Pertuzumab, trastuzumab and taxane-based treatment for visceral organ metastatic, trastuzumab-naïve breast cancer: real-life practice outcomes

PURPOSE

In this study, we aimed to describe the real-life practice outcomes of pertuzumab-trastuzumab-taxane (PTT) combination in visceral organ metastatic, trastuzumab-naive breast cancer (BC) patients.

METHODS

This study was conducted by Turkish Oncology Group and included 317 patients' data from 36 centers.

RESULTS

Median age was 51 (22-82). Median PFS was 28.5 months, while median OS was 40.3 months. Patients with brain metastases (n: 13, 4.1%) had worse PFS (16.8 m vs. 28.5 m; p = 0.002) and OS (26.7 m vs. 40.3 m; p = 0.009). Patients older than 65 years of age (n: 42, 13.2%) had significantly lower OS results (19.8 m vs. 40.3 m; p = 0.01). Two hundred sixty-eight patients (86.7%) received docetaxel while 37 patients (11.7%) received paclitaxel. PFS and OS were similar between taxane groups. In eight patients (2.5%), 5-40% ejection fraction decrement from baseline was detected without any clinical sign of heart failure.

CONCLUSIONS

Our RLP trial included only visceral metastatic, trastuzumab-naïve BC patients including cases with brain involvement who received PTT combination in the first-line treatment. Regardless of negative prognostic characteristics, our results are in parallel with pivotal trial. Further strategies for brain metastasis should be developed to improve outcomes despite encouraging results with PTT treatment. Taxane selection can be personalized and endocrine maintenance may further improve outcomes after taxanes were discontinued. To our knowledge, this is the largest scale real-life clinical practice study of pertuzumab-trastuzumab-taxane therapy to date.

The access rate to diagnosis and treatment modalities in breast cancer patients in Turkey; multicenter observational study

PURPOSE

To determine the time elapsed between the first notification of the disease and the access to the diagnosis and treatment modalities and the associated factors in female patients with breast cancer in Turkey.

METHODS

Data was acquired from a questionnaire involving 535 patients who applied to 14 various oncology clinics in Turkey between 1st and 28th of February 2010. Analyses were performed by the participating clinics and were divided into 3 groups: centers located in metropolitan areas formed group 1 (n=161), those located in Marmara and central Anatolia region formed group 2 (n=189), and centers located in Karadeniz and East-Southeast Anatolia region formed group 3 (n=185). The groups of these centers were formed according to the socioeconomic development of the provinces.

RESULTS

The median patient age was 48 years, 56.1% of patients were less than 50 years of age. Eighty-five percent of the patients detected a mass in their breast by self examination and 27% of the patients older than 50 years never had breast imaging until the definite diagnosis was established. The median time elapsed between disease noticed by the patient and application to a health care center was 10 days, between application and biopsy 19 days, between biopsy and surgery 10 days, and between surgery and systemic therapy 31 days. The median time elapsed between patients applying for surgery in groups 1 and 2 centers was 11 and 21 days, respectively (p=0.01). The median time elapsed between biopsy and surgery in groups 1,2 and 3 centers was 14,1.5, and 12 days, respectively (p<0.05).

CONCLUSION

A high level of awareness regarding breast cancer in our country is related with the time that is defined as 10 days between disease recognition and medical application. The time elapsed between the application and biopsy, surgery and systemic therapy was longer compared with the corresponding figures in developed countries.

Efficacy, safety and prognostic features of resected colon carcinoma treated in "real world" practice: a retrospective cohort-study

PURPOSE

Treatment outcomes and prognostic features of a specific cancer generally come from prospective randomized studies. It seems reasonable to ask the question whether the results of prospective randomized studies entirely reflect the results of the population treated in "real world" practice. Therefore we performed a retrospective cohort analysis in order to find out the efficacy of adjuvant chemotherapy as well as the prognostic factors of our patient population treated in daily practice, and compared these findings with those defined in the prospective studies.

METHODS

Data of patients with high risk stage II and all stage III colon cancers treated with adjuvant chemotherapy were retrospectively analyzed.

RESULTS

A total of 190 patients were retrospectively analyzed. The rates of T2, T3, and T4 tumors were 4.2, 77.9, and 17.9%, respectively. Over 35% of the patients had stage II disease. Of the 5- fluorouracil (5-FU)-based chemotherapy group (n=141), 15% had a dose reduction because of toxicity and 73% were given the total planned dose and cycles, whereas these rates were 18.5 and 66% for oxaliplatin+5-FU treated group, respectively (p=0.66 and 0.44, respectively). The 3-year disease-free survival (DFS) and 5-year cancer-specific overall survival (OS) for all patients were 69.4 and 73%, respectively. In multivariate analysis, cancer-specific OS showed significant correlation with T stage (p=0.015) and with perineural invasion (p=0.024). Also patients ≥ 65 years old had significantly lower OS (p= 0.003)

CONCLUSION

This study is the fi rst to report the efficacy of adjuvant treatment in a curatively resected Turkish colon carcinoma population treated in "real world" practice. Our study showed that the treatment results and the prognostic parameters of Turkish colon carcinoma patients treated in "real world" practice are not different from those of selected patients treated in randomized prospective studies.

Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer

The long-term use of subcutaneous implanted ports for chemotherapy in cancer patients has been associated with the occurrence of thrombosis and infection. In this study, we compared the safety and efficacy of administration of 1000 U of heparin flushes in prolonged interval (every 6 weeks) with standard dose and schedule (500 U every 4 weeks) for port-related infections and thrombosis during periods of non-use. Data were collected retrospectively from patients treated for various cancer types (matched as 2:1 for age, gender, stage of the disease). Patients who had diseases that could cause thrombosis or bleeding in their past medical history, or were taking oral anticoagulants, or had contraindications for heparin usage were excluded. After completing their chemotherapy, 59 patients received prolonged interval, while 30 patients received standard schedule. All patients were followed for at least 1 year. No clinically documented port-related infection or thrombosis has been found in both groups. Also, none of the devices was removed during this time. Prophylactic flushing of central venous ports with 1000 U of heparin in every 6 weeks might be a safe, easy, cheaper, comfortable and effective alternative to standard dose and schedule for preventing thrombosis and infections.

Pulmonary toxicity in patients receiving docetaxel chemotherapy

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Background: Docetaxel is used widely as monotherapy or in combination for the treatment of various types of cancers. Although rarely observed, pulmonary toxicity can be seen with docetaxel. This side effect had been reported mostly in non-small cell lung cancer patients receiving docetaxel. We aimed to investigate the pulmonary toxicity in patients receiving docetaxel chemotherapy other than lung cancer. Methods: 34 patients were investigated prospectively to demonstrate the pulmonary toxicity of docetaxel. Pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT) scans were applied to all patients before chemotherapy and 14 - 21 days after completion of treatment. We used a HRCT scoring system that was based on the previous studies. All HRCT images were reviewed by two different observers. Results: We have seen no pulmonary symptoms that may reflect pulmonary toxicity in 34 patients. There were statistically significant differences between pre- and post-treatment values of FEV1 (L/sec) (p<0.05), FEV1/FVC (%) (p<0.05), FEF25–75 (L/sec) (p<0.01), FEF25–75 (%) (p<0,01), DLCO (mL/mmHg/min) (p<0.001), DLCO (%) (p<0.001), DLCO/VA (DLCO/L) (p<0.05), and DLCO/VA (%) (p<0.05). Also, there was a statistically significant difference between the pre- and post-treatment HRCT scores. The differences between pre- and post- treatment values of pulmonary function tests were not correlated with the number of docetaxel cycles and cumulative dose. There was a statistical relationship between number of docetaxel cycles (r =0.468, p<0.0001), docetaxel cumulative dose (r=0,596, p<0.0001) and HRCT scores after completion of docetaxel treatment. Conclusions: Although we have shown that docetaxel treatment causes a decline in PFTs and worsens HRCT scores, the symptoms of patients were not consistent with these differences. Therefore, it should be noted that the negative effects of docetaxel on PFTs and HRCT scores should be investigated by increasing the number of patients.

No significant financial relationships to disclose.

Impact of dose reductions of platinum compounds on survival in stage IIIB/IV non-small cell lung cancer (NSCLC)

e19055

Background: Platinum compounds are the main component of the CT in NSCLC. Standard recommended doses of cisplatin/carboplatin is usually couldn’t be administered and dose reductions are necessary because of side effects. We aimed to determine the effect of dose reductions of platinums on outcome of stage IIIB/IV NSCLC. Methods: Data of 420 patients were retrospectively reviewed. A platinum analogue was used in combination with vinorelbine, gemcitabine, paclitaxel, docetaxel or etoposide as first line treatment in 85% patients. Cumulative platinum doses and dose reduction ratios compared to standard doses were calculated. Patients with decreased GFR were excluded from the analysis. Results: Median age was 60 years (range: 28-87), 79% of patients were male, 31% were 65 yearsold/older, 55% had PS of 0, and 27% had stage IIIB disease. Histological subtypes were squamous cell in 32%, adenocarcinoma in 34%, and NSCLC in 31%. Median dose of cisplatin used per cycle was 67mg/m2 and carboplatin was 287mg/m2. 51% of the patients received standard or less than 10% reducted doses of platinum, while dose reductions were 10–20% in 19%, 21–30% in 24% of patients, and more than 31% in 6%. Median overall survival (OS) was 11 months, 1- year and 2-year OS ratios were 56% and 25%, respectively. Median time to progression was 5 months; 1-year progression free survival ratio was 18%. Gender, age, histologic subtype, and treatment with lower dose of platinum didn’t have any statistically significant impact on survival in univariate analysis. Patients with PS of 0, no weight loss, stage IIIB disease, receiving combination CT with docetaxel-cisplatin, and having partial response to treatment lived significantly longer. On multivariate analysis weight loss, stage and type of response to treatment had an impact on OS. Conclusions: Using lower doses of platinum compounds in combination chemotherapy for stage IIIB/IV non-small cell lung cancer might not have a negative impact on survival and definitely have a better toxicity profile.

No significant financial relationships to disclose.

The outcome of patients with triple negative breast cancer: Evidence for a favorable ethnic subgroup? The Turkish Oncology Group experience

e22158

Background: Triple negative breast cancer (TNBC) is generally considered as a poorer prognostic subgroup, with a propensity for earlier relapse and visceral involvement. The aim of this study is to evaluate the outcome of non-metastatic TNBC patients in a National registry setting and identify clinical and pathologic variables associated with survival. Methods: From a retrospective registry cohort of 296 TNBC patients treated and followed between 1993–2007, we identified 248 patients with early stage disease, with follow-up of at least 12 months. The prognostic impact of several clinical variables were evaluated by the Kaplan-Meier and Cox multivariate anayses. Results: Median age was 48. The majority of the patient group had invasive ductal carcinoma (n:204, 82.3%). Distribution by stage was as follows: stage 1: 49 (19.8%), st 2: 125 (50.4%), st 3: 69 (27.8%). Excluding 11 patients, all had received adjuvant chemotherapy. 5 year overall survival (OS) and disease-free survival (DFS) rates were 84±2.7 % and 69±3.3%, respectively. Median survival after initial recurrence was 20 months. Sites of relapse were as follows: lung: 26 (36.1%), liver:8 (11.1%), brain: 8 (11.1%), bone: 14 (19.4%), skin/lymphatic: 7 (9.7%). Univariate analysis revealed locally advanced disease (p:0.0001), larger tumor size (p:0.004), nodal positivity (p<0.00001), and extent of nodal involvement as significant factors for DFS; whereas, locally advanced disease (p:0.0099) and extent of nodal involvement (p:0.018) were identified as prognostic factors with an impact on OS. Multivariate analysis revealed locally advanced disease (HR: 3.3, p:0.02, 95% CI: 0.14–0.64) and extent of nodal involvement (HR:4.3, p:0.033, 95% CI: 0.059–0.88) as significant independent prognostic factors for DFS and OS, respectively. Conclusions: The outcome of patients with TNBC in this National registry cohort is comparable to other subsets with similar prognostic features and do not support the generally accepted notion that TNBC entails poor prognosis. It may be speculated that there may be inherent ethnic differences leading to distinctive tumor behaviour. Further translational research is required to identify molecular prognostic groups within the TN subset.

No significant financial relationships to disclose.

A case of Kikuchi-Fujimoto disease misdiagnosed as Hodgkin's lymphoma: the importance of second opinion

Kikuchi-Fujimoto disease (KFD), a rare clinicopathological entity, is a benign and self-limiting disease. It was first described in 1972 by Kikuchi and Fujimoto in Japan independently. KFD is prevalent in Asia, although it may be seen in wide geographical areas, including Turkey. It mainly affects young women. Cervical lymphadenopathy is the most prominent sign and should be differentiated from lymphoproliferative, autoimmune, and infectious diseases. We report on a 30-year-old female patient who was referred to our medical oncology unit for chemotherapy and/or radiotherapy with diagnosis of Hodgkin's lymphoma. Ultimately her diagnosis was corrected as KFD after second opinion of the pathology specimens. We herein provide a brief review about KFD and the importance of second opinion of the pathology specimens.

Impact of body mass index on cancer development

PURPOSE

To determine the impact of body mass index (BMI) on cancer in a hospital-based Turkish population.

PATIENTS AND METHODS

The study group consisted of 2015 (1172 females: 423 pre- and 749 postmenopausal; and 843 males) patients with histologically proven cancer who applied to Marmara University Medical School, Medical Oncology Clinic. The control group included 305 healthy caregivers (192 females: 110 pre- and 82 postmenopausal; and 113 males).

RESULTS

Mean BMI of the patients with breast, ovarian and cervical carcinoma was significantly higher than that of the healthy female controls (p<0.001, 0.003, <0.001, respectively). Postmenopausal breast cancer patients had significantly higher BMI than postmenopausal female controls (odds ratio [OR] 1.3; 95% confidence interval [CI], 1.06-1.6; p=0.012), while this was not seen in premenopausal patients. When compared with controls obese postmenopausal female patients had 3.26-fold (95% CI 1.54-6.90) increased risk for breast cancer (p=0.002). Mean BMI of lung, stomach, esophagus, pancreas and head and neck carcinoma patients was significantly lower than that of the healthy controls. Female patients with lung and colorectal carcinoma had higher BMI than female controls.

CONCLUSION

Elevated BMI might be a risk factor for breast cancer in postmenopausal women. Case-control studies may not show the actual association between BMI and cancers that present with pre-diagnosis weight loss and advanced stage.

The role of adjuvant chemoradiotherapy (CRT) in Turkish patients with gastric carcinoma

15159

Background: Increased disease free and overall survivals were seen in curatively resected patients with gastric and gastroesophageal adenocarcinoma treated with postoperative adjuvant CRT compared to surgery alone. There is no study analyzing the outcome of gastric cancer patients who received adjuvant CRT after curative resection in Turkish patients. Thus, we aimed to analyze the treatment outcome of postoperative CRT, and the prognostic significance of various parameters in these patients. Material Metod: Overall 130 patients with gastric cancer staged IB to IV(M0) were treated with chemoradiotherapy after curative resection, in two outpatient clinics in Istanbul. The chemotherapy consisted of fluorouracil 425 mg/m2 plus leucovorin 20 mg/m2 for 5 days, followed by 4500 cGy of radiotherapy for 5 weeks with fluorouracil (400 mg/m2) and leucovorin (20 mg/m2) on the first 4 days and the last 3 days of radiotherapy. Two 5-day cycles of chemotherapy with the doses used in the first cycle were given 4 weeks after the completion of radiotherapy. The demographic features and histopathological characteristics of the patients were analyzed as prognostic factors. Results: The median follow up was 13 months (range: 1–77) starting from surgery date. The median age was 58 years (range:33–75). About 28 % of the patients were female. ECOG performance score (PS) was =1 in 92.9 %, whereas it was 2 in the remaining 7.1%. Twenty-one patients had gastroesophageal junction and 109 had gastric primaries. The rates of T1, T2, T3, and T4 tumors were 3.8%, 26.9%, 61.5%, and 7.7%, respectively. A hundred and nine (83.8%) patients had regional node involvement. The 3 year disease free survival and overall survival for all patients were 50.1%, and 61.7%, respectively. The median overall survival was 54 months. In multivariate Cox regression analysis; nodal status (p: 0.003) was the only independent prognostic factor for overall survival. Tolerance was acceptable, and the main toxicity was related to gastrointestinal system. Conclusion: The adjuvant CRT after curative resection of gastric cancer was feasible, with acceptable toxicities in our Turkish patient population.

No significant financial relationships to disclose.

Outcome of metastatic colorectal cancer patients receiving second line chemotherapy in Marmara University Hospital

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Background: With the development of oxaliplatin and irinotecan, multiple effective regimens are now available in advanced colorectal cancer (CRC), both as first- and second-line treatment options. Exposure to all of the active drugs is effective in prolonging overall survival (OS) and time to progression (TTP). There are limited studies, if any, analyzing the outcome of second line chemotherapy in metastatic CRC in Turkey. Thus, we aimed to evaluate the outcome of second-line treatments in metastatic CRC patients. Methods: Among 173 patients with metastatic CRC who were given first line chemotherapy 106 (47 female, 59 male) were administered second line treatment after progression. All patients histologically confirmed colorectal adenocarcinoma with ECOG performance score of 2 or lower, and received second line therapy for metastatic CRC after experienced disease progression during or following treatment with first-line therapy were entered the study. The patients were evaluated clinically and radiologically after each three-cycle period, and chemotherapy was changed or stopped if the cancer has progressed. Age, gender, grade, chemotherapy type (combination vs single agent), lymphatic, vascular, and perineural invasion, were analyzed as prognostic factors. Results: At a median follow up of 10 (range 1–40) months from the start of second line chemotherapy median TTP and OS time were 5 and 16 months respectively. Median age was 62 years (range 27–89). After second line therapy 16% of the patient had objective response rate (0.9% complete responses plus 15.1% partial responses), 37.7% had stable disease resulting in a tumor control rate of 53.7%, and 46.2% had progressive disease. One-year progression free survival and OS rates were 15 % and 53.5%, respectively. No difference was seen in the survival of patients received combination or single agent second line chemotherapy (p=0.14). Overall, over 12% of the patients suffered from grade 3 or 4 adverse effects. In multivariate analysis histological grade (p=0.015) was the only independent prognostic factor for survival. Conclusion: The survival outcome and adverse effects of second line treatments in Turkish patients in our department with metastatic CRC is consistent with the worlds’ literature.

No significant financial relationships to disclose.

Concomitant administration of uracil-tegafur and leucovorin during adjuvant radiotherapy for locally advanced rectal cancer

PURPOSE

We report the feasibility and toxicity profile, and the impact on local control, disease-free survival and overall survival rates of our study which consisted of postoperative concurrent chemoradiotherapy, followed by adjuvant chemotherapy using uracil-tegafur (UFT)/leukovorin (LV) in locally advanced rectal cancer patients.

PATIENTS AND METHODS

Thirty-one patients operated for rectal adenocarcinoma (pT3/4 or N+) were enrolled onto the study. Twenty-three patients were males and 8 females with median age 62 years (range 21-85). Radiotherapy (RT) to the pelvis with conformal technique and individual blocks was delivered within 8 weeks following surgery. Total RT dose was 50.4 Gy and was given in a conventional single fraction of 1.8 Gy per day. Chemotherapy was administered concomitantly and consisted of UFT (300 mg/m(2)/day) and LV (30 mg/day) during RT-days. Following chemoradiotherapy, chemotherapy alone was administered for 4 cycles in the same dose for 28 days every 35 days.

RESULTS

No lethal toxicity occurred. All patients completed the scheduled RT. Concurrent chemotherapy continued in 22 (70.9%) patients until the end of RT. Seventeen (54.8%) patients completed the whole concurrent chemoradiotherapy and adjuvant chemotherapy as planned. No grade 3-4 stomatitis/mucositis or haematological toxicities were observed during the whole treatment period. During concomitant therapy grade 1-2 toxicities were: nausea/vomiting 60%, dyspepsia/gastric pain 39%, diarrhea 39% and dysuria 10%, whereas grade 3 nausea and diarrhea occurred in 6% and 19%, respectively. Median follow-up was 22 months. Two-year local control, disease-free survival and overall survival rates were 96.3%, 72.3% and 83.2%, respectively.

CONCLUSION

The acute toxicity profile of UFT/LV, local control, disease-free survival and overall survival in the concurrent chemoradiotherapy setting for operated, locally advanced rectal cancer seem comparable with the standard 5-fluorouracil (5-FU)-based therapies.

HPV DNA frequency and subset analysis in human breast cancer patients' normal and tumoral tissue samples

Viruses are known to be associated with human malignancies, e.g., Epstein-Barr virus, human papillomavirus (HPV) and human T-cell leukemia virus type I. We conducted a prospective study to define the role of HPV in breast cancer. The malignant and normal breast tissue samples of 50 consecutive breast cancer patients were obtained postoperatively. DNA extracted from all tissues was amplified with the polymerase chain reaction using HPV primers. HPV 11, 16, 18, 33 subtypes were searched in HPV-DNA positive samples. Thirty-seven samples (74%) of tumoral breast tissue expressed HPV-DNA, 16 normal breast tissue samples (32%) were positive as well. There was a significant difference in HPV-DNA positivity between normal and tumoral breast tissue samples. HPV 18 was detected in 20 of the HPV-DNA positive tumoral tissue (54.4%) and in 9 of the HPV-DNA positive normal tissue (56.3%). HPV-33 also was detected in 35 (94.6 %) of the HPV-DNA positive tumoral tissue and in 14 (87.5 %) of the HPV-DNA positive normal tissue samples. HPV DNA was significantly associated with breast tumor tissue compared to normal breast tissue. Additional studies looking at HPV and HPV subtypes are needed to clarify the etiological role of the HPV in breast cancer.

Outcome of rectal carcinoma patients receiving adjuvant chemoradiotherapy in Marmara University Hospital

13584

Background: Surgical resection is the cornerstone of curative therapy for rectal cancer. Relapse rate following potentially curative resection is high in patients with stage II/III disease. Thus, chemoradiotherapy is the standard adjuvant treatment in resected stage II/III rectal carcinoma. There are limited studies, if any, analyzing the outcome of rectal cancer patients with stage II/III who received adjuvant chemoradiotherapy after curative resection in Turkey. Therefore, we aimed to analyze the treatment outcome, and the prognostic significance of various parameters in these patients. Methods: 106 patients with stage II/III rectal cancer treated with adjuvant chemoradiotherapy since 1997 until present were analyzed retrospectively. Patients received 5-fluorouracil (370–425mg/m2/day × 5days) and calcium leucovorin (20mg/m2/day × 5days), q4weeks, two courses before and two courses after radiotherapy. The 5-fluorouracil dose was reduced to, 225mg/m2/day given continuously as protracted short-term infusion during radiotherapy. 45–50.4 Gy radiotherapy was given to the pelvic region. Patients were followed-up every 3 months for the first 2 years and every 6 months thereafter. Age, gender, T stage, N stage, histological grade, lymphatic, vascular, and perineural invasion were analyzed as prognostic factors. Results: The median follow-up was 34 months. Median age was 59.5 years. Forty-four percent of the patients were node-negative. Lymphatic, vascular, and perineural invasion rate were 50.5%, 47.3%, and 32.3% respectively. Five-year disease-free and overall survival rates were 68.8% and 72.2%, respectively. Median survival time and median disease free-survival time were not reached at the time of analysis. In multivariate Cox regression analysis; T stage (p: 0.022), nodal stage (0.019), presence of lymphatic invasion (p: 0.0001), and the presence of vascular invasion (p:0.01) were independent prognostic factors. Conclusion: The adjuvant treatment outcome in Turkish patients in our department with stage II/III rectal cancer is similar to those reported in the Western studies.

No significant financial relationships to disclose.

Amantadine monotherapy of chronic hepatitis C patients infected with genotype lb

We aimed to test the efficacy of amantadine in chronic hepatitis C (CHC) patients infected with genotype b. Twenty patients completed treatment with amantadine HCl, 100 mg b.i.d., for 6 months. Non-sustained biochemical improvement was observed without loss of HCV-RNA. We conclude that amantadine monotherapy is not effective in CHC.