goldvaser H, Ribnikar D, Majeed H, Ocaña A, Amir E. Absolute benefit from adjuvant chemotherapy in contemporary clinical trials: A systemic review and meta-analysis. Cancer Treat Rev 2018; 71:68-75. [PMID: 30366201 DOI: 10.1016/j.ctrv.2018.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many adjuvant breast cancer trials have observed smaller than anticipated differences between experimental and control groups. Accurate estimation of the absolute benefits of treatment is essential for the planning of clinical trials. METHODS We searched PubMed to identify contemporary randomized trials comparing different adjuvant chemotherapy regimens in breast cancer. The absolute difference in 5-year disease-free survival (DFS) and overall-survival between experimental and control groups were extracted, weighted by individual study sample size and pooled. Analyses were performed for estrogen receptor (ER) negative and ER-positive disease. Meta-regression explored the influence of patients and tumor characteristics and median follow-up on the benefit from treatment. RESULTS Analysis included 19 studies comprising 41,564 patients. Studies comparing chemotherapy regimens of different generations showed the largest difference in 5-year DFS (+7.4% for 3rd vs. 2nd generation and +5.9% for 2nd vs. 1st generation for ER-negative disease, and +2.3% for 3rd vs. 2nd generation and +1.8% for 2nd vs. 1st generation for ER-positive disease). Studies comparing chemotherapy regimens from the same generation showed smaller differences in DFS in both subgroups. Meta-regression showed that larger tumors and nodal involvement had significant greater magnitude of effect on 5-year DFS for ER-negative, but not ER-positive disease. Age and menopausal status had no effect in either subgroup. CONCLUSIONS Absolute differences between adjuvant chemotherapy regimens of the same generation are small even in ER-negative disease. Enrichment of trials for patients with poor clinical features results in larger magnitudes of benefit from treatment at 5 years in ER-negative, but not ER-positive disease.
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Affiliation(s)
- Hadar Goldvaser
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2M9, Canada; Sackler Faculty of Medicine, Tel Aviv University, POB 39040, Tel Aviv 6997801, Israel
| | - Domen Ribnikar
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2M9, Canada.
| | - Habeeb Majeed
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2M9, Canada.
| | - Alberto Ocaña
- Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, calle Francisco Javier de Moya, 02006 Albacete, Spain
| | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, 610 University Ave, Toronto, ON M5G 2M9, Canada.
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Algorashi I, Goldvaser H, Ribnikar D, Cescon DW, Amir E. Evolution in sites of recurrence over time in breast cancer patients treated with adjuvant endocrine therapy. Cancer Treat Rev 2018; 70:138-143. [DOI: 10.1016/j.ctrv.2018.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/19/2018] [Accepted: 08/20/2018] [Indexed: 12/28/2022]
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Ribnikar D, Volovat SR, Cardoso F. Targeting CDK4/6 pathways and beyond in breast cancer. Breast 2018; 43:8-17. [PMID: 30359883 DOI: 10.1016/j.breast.2018.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022] Open
Abstract
Metastatic or advanced breast cancer (mBC/ABC) remains incurable despite many different systemic treatment options. Hormone receptor positive (HR+) disease represents the most common subtype in both early and advanced disease. A better understanding of the biology of this BC subtype, in particular regarding potential mechanisms of endocrine resistance, has led to the development of CDK4/6 inhibitors. All three selective CDK4/6 inhibitors, palbociclib, ribociclib and abemaciclib have shown to significantly improve progression-free survival (PFS) when combined to endocrine therapy as first-line treatment for patients with HR+/HER-2 negative ABC, who have progressed on or after adjuvant endocrine therapy. All three of them have also shown an improved PFS as 2nd line therapy for HR+/Her2 negative ABC. Their toxicity profile is favorable, with hematological toxicity (mainly neutropenia) being predominant, followed by diarrhea and fatigue. Quality of life has been maintained in the 1st line setting or improved in the 2nd line setting. Overall survival (OS) has been reported so far only in 2 out of 7 trials as first line therapy and the difference did not reach statistical significance. In this article we review the biology of CDK signaling pathway and its inhibitors, preclinical and clinical data of all three investigated selective CDK4/6 inhibitors and their toxicity. We also discuss how these agents are being included in current international guidelines and future directions for these agents in other subtypes of breast cancer, in both advanced disease and early-stage disease.
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Affiliation(s)
- Domen Ribnikar
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada, 700 University Ave, 7W 427, Toronto, ON, M5G 2M9, Canada
| | - Simona Ruxandra Volovat
- Department of Medical Oncology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Str. Universitatii nr 16, 700115, Iasi, Romania
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal, Av. De Brasilia, s/n, 1400-048, Lisbon, Portugal.
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Goldvaser H, Majeed H, Ribnikar D, Šeruga B, Ocaña A, Cescon DW, Amir E. Influence of control group therapy on the benefit from dose-dense chemotherapy in early breast cancer: a systemic review and meta-analysis. Breast Cancer Res Treat 2018; 169:413-425. [PMID: 29423899 DOI: 10.1007/s10549-018-4710-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/03/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Results from clinical trials of adjuvant dose-dense chemotherapy in patients with breast cancer are inconsistent. METHODS A systematic search of MEDLINE identified studies comparing the efficacy of dose-dense adjuvant chemotherapy to a standard treatment. The primary analysis included studies that used identical regimens in the experimental and control groups, but varied only dose density. A secondary analysis included studies that used either different drugs or doses in the experimental and the control groups. Hazard ratios (HRs) and 95% confidence intervals were computed for disease-free survival (DFS) and overall survival (OS) and pooled in a meta-analysis. Subgroup analyses and meta-regression explored drug schedules utilized in control groups and the influence of clinicopathologic variables on benefit from dose-dense therapy. RESULTS The primary analysis included 5 studies comprising 9819 patients while the secondary analysis included 6 studies comprising 9679 patients. Dose-dense treatment significantly improved DFS (HR 0.85, p < 0.001) and OS (HR 0.86, p = 0.008) in the primary analysis. Similar results were observed in the secondary analysis. Dose-dense schedule was important primarily in studies utilizing paclitaxel every 3 weeks as the control group (interaction p = 0.04 for DFS interaction p = 0.001 for OS). A significantly greater relative magnitude of benefit was observed in pre-menopausal women and those with nodal involvement, but there was no influence of hormone receptor status on results. CONCLUSIONS Adjuvant dose-dense regimens improve breast cancer outcomes. It remains uncertain whether the observed benefit reflects the impact of dose density or the inferiority of paclitaxel every 3 weeks as a control group.
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Affiliation(s)
- Hadar Goldvaser
- Division of Medical Oncology, Princess Margaret Cancer Centre and the University of Toronto, 610 University Ave, Toronto, ON, M5G 2M9, Canada
- Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 39040, 6997801, Tel Aviv, Israel
| | - Habeeb Majeed
- Division of Medical Oncology, Princess Margaret Cancer Centre and the University of Toronto, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Domen Ribnikar
- Division of Medical Oncology, Princess Margaret Cancer Centre and the University of Toronto, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Boštjan Šeruga
- Department of Medical Oncology, Institute of Oncology Ljubljana, 2 Zaloska cesta, 1000, Ljubljana, Slovenia
| | - Alberto Ocaña
- Translational Research Unit, Albacete University Hospital and CIBERONC, calle Francisco Javier de Moya, 02006, Albacete, Spain
| | - David W Cescon
- Division of Medical Oncology, Princess Margaret Cancer Centre and the University of Toronto, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Eitan Amir
- Division of Medical Oncology, Princess Margaret Cancer Centre and the University of Toronto, 610 University Ave, Toronto, ON, M5G 2M9, Canada.
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Ribnikar D, Goldvaser H, Ocana A, Templeton AJ, Seruga B, Amir E. Safety and tolerability of cancer drugs studied in phase 3 randomized controlled trials (RCTs) over the last decade. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.6588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Alberto Ocana
- Medical Oncology Department and Translational Research Unit, Albacete University Hospital, Albacete, Spain
| | - Arnoud J. Templeton
- Department of Medical Oncology, St. Claraspital and Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Eitan Amir
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Goldvaser H, Ribnikar D, Majeed H, Ocana A, Amir E. Absolute benefit from adjuvant chemotherapy in triple negative breast cancer (TNBC): A systemic review and meta-analysis. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e12501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Habeeb Majeed
- Princess MArgaret Cancer Centre, Toronto, ON, Canada
| | - Alberto Ocana
- Medical Oncology Department, Salamanca University Hospital, Salamanca, Spain
| | - Eitan Amir
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Goldvaser H, Ribnikar D, Fazelzad R, Seruga B, Templeton AJ, Ocana A, Amir E. Abstract P3-17-02: Influence of non-measurable disease on progression-free survival in patients with metastatic breast cancer. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p3-17-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background:
Progression free-survival (PFS) is the dominant endpoint in phase 3 randomized controlled trials (RCTs) in women with metastatic breast cancer (MBC), and requires the ability to measure target lesions. It is unknown whether treatment effect on PFS is consistent among patients with measurable and non-measurable disease.
Methods:
We searched MEDLINE, EMBASE and COCHRANE for phase 3 RCTs in MBC that reported outcomes in subgroups with non-measurable (or bone only disease, if not reported explicitly) and measurable disease. Data were extracted and a single hazard ratio (HR) and 95% confidence intervals (CI) were computed to compare the individual trial treatment effect in non-measurable versus measurable disease. Data were then pooled in a meta-analysis. We repeated the analysis comparing bone only to non-bone only disease and performed subgroup analyses based on drug mechanism of action.
Results:
Of 82 RCTs that enrolled patients with non-measurable disease, 16 trials comprising 8516 patients were eligible for analysis. All included RCTs used PFS or time to progression as primary endpoints. There was no difference in pooled treatment effect between patients with non-measurable and measurable disease (HR 1.01, 95% CI 0.89-1.15, p=0.82). However, compared to non-bone only disease, a significantly greater effect on PFS was seen in those with bone only disease (HR 0.82, 95% CI 0.70-0.98, p=0.03). Subgroups analyses according to drug mechanism are shown in Table 1
Intra-study comparison, according to evaluated drug mechanismCohort/ Investigational drugNo. studies includedMeasurable HR (95% CI)Non measurable HR (95% CI)Intra- study comparison HR (95% CI)P – for intra-study comparisonAll160.69 (0.65-0.73)0.72 (0.64-0.80)1.01 (0.89-1.15)0.82Chemotherapy30.99 (0.87-1.13)0.67 (0.44-1.02)0.73 (0.44-1.21)0.22Endocrine treatment40.86 (0.77-0.96)0.94 (0.80-1.10)1.13 (0.92-1.40)0.23Signal transduction inhibitors40.52 (0.48-0.57)0.41 (0.33-0.50)0.74 (0.59-0.94)0.01Anti-angiogenetic agents50.66 (0.59-0.73)0.84 (0.67-1.04)1.34 (1.05-1.71)0.02CI- confidence interval, HR- hazard ratio
. Compared to patients with measurable disease, there was a greater effect on PFS in those with non-measurable disease in RCTs of signal transduction inhibitors and endocrine therapy (HR 0.74, 95% CI 0.59-0.94, p=0.01). There was a lesser effect on PFS in patients with non-measurable disease in RCTs of antiangiogenic drugs (HR 1.34, 95% CI 1.05-1.71, p=0.02). Comparable effect on PFS was shown in RCTs evaluating endocrine therapy and chemotherapy.
Conclusions:
There is variability in treatment effect on PFS in patients with measurable and non-measurable disease. There is greater effect on PFS in RCTs of endocrine therapy and signal transduction inhibitors and in patients with bone only disease. Standardization of PFS determination in patients with non-measurable and bone only disease is warranted.
Citation Format: Goldvaser H, Ribnikar D, Fazelzad R, Seruga B, Templeton AJ, Ocana A, Amir E. Influence of non-measurable disease on progression-free survival in patients with metastatic breast cancer [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 P3-17-02.
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Affiliation(s)
- H Goldvaser
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
| | - D Ribnikar
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
| | - R Fazelzad
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
| | - B Seruga
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
| | - AJ Templeton
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
| | - A Ocana
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
| | - E Amir
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Institute of Oncology Ljubljana, Slovenia, Ljubljana, Slovenia; St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland; 5Research Unit. Albacete University Hospital, Albacete, Spain
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Goldvaser H, Algorashi I, Ribnikar D, Majeed H, Ocana A, Seruga B, Templeton AJ, Amir E. Abstract P3-12-04: Efficacy of extended adjuvant aromatase inhibitors in subgroups of women with early breast cancer. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p3-12-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Randomized trials (RCTs) have reported improvements in breast cancer outcomes from extending treatment with aromatase inhibitors (AIs) beyond the initial 5 years after diagnosis. It is uncertain whether this effect is consistent in different subgroups.
Methods: We identified RCTs that compared extended AIs to placebo or no treatment using a systematic search of MEDLINE. The search was supplemented by a review of abstracts from the American Society of Clinical Oncology and San Antonio Breast Cancer Symposium meetings between 2013 and 2016. Hazard ratios (HRs) and 95% confidence intervals (CI) for disease-free survival (DFS) were extracted or estimated from forest plots and included in a meta-analysis using generic inverse variance and random effects modelling. Pre-specified subgroups included age (<60 ± 5 years vs. ≥60 ± 5 years), tumor size (≤2 cm vs. >2 cm), nodal status (positive vs. negative), hormone receptor status (estrogen [ER] and progesterone receptor [PR] positive vs. ER or PR positive) and administration of adjuvant chemotherapy (yes vs. no).
Results: Seven trials comprising 16,349 patients were analyzed. Studies designs and prior endocrine therapy are shown in Table 1
Table 1: Characteristics of included studies.TrialTreatment ArmsSample sizePrior endocrine treatmentABCSG 6aAnastrozole 3 years vs. none387/ 469Tamoxifen± aminoglutethimide: 100%, 5 yearsMA 17Letrozole 5 years vs. placebo2572/ 2577Tamoxifen: 100%, ∼5 yearsNSABP B-33Exemestane 5 years vs. placebo783/ 779Tamoxifen: 100%, ∼5 yearsDutch DATAAnastrozole 6 years vs,. anastrozole 3 years827/ 833Tamoxifen: 100%, 2-3 yearsIDEALLetrozole 5 years vs. letrozole 2.5 years903/ 898Any endocrine treatment (tamoxifen/AIs/sequence of tamoxifen+ AIs): 100%, 5 yearsMA.17RLetrozole 5 years vs. placebo959/ 959AIs: 100%, ∼5 years Prior tamoxifen: 79.3%NSABP B-42Letrozole 5 years vs. placebo1959/ 1964Any endocrine treatment (AIs/sequence of tamoxifen+ AIs): 100%, 5 years
. The pooled effect of prolonged treatment with AIs in different subgroups is shown in the Table 2.
Table 2: Intra-subgroup comparison of longer AIs treatment effect by subgroupsSubgroup ASubgroup BHR (95% CI) Subgroup AHR (95% CI) Subgroup BP for differenceAge <60 ± 5Age ≥60 ± 50.83 (0.70-0.99)0.85 (0.74-0.97)0.64T >2 cmT ≤2 cm0.77 (0.55-1.06)0.88 (0.68-1.13)0.44N positiveN negative0.72 (0.63-0.83)0.83 (0.64-1.08)0.22ER and PR positiveER or PR positive0.68 (0.44-1.04)1.03 (0.53-2.02)0.27Adjuvant chemotherapyNone0.71 (0.59-0.86)0.80 (0.65-0.98)0.51
Overall, the effect of prolonged AIs was similar in all subgroups. However, non-significantly greater effect sizes were seen in patient with larger tumors, nodal involvement, presence of both ER and PR expression and those treated with adjuvant chemotherapy.
Conclusions: Extended treatment with adjuvant AIs is associated with similar relative improvements in DFS in all subgroups analyzed. The greater effect size seen in node positive and large tumor subgroups and the higher baseline risk of recurrence will likely translate to a higher absolute benefit from extended AIs in these groups.
Citation Format: Goldvaser H, Algorashi I, Ribnikar D, Majeed H, Ocana A, Seruga B, Templeton AJ, Amir E. Efficacy of extended adjuvant aromatase inhibitors in subgroups of women with early breast cancer [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 P3-12-04.
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Affiliation(s)
- H Goldvaser
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - I Algorashi
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - D Ribnikar
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - H Majeed
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - A Ocana
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - B Seruga
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - AJ Templeton
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
| | - E Amir
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Translational Research Unit, Centro Regional de Investigaciones Biomedicas Universidad de Castilla La Mancha, Albacete University Hospital, Albacete, Spain; Institute of Oncology Ljubljana, Ljubljana, Slovenia; St. Claraspital, Faculty of Medicine, University of Basel, Basel, Swaziland
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Goldvaser H, Barnes TA, Šeruga B, Cescon DW, Ocaña A, Ribnikar D, Amir E. Toxicity of Extended Adjuvant Therapy With Aromatase Inhibitors in Early Breast Cancer: A Systematic Review and Meta-analysis. J Natl Cancer Inst 2018; 110:4065461. [PMID: 28922781 DOI: 10.1093/jnci/djx141] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/13/2017] [Indexed: 09/19/2023] Open
Abstract
Background A number of randomized controlled trials (RCTs) have reported improvement in breast cancer outcomes from extending treatment with aromatase inhibitors (AIs) beyond the initial five years after diagnosis. However, the toxicity profile of extended AIs is uncertain. Methods We identified RCTs that compared extended AIs to placebo or no treatment using MEDLINE and a review of abstracts from key conferences between 2013 and 2016. Odds ratios (ORs), 95% confidence intervals (CIs), absolute risks, and the number needed to harm (NNH) were computed for prespecified safety and tolerability outcomes including cardiovascular events, bone fractures, second cancers (excluding new breast cancer), treatment discontinuation for adverse events, and death without recurrence. All statistical tests were two-sided. Results Seven trials comprising 16 349 patients met the inclusion criteria. Longer treatment with AIs was associated with increased odds of cardiovascular events (OR = 1.18, 95% CI = 1.00 to 1.40, P = .05, NNH = 122), bone fractures (OR = 1.34, 95% CI = 1.16 to 1.55, P < .001, NNH = 72), and treatment discontinuation for adverse events (OR = 1.45, 95% CI = 1.25 to 1.68, P < .001, NNH = 21). Longer treatment with AIs did not influence the odds of either second malignancy (OR = 0.93, 95% CI = 0.73 to 1.18, P = .56) or deaths without breast cancer recurrence (OR = 1.11, 95% CI = 0.90 to 1.36, P = .34). Conclusions Extended treatment with AIs is associated with an increased risk of cardiovascular events and bone fractures. There is no statistically significant increase in deaths without breast cancer recurrence among patients receiving longer treatment with AIs. These data should be taken into account when considering extended adjuvant AIs.
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Affiliation(s)
- Hadar Goldvaser
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Tristan A Barnes
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Boštjan Šeruga
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - David W Cescon
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Alberto Ocaña
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Domen Ribnikar
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
| | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Research Unit, Albacete University Hospital, Albacete, Spain; Translational Oncology Laboratory, Regional Center for Biomedical Research, Castilla La Mancha University, Albacete, Spain
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Ribnikar D, Ratoša I, Perhavec A, Amir E. General Overview and Treatment Recommendations for Young Women with Breast Cancer. Rev Invest Clin 2017; 69:77-93. [PMID: 28453506 DOI: 10.24875/ric.17002175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Breast cancer in young women is a complex disease to manage due to its biological heterogeneity and special issues related to toxicity of different treatment strategies. Defining a cut-off for young age has been challenging since it is not clear whether the prognostic effect of age is continuously variable or whether there are certain thresholds at which the prognosis changes (e.g. those < 50 years of age or ≤ 35 years of age). In this review article, we define young patients as those being premenopausal. In addition, we discuss the most recent data of the biological diversity of breast cancer arising in premenopausal patients and current treatment modalities in early and advanced settings. Survivorship, with special emphasis on the importance of early supportive care, is also discussed.
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Affiliation(s)
- Domen Ribnikar
- Division of Medical Oncology, University of Toronto and Princess Margaret Hospital, Toronto, Canada
| | - Ivica Ratoša
- Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | | | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Hospital, Toronto, Canada
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Affiliation(s)
- Domen Ribnikar
- Division of Medical Oncology & Hematology, Department of Medicine, University of Toronto & Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z9, Canada
| | - Philippe L Bedard
- Division of Medical Oncology & Hematology, Department of Medicine, University of Toronto & Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z9, Canada
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Ribnikar D, Goldvaser H, Ocana A, Templeton AJ, Seruga B, Amir E. Reporting of Randomized Trials in Common Cancers in the Lay Media. Oncology 2017; 94:65-71. [PMID: 29151109 DOI: 10.1159/000484630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/25/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limited data exist about the role of the lay media in the dissemination of results of randomized controlled trials (RCTs) in common cancers. METHODS Completed phase III RCTs evaluating new drugs in common cancers between January 2005 and October 2016 were identified from ClinicalTrials.gov. Lay media reporting was identified by searching LexisNexis Academic. Scientific reporting was defined as presentation at an academic conference or publication in full. Associations between reporting in the lay media before scientific reporting and study design and sponsorship were evaluated using logistic regression. RESULTS Of 180 RCTs identified, 52% were reported in the lay media and in 27%, lay media reporting occurred before scientific reporting with an increasing trend over time (p = 0.009). Reporting in the lay media before scientific reporting was associated with positive results (OR: 2.10, p = 0.04), targeted therapy compared to chemotherapy (OR: 4.75, p = 0.006), immunotherapy compared to chemotherapy (OR: 7.60, p = 0.02), and prostate cancer compared to breast cancer (OR: 3.25, p = 0.02). CONCLUSIONS Over a quarter of all RCTs in common cancers are reported in the lay media before they are reported scientifically with an increasing proportion over time. Positive trials, studies in prostate cancer, and trials of immunotherapy are associated with early reporting in the lay media.
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Affiliation(s)
- Domen Ribnikar
- Division of Medical Oncology and Hematology, University of Toronto and Princess Margaret Cancer Centre, Toronto, ON, Canada
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Goldvaser H, AlGorashi I, Ribnikar D, Seruga B, Templeton AJ, Ocana A, Amir E. Efficacy of extended adjuvant therapy with aromatase inhibitors in early breast cancer among common clinicopathologically-defined subgroups: A systematic review and meta-analysis. Cancer Treat Rev 2017; 60:53-59. [DOI: 10.1016/j.ctrv.2017.08.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 01/05/2023]
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Goldvaser H, Ribnikar D, Fazelzad R, Seruga B, Templeton AJ, Ocana A, Amir E. Influence of non-measurable disease on progression-free survival in patients with metastatic breast cancer. Cancer Treat Rev 2017; 59:46-53. [DOI: 10.1016/j.ctrv.2017.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 11/16/2022]
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Ribnikar D, Goldvaser H, Ocana Fernandez A, Templeton A, Seruga B, Amir E. Reporting of results of randomized trials in common cancers in the lay media. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx385.005a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Goldvaser H, Ribnikar D, Barnes TA, Cescon DW, Ocana A, Amir E. Toxicity of extended adjuvant aromatase inhibitors therapy in postmenopausal breast cancer patients: A systematic review and meta-analysis. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
549 Background: Aromatase inhibitors (AI) are a gold standard adjuvant endocrine therapy for postmenopausal women with breast cancer. A number of randomized trials (RCTs) have reported modest improvements in breast cancer outcomes from extending treatment with AI beyond the initial 5 years after diagnosis. However, less in known about the toxicity of extended AI compared with no therapy. Methods: We conducted a systematic review of MEDLINE to identify RCTs that compared extended AI to placebo or no treatment. The search was supplemented by a review of abstracts from the American Society of Clinical Oncology and San Antonio Breast Cancer Symposium meetings between 2013 and 2016. Odds ratios (ORs), 95% confidence intervals (CI), absolute risks, and the number needed to harm (NNH) associated with one adverse event were computed for prespecified safety and tolerability outcomes including cardiovascular disease, bone fractures, second cancers (excluding new breast cancer), treatment discontinuation due to adverse events and death without recurrence. Results: Seven trials comprising 16349 patients met the inclusion criteria. Longer treatment with AI was associated with increased odds of cardiovascular disease (OR = 1.18, 95% CI 1.00-1.40, P=0.05; NNH = 122) and bone fractures (OR = 1.34, 95% CI 1.16 - 1.55, P < 0.001; NNH = 72). Compared to control, longer AI therapy was associated with a higher odds of treatment discontinuation due to adverse events (OR = 1.45, 95% CI 1.25 - 1.68, P < 0.001; NNH = 20). Longer AI therapy did not influence the odds of second cancers (OR = 0.93, 95% CI 0.73-1.18, P = 0.56). There was a numerical excess of death without recurrence with longer AI therapy, but this was not statistically significant (OR = 1.11, 95% CI 0.9 - 1.36, P = 0.34). Conclusions: Longer durations of AI use are associated with increased cardiovascular events and bone fracture. There is a numerical, but non-statistically significant excess of deaths without breast cancer recurrence among patients receiving longer AI therapy. These data should be taken into account when considering extended adjuvant AI therapy for breast cancer patients.
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Affiliation(s)
- Hadar Goldvaser
- Rabin Medical Center, Beilinson Hospital, Davidoff Center, Toronto, ON, Canada
| | | | | | | | | | - Eitan Amir
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Ribnikar D, Sousa B, Cufer T, Cardoso F. Extended adjuvant endocrine therapy - A standard to all or some? Breast 2017; 32:112-118. [PMID: 28152498 DOI: 10.1016/j.breast.2017.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/11/2017] [Indexed: 10/20/2022] Open
Abstract
Patients with estrogen receptor-positive (ER +) early breast cancer (EBC) are at a continuous risk for distant relapse despite 5 years of standard endocrine therapy, even after 10-15 years after primary diagnosis. Hence, large randomized clinical trials were conducted to evaluate the role of extended endocrine treatment (ET) with the primary goal to prevent or at least delay distant relapse. Two very large trials of extended tamoxifen (TAM), the ATLAS and the aTTom trial, proved the efficacy of prolonged TAM particularly important after 10 years due to the carry-over effect of the five initial years. Additionally, the extended use of AIs after 5 years of tamoxifen, also proved to be efficacious in preventing late distant relapses. For letrozole (LET) it was shown in the MA.17 trial that it also improves overall survival (OS) in node-positive BC patients. There are many options and still unanswered questions related to extended ET, which are discussed in this review. The most important issue in deciding prolonged duration of ET is undoubtfully how to identify ER+ patients who benefit most from this approach. With this purpose, not only classical pathological factors have been studied, but also molecular profiles of individual tumors, which might help us in the near future to better tailor ET. Not only efficacy, but also toxicity of such prolonged treatment is essential for optimal use, particularly maintained compliance in a routine clinical practice. These issues are discussed in this review.
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Affiliation(s)
| | - Berta Sousa
- Champalimaud Clinical Center, Lisbon, Portugal.
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Abstract
The question of whether to offer adjuvant chemotherapy to patients with early-stage breast cancer has always been challenging to answer. It is well known that a substantial proportion of patients with early-stage breast cancer are over treated, especially when staging and hormonal and HER2 receptors are solely taken into consideration. The advances in our knowledge of breast cancer biology and its clinical implications were the basis for the discovery of additional reliable prognostic markers to aid decision making for adjuvant treatment. Gene expression profiling is a molecular tool that more precisely defines the intrinsic characteristics of each individual tumor. The application of this technology has led to the development of gene signatures/profiles with relevant prognostic-and some predictive-value that have become important tools in defining which patients with early-stage breast cancer can be safely spared from chemotherapy. However, the exact clinical utility of these tools will only be determined after the results of two large prospective randomized trials, MINDACT and TailorX, evaluating their role become available. Notwithstanding the existence of these genomic tools, tumor burden (defined as tumor size and nodal status) still has independent prognostic value and must be incorporated in decision making. In addition, these gene signatures have limited predictive value, and new biomarkers and new targets are needed. Therefore close collaboration between clinicians and scientists is crucial. Lastly, issues of cost-effectiveness, reimbursement, and availability are crucial and widely variable around the globe.
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Affiliation(s)
- Domen Ribnikar
- From the Department of Medical Oncology, Institute of Oncology, Ljubljana, Slovenia; Breast Unit, Champalimaud Cancer Center, Champalimaud Foundation, Lisbon, Portugal
| | - Fatima Cardoso
- From the Department of Medical Oncology, Institute of Oncology, Ljubljana, Slovenia; Breast Unit, Champalimaud Cancer Center, Champalimaud Foundation, Lisbon, Portugal
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Grasic Kuhar C, Matos E, Demsar A, Zabukovec M, Mencinger M, Ovcaricek T, Ribnikar D, Bokal U, Borstnar S. 1836 Surgery and systemic therapy improve overall survival of HER2-positive breast cancer patients with central nervous system metastases. Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)30787-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ribnikar D, Ribeiro JM, Pinto D, Sousa B, Pinto AC, Gomes E, Moser EC, Cardoso MJ, Cardoso F. Breast cancer under age 40: a different approach. Curr Treat Options Oncol 2015; 16:16. [PMID: 25796377 DOI: 10.1007/s11864-015-0334-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Breast cancer (BC) under age 40 is a complex disease to manage due to the additionally fertility-related factors to be taken in consideration. More than 90% of young patients with BC are symptomatic. Women<40 years are more likely to develop BC with worse clinicopathological features and more aggressive subtype. This has been frequently associated with inferior outcomes. Recently, the prognostic significance of age<40 has been shown to differ according to the BC subtype, being associated with worst recurrence-free survival (RFS) and overall survival (OS) for luminal BC. The biology of BC<40 has also been explored through analysis of large genomic data set, and specific pathways overexpressed in these tumors have been identified which can lead to the development of targeted therapy in the future. A multidisciplinary tumor board should determine the optimal locoregional and systemic management strategies for every individual patient with BC before the start of any therapy including surgery. This applies to both early (early breast cancer (EBC)) and advanced (advanced breast cancer (ABC)) disease, before the start of any therapy. Mastectomy even in young patients confers no overall survival advantage when compared to breast-conserving treatment (BCT), followed by radiotherapy. Regarding axillary approach, indications are identical to other age groups. Young age is one of the most important risk factors for local recurrence after both breast-conserving surgery (BCS) and mastectomy, associated with a higher risk of distant metastasis and death. Radiation after BCS reduces local recurrence from 19.5 to 10.2% in BC patients 40 years and younger. The indications for and the choice of systemic treatment for invasive BC (both early and advanced disease) should not be based on age alone but driven by the biological characteristics of the individual tumor (including hormone receptor status, human epidermal growth factor receptor 2 (HER-2) status, grade, and proliferative activity), disease stage, and patient's comorbidities. Recommendations regarding the use of genomic profiles such as MammaPrint, Oncotype Dx, and Genomic grade index in young women are similar to the general BC population. Especially in the metastatic setting, patient preferences should always be taken into account, as the disease is incurable. The best strategy for these patients is the inclusion into well-designed, independent, prospective randomized clinical trials. Metastatic disease should always be biopsied whenever feasible for histological confirmation and reassessment of biology. Endocrine therapy is the preferred option for hormone receptor-positive disease (HR+ve), even in presence of visceral metastases, unless there is concern or proof of endocrine resistance or there is a need for rapid disease response and/or symptom control. Recommendations for chemotherapy (CT) should not differ from those for older patients with the same characteristics of the metastatic disease and its extent. Young age by itself should not be an indication to prescribe more intensive and combination CT regimens over the sequential use of monotherapy. Poly(ADP-ribose) polymerase inhibitors (PARP inhibitors) represent an important group of promising drugs in managing patients with breast cancer susceptibility gene (BRCA)-1- or BRCA-2-associated BC. Specific age-related side effects of systemic treatment (e.g., menopausal symptoms, change in body image, bone morbidity, cognitive function impairment, fertility damage, sexual dysfunction) and the social impact of diagnosis and treatment (job discrimination, taking care for children) should also be carefully addressed when planning systemic long-lasting therapy, such as endocrine therapy. Survivorship concerns for young women are different compared to older women, including issues of fertility, preservation, and pregnancy.
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Affiliation(s)
- D Ribnikar
- Medical Oncology Department, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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