New approach to implement cancer patient care: The valutazione percorso rete oncologica campana (ValPeROC)‐experience from an Italian oncology network

OBJECTIVE

The primary goal of the Campania Oncology Network (ROC) was to reduce cancer delay and care fragmentation through the establishment of cancer-specific multidisciplinary oncologic groups (GOMs) and diagnostic and therapeutic assistance paths (PDTAs).

METHODS

Five cancer centres of the ROC, with their own cancer specific GOM, were selected. In our analysis, we have focused on four neoplasms: lung, colon, ovarian and prostate cancers. The median time for pre-GOM and GOM Times was calculated for each tumour site. Univariate and multivariate logistic regressions were performed to individuate risk factors for pre-GOM and GOM Time.

RESULTS

Significant differences were observed for prostate cancer compared to other patients either for pre-GOM or GOM Times. Significant risks were found for ovarian and prostate cancers in pre-GOM time and for prostate cancer in GOM-Time.

CONCLUSIONS

This experience will produce knowledge and data to guide decision-making and to manage more effectively the challenges of fighting cancer in Campania region. The Valutazione Percorso Rete Oncologica Campana (ValPeROC) study evaluates, for the first time, the ROC activity, through the analysis of key performance indices. Pre-GOM and GOM Time represent the quality of the entire regional health system and are useful to define models, which can evaluate the performance of the ROC over time.

Randomized intermittent or continuous panitumumab plus FOLFIRI (FOLFIRI/PANI) for first-line treatment of patients (pts) with RAS/BRAF wild-type (wt) metastatic colorectal cancer (mCRC): The IMPROVE study

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Background: Continuous anti-EGFR-based FOLFIRI is a first-line standard of care in pts with RAS/BRAF wt mCRC. The emergence of resistance and treatment-related toxicity limit the efficacy of continuous treatment. Thus, an intermittent strategy could reduce both toxicity and resistance. Methods: This is a prospective, randomized, non-comparative, open-label, multicenter phase II study. Unresectable, previously untreated RAS/BRAF wt mCRC pts, were randomized to a control arm (A) receiving FOLFIRI/PANI continuously until progression or to the experimental arm (B), receiving 8 cycles of the same regimen followed by a treatment free interval. This lasted untill progressive disease, when another treatment period of up to 8 cycles was restarted. This intermittent strategy was continued until progression occurred on treatment. Tumor assessment was always done every 8 weeks in both arms. Pts were stratified for center, ECOG PS (0-1 vs 2), previous adjuvant therapy (yes or no), sidedness (right vs left) and metastatic sites (1 vs ≥ 2). The primary endpoint was the progression-free survival on treatment (PFSOT) at 1 year. Assuming p1=43% PFSOT at 1 year, corresponding to an expected median PFSOT time ≥ 10 months in the experimental arm, and a 5% drop-out rate, a sample size of 68 pts in each arm granted the study a power of 80%, with a type I error of 10% (binomial test) for rejecting the null hypothesis, p0=30%, corresponding to a median PFSOT time of ≤ 7 months. Secondary endpoints were safety, quality of life, OS and response rate (ORR); ctDNA samples were also collected. No formal comparison between the two arms was planned. Results: From May 2018 to June 2021, 137 pts were randomized (69 arm A/68 arm B). Main pts’ characteristics were (arm A/B): males 59/61%; median age 62/66yrs; PS 0 84/72%; right colon 17/15%; previous adjuvant therapy 22/29%; single metastatic site 33/26%. At a median follow-up of 18 months (IQR: 10-26), median PFS OT was 12.6 months (95% CI: 9.0-16.1) in arm A and 17.6 months (95% CI: 7.5-27.8) in arm B with a 1 year PFSOT rate of 51.7% and 61.3%, respectively. ORR (arm A/B) was 64/56%. Median number of FOLFIRI/PANI cycles administered per patient were (arm A/B) 13/12. Main grade 3-4 toxicities were (arm A/B): skin 27/13%, neutropenia 23/22%; diarrhea 13/15%. Conclusions: The primary endpoint of the study was met with the intermittent FOLFIRI-PANI strategy producing a long PFS with a reduced skin toxicity. These data deserve further investigations in a phase III trial. Clinical trial information: NCT04425239.

Skin Toxicity as Predictor of Survival in Refractory Patients with RAS Wild-Type Metastatic Colorectal Cancer Treated with Cetuximab and Avelumab (CAVE) as Rechallenge Strategy

The single-arm phase II CAVE mCRC trial evaluated the combination of cetuximab plus avelumab as rechallenge strategy in RAS wild-type (WT) metastatic colorectal cancer (mCRC) patients, with clinical response to first-line anti-EGFR-based chemotherapy, who progressed and received a subsequent line of therapy. The correlation of skin toxicity (ST) and different clinico-molecular variables with overall survival (OS), progression-free survival (PFS) and response rate (RR) was assessed at univariate and multivariate analysis. A total of 33/77 (42.9%) patients experienced grade 2-3 ST and displayed median OS (mOS) of 17.8 months (CI 95%, 14.9-20.6); whereas 44/77 (57.1%) patients with grade 0-1 ST exhibited mOS of 8.2 months (CI 95%, 5.5-10.9), (hazard ratio (HR), 0.51; CI 95%, 0.29-0.89; p = 0.019). Median PFS (mPFS) was 4.6 months (CI 95%, 3.4-5.7) in patients with grade 2-3 ST, compared to patients with grade 0-1 ST with mPFS of 3.4 months (CI 95%, 2.7-4.1; HR, 0.49; CI 95%, 0.3-0.8; p = 0.004). Grade 2-3 ST (HR, 0.51; CI 95%, 0.29-0.89; p = 0.019) and RAS/BRAF/EGFR WT circulating tumor DNA (ctDNA) (HR, 0.50; CI 95%, 0.27-0.9; p = 0.019) had a statistically significant effect on OS at univariate analysis. At the multivariate analysis, RAS/BRAF/EGFR WT ctDNA status maintained statistical significance (HR, 0.49; CI 95%, 0.27-0.9; p = 0.023), whereas there was a trend towards ST grade 2-3 (HR, 0.54; CI 95%, 0.29-1.01; p = 0.054). Skin toxicity is a promising biomarker to identify patients with mCRC that could benefit of anti-EGFR rechallenge.

Cetuximab Rechallenge Plus Avelumab in Pretreated Patients With RAS Wild-type Metastatic Colorectal Cancer: The Phase 2 Single-Arm Clinical CAVE Trial

Importance

Rechallenge therapy with anti-epidermal growth factor receptor (EGFR) drugs has been suggested in patients with chemo-refractory RAS wild-type (WT) metastatic colorectal cancer (mCRC) after initial response to anti-EGFR-based first-line treatment. The association of treatment with cetuximab plus avelumab with overall survival (OS) may be worthy of investigation in this setting.

Objective

To assess the efficacy and safety of cetuximab rechallenge therapy plus avelumab.

Design, Setting, and Participants

This single-arm, multicenter phase 2 trial enrolled patients from August 2018 to February 2020. Eligible patients with RAS WT mCRC had a complete or partial response to first-line chemotherapy plus anti-EGFR drugs, developed acquired resistance, and failed second-line therapy. Baseline circulating tumor DNA (ctDNA) for KRAS, NRAS, BRAF, and EGFR-S492R mutation analysis was done.

Interventions

Patients received avelumab (10 mg/kg every 2 weeks) and cetuximab (400 mg/m2 and, subsequently, 250 mg/m2 weekly) until disease progression or unacceptable toxic effects.

Main Outcomes and Measures

The primary end point was OS. Secondary end points were progression-free survival (PFS), overall response rate (ORR), and safety.

Results

Seventy-seven patients were enrolled (42 men, 35 women; median age, 63 years); 71 had microsatellite stable tumors (MSS), 3 microsatellite instability-high tumors (MSI-H), 3 unknown. The study met the primary end point, with median OS (mOS) of 11.6 months (95% CI, 8.4-14.8 months). Median PFS (mPFS) was 3.6 months (95% CI, 3.2-4.1 months). Common grade-3 adverse events were cutaneous eruption, 11 (14%), and diarrhea, 3 (4%). For 67 of 77 (87%) patients, baseline analysis of plasma circulating tumor DNA (ctDNA) for KRAS, NRAS, BRAF, and EGFR-S492R variations was feasible. Forty-eight patients had WT disease, whereas 19 had mutations. Patients with RAS/BRAF WT ctDNA had mOS of 17.3 months (95% CI, 12.5-22.0 months) compared with 10.4 months (95% CI, 7.2-13.6 months) in patients with mutated ctDNA (hazard ratio [HR], 0.49; 95% CI, 0.27-0.90; P = .02). The mPFS was 4.1 months (95% CI, 2.9-5.2 months) in RAS/BRAF WT patients compared with 3.0 months (95% CI, 2.6-3.5 months) in patients with mutated ctDNA (HR, 0.42; 95% CI, 0.23-0.75; P = .004).

Conclusions and Relevance

The findings of this single-arm phase 2 trial suggest that cetuximab plus avelumab is an active, well tolerated rechallenge therapy in RAS WT mCRC. Plasma ctDNA analysis before treatment may allow selection of patients who could benefit.

Trial Registration

ClinicalTrials.gov Identifier: NCT04561336.

Final results from the CAVE (cetuximab rechallenge plus avelumab) mCRC phase II trial: Skin toxicity as a predictor of clinical activity

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Background: Promising antitumor activity of so called rechallenge treatment with anti-epidermal growth factor receptor (EGFR) drugs in patients with RAS wild type (RAS WT) metastatic colorectal cancer (mCRC) has been recently reported. Beside the absence of resistance mutations at plasma circulating tumor DNA (ctDNA) analysis, no biomarkers of response to anti-EGFR rechallenge strategy have been identified. Methods: We conducted the single arm phase II CAVE mCRC trial to evaluate the combination of cetuximab as rechallenge plus avelumab treatment in 77 RAS WT mCRC patients, with complete (CR) or partial response (PR) to first line chemotherapy plus anti-EGFR drugs, who developed acquired resistance and received a subsequent line of therapy. A post-hoc baseline analysis of circulating tumor DNA (ctDNA) for KRAS, NRAS, BRAF and EGFR-S492R mutations was performed for 67/77 (87%) patients. The correlation of skin toxicity (ST) and other clinical variables with OS, PFS and response rate (RR) was assessed. Results: Cetuximab plus avelumab provided in the intention to treat population (ITT) median overall survival (mOS) of 11.6 months [95% Confidence Interval (CI), 8.4-14.8] and median PFS (mPFS) of 3.6 months (95% CI, 3.2-4.1) with a manageable toxicity profile. Thirty-three (42.9%) patients experienced grade 2-3 ST with mOS of 17.8 months (CI 95% 14.9-20.7), whereas 44 (57.1%) patients with grade 0-1 ST exhibited mOS of 8.2 months (CI 95% 5.6-11), (HR 0.51, CI 95% 0.29-0.89, P = 0.019). mPFS was 4.6 months (CI 95% 3.5-5.8) in patients with grade 2-3 ST, compared to 3.4 months (CI 95% 2.8-4.1) in patients with grade 0-1 ST (HR 0.49, CI 95% 0.3-0.8, P = 0.004). Grade 2-3 ST and baseline RAS/BRAF/EGFR WT ctDNA were the only variables with statistically significant effect on OS both at univariate and multivariate analyses. ST, number of metastatic sites ≤2, surgery of primary tumor and RAS/BRAF/EGFR WT ctDNA were associated with an improvement in PFS only at univariate analysis. In the 33 patients with grade 2-3 ST, 1 (3%) CR, 2 (6.1%) PR and 24 (72.7%) stable disease (SD) were observed, with disease control rate (DCR) of 81.8%. In the 44 patients with grade 0-1 ST 0 CR, 3 (6.8%) PR, 20 (45.5%) SD, with 52.3% DCR were reported. Conclusions: Cetuximab plus avelumab is effective and well tolerated as rechallenge treatment in mCRC. ST is a clinical biomarker for the identification of RAS/BRAF mCRC patients that could benefit from anti-EGFR rechallenge. Clinical trial information: NCT04561336.

Impact of COVID-19 outbreak on cancer immunotherapy in Italy: a survey of young oncologists

Background

The coronavirus disease 2019 (COVID-19) pandemic has overwhelmed the health systems worldwide. Data regarding the impact of COVID-19 on cancer patients (CPs) undergoing or candidate for immune checkpoint inhibitors (ICIs) are lacking. We depicted the practice and adaptations in the management of patients with solid tumors eligible or receiving ICIs during the COVID-19 pandemic, with a special focus on Campania region.

Methods

This survey (25 questions), promoted by the young section of SCITO (Società Campana di ImmunoTerapia Oncologica) Group, was circulated among Italian young oncologists practicing in regions variously affected by the pandemic: high (group 1), medium (group 2) and low (group 3) prevalence of SARS-CoV-2–positive patients. For Campania region, the physician responders were split into those working in cancer centers (CC), university hospitals (UH) and general hospitals (GH). Percentages of agreement, among High (H) versus Medium (M) and versus Low (L) group for Italy and among CC, UH and GH for Campania region, were compared by using Fisher’s exact tests for dichotomous answers and χ² test for trends relative to the questions with 3 or more options.

Results

This is the first Italian study to investigate the COVID-19 impact on cancer immunotherapy, unique in its type and very clear in the results. The COVID-19 pandemic seemed not to affect the standard practice in the prescription and delivery of ICIs in Italy. Telemedicine was widely used. There was high consensus to interrupt immunotherapy in SARS-CoV-2–positive patients and to adopt ICIs with longer schedule interval. The majority of the responders tended not to delay the start of ICIs; there were no changes in supportive treatments, but some of the physicians opted for delaying surgeries (if part of patients’ planned treatment approach). The results from responders in Campania did not differ significantly from the national ones.

Conclusion

Our study highlights the efforts of Italian oncologists to maintain high standards of care for CPs treated with ICIs, regardless the regional prevalence of COVID-19, suggesting the adoption of similar solutions. Research on patients treated with ICIs and experiencing COVID-19 will clarify the safety profile to continue the treatments, thus informing on the most appropriate clinical conducts.

Overcoming Resistance to EGFR Inhibitors in NSCLC

BACKGROUND

The clarification of several molecular pathways underlying the tumorigenesis has led to the development of several targeted drugs that have substantially improved the treatment of Non-Small-Cell Lung Cancer (NSCLC). The Epidermal Growth Factor Receptor (EGFR) is the target of several Tyrosine-Kinase Inhibitors (TKIs), some of them approved for treatment and others currently in clinical development. EGFR-TKIs markedly improve progression-free survival of patients with advanced NSCLC with EGFR mutations compared with chemotherapy.

METHODS

We undertook a structured search of bibliographic databases for peer-reviewed research literature using a focused review question.

RESULTS

Although first- and second-generation agents offer in target population (with EGFR mutations) a substantial improvement of outcomes compared with standard chemotherapy, unfortunately, drug resistance develops after initial benefit, through a variety of mechanisms. Novel- (third) generation EGFR inhibitors have a selective mechanism of action and are currently in advanced clinical development, producing encouraging results in patients with acquired resistance to previous generation agents.

CONCLUSION

The search for new drugs or strategies to overcome the TKI resistance in patients with EGFR mutations is to be considered a priority for the improvement of outcomes in the treatment of advanced NSCLC, and third-generation EGFR inhibitors are the most promising approach to the issue.

The safety of second-line treatment options for non-small cell lung cancer

INTRODUCTION

Non-small-cell lung cancer (NSCLC) patients after first-line therapy ultimately suffer progression. At this time, many patients still have a good performance status and can be considered for further active treatment. Two chemotherapeutic agents, docetaxel and pemetrexed (only in non-squamous histology), and the biological drug anti-epidermal growth factor receptor (EGFR) erlotinib, were approved for clinical use in the second-line treatment of NSCLC patients. In the last few years further new second-line therapies have become available in the clinical practice. Areas covered: This review will discuss the adverse events of the pivotal trials ledding to the approval of second-line therapies for the treatment of not oncogene-addicted NSCLC patients. Expert opinion: In recent years, new second-line options for NSCLC are: the anti-EGFR, afatinib (only in squamous NSCLC); the anti-angiogenics, nintedanib (only in lung adenocarcinoma) and ramucirumab, in combination with docetaxel; the immunotherapeutics, nivolumab, pembrolizumab, and atezolizumab. In the second-line approach, the main endpoint of treatment should always be survival, but with great respect for symptoms palliation and preserving patients' quality of life. Therefore, differing toxicity profiles of the available therapeutic options are often a deciding factor in second-line setting for NSCLC.

Complete response to capecitabine in a frail, elderly patient with metastatic colorectal cancer: A case report

The clinical management of frail, elderly patients affected by colorectal cancer (CRC) remains a subject of debate. The present study reports the case of an elderly man with metastatic CRC (mCRC) who was successfully treated with capecitabine. The patient survived for 29 months, thus highlighting its potential activity in terms of obtaining a complete response and high efficacy. A 77-year-old man presented with adenocarcinoma of the rectum with multiple and synchronous liver metastases, in addition to several comorbidities. The patient received single-agent capecitabine chemotherapy (825 mg/mq twice a day) on days 1-14 of a 21-day cycle. Following 12 cycles of well-tolerated therapy, a computed tomography scan revealed a complete response with no evidence of liver metastases. An overall survival of 29 months was documented, and the patient eventually succumbed to a diabetes-related complication. In compromised patients with mCRC, reduced-dose capecitabine is an excellent therapeutic option due to its positive safety profile, activity and efficacy.

Developments in pharmacotherapy for treating metastatic non-small cell lung cancer

INTRODUCTION

Most patients with non-small cell lung (NSCLC), including squamous cell carcinoma, adenocarcinoma and large cell carcinoma, have advanced disease at diagnosis and systemic therapy is the standard-of-care. About 20% of Caucasian patients are affected by an oncogene-addicted advanced NSCLC for which correspondent inhibitors are available. Areas covered: The main state-of-the-art synthetic anticancer drugs in the groups of chemotherapeutics, epidermal growth factor receptor and anaplastic lymphoma kinase tyrosine kinase inhibitors for NSCLC treatment, are reviewed and discussed from phase III randomized practice-changing trials onwards. A structured search of bibliographic databases for peer-reviewed research literature and of main meetings using a focused review question was undertaken. Expert opinion: The survival of NSCLC patients is increasing, regardless of the presence or not of a specific target, due to the availability of new generation drugs. The continuous deep knowledge of the mechanisms of NSCLC development and the constant research into new drugs should lead to the discovery of new potential targets and the synthesis of corresponding inhibitors to improve the outcomes of each subgroup of patients in order to control the disease in a constantly growing percentage of patients.

The Role of the Antiangiogenetic Ramucirumab in the Treatment of Advanced Non Small Cell Lung Cancer

Angiogenesis is one of the most important phenomena sustaining tumor development and metastatization, including for non small cell lung cancer (NSCLC). A dominant role in angiogenesis is played by the vascular endothelial growth factor (VEGF) and its signaling pathway. Ramucirumab, is a fully human immunoglobulin G1 monoclonal antibody that binds to the extracellular domain of the VEGF receptor-2 (VEGFR-2) with high specificity and affinity blocking the interaction of VEGFR-2 and VEGF ligands, thus inhibiting their signaling pathways and the consequential endothelial proliferation and migration. A recent phase III randomized trial named REVEL, demonstrated the efficacy of ramucirumab in combination with docetaxel as second line treatment of advanced NSCLC, leading to its FDA and EMA approval in this clinical setting. In the REVEL trial advanced NSCLC patients whose disease had progressed after first line platinum-based chemotherapy, were administered ramucirumab plus docetaxel or placebo plus docetaxel. More than 1,250 patients were treated and patients randomized to the treatment with ramucirumab plus docetaxel showed a significant longer median overall survival compared to those randomized to chemotherapy only. Ramucirumab is the first antiangiogenetic agent approved in the treatment both of squamous and non squamous NSCLC. In fact, it is not associated with increased risk of respiratory bleeding in the squamous histology, and also has demonstrated efficacy in both histology types. The role of ramucirumab, already cleared in the second-line treatment of advanced NSCLC, needs to be clarified further and is currently being explored also in the first-line treatment of advanced NSCLC.

The role of pembrolizumab in the treatment of advanced non-small cell lung cancer

Lung cancer is the leading cause of death cancer related worldwide. The standard therapies have unmet medical needs both due to the limited activity and relevant toxicity of platinum-based chemotherapy and to the low frequency of specific alterations required to use targeted therapies. Immune checkpoint inhibition due to restoring the immune system's capacity to eradicate tumors is undergoing in extensive investigation in non-small cell lung cancer (NSCLC) as a new treatment approach. Programmed cell death protein-1 (PD-1) and its ligand, programmed cell death-ligand 1 (PD-L1) have recently led to significantly and durable improvements in the clinical outcome of several kind of tumors including lung cancer. Pembrolizumab, approved by the U.S. FDA for the treatment of advanced NSCLC progressed after other therapies and with expression of PD-L1, has demonstrated durable response and prolonged overall survival (OS) especially in patients with high PD-L1 expression. Further investigation are needed to improve treatment outcomes through combination of immunotherapy or combined with other targeted therapies.

Endocrinopathies induced by immune-checkpoint inhibitors in advanced non-small cell lung cancer

The advent of immunotherapy has recently expanded the therapeutic options in advanced non-small cell lung cancer (NSCLC). In these patients, the recent efficacy demonstration of antibodies against immune checkpoints: the anti-programmed death-1 (PD-1) and anti-programmed death ligand-1 (PD-L1), has led to approval of nivolumab and pembrolizumab (anti-PD-1) in the treatment of advanced NSCLC. The mechanism of action of checkpoint inhibitors explains the development of autoimmune diseases as a side-effect of these medications. Among these, a spectrum of endocrine disorders has been also reported. This manuscript focuses particularly on endocrine disorders induced by immuno-checkpoint inhibitors employed in NSCLC, in order to suggest the strategies for their diagnosis and effective management.

Current status of targeted therapies in advanced gastric cancer

INTRODUCTION

In metastatic gastric cancer, chemotherapy is the standard treatment because it prolongs survival when compared to best supportive care alone. However, even after the use of more effective regimens, the overall survival remains disappointing, justifying the need for new treatment options.

AREAS COVERED

Areas covered in this review include the most common molecular pathways, which have provided novel targets in gastric cancer therapy. These therapeutic strategies include EGFR inhibitors, anti-angiogenic agents, cell cycle inhibitors and apoptosis promoters.

EXPERT OPINION

Several mAbs and kinase inhibitors, especially those targeting EGFR and VEGF/VEGFR, have already demonstrated promising activity in gastric cancer. The Phase III ToGA trial reported an increase in overall survival for patients with human EGF receptor (HER)2-positive gastric cancer treated with chemotherapy and trastuzumab compared to chemotherapy alone. This means that accurate HER2 testing in gastric cancer is necessary. Final data of ongoing trials with novel agents will be critical to further progress with this cancer.

Neo-adjuvant and adjuvant chemotherapy of gastric cancer

Gastric cancer is still a major health problem and a leading cause of cancer mortality despite a worldwide decline in incidence. Surgery is the primary curative treatment of locoregional gastric cancer. In Western countries, however, at the time of resection, most patients are expected to have regional lymph node involvement with poor prognostic implications. To improve these results, different trials have been carried out in the adjuvant or neo-adjuvant setting. Many phase III trials of adjuvant therapy have been conducted; however, postoperative treatment modalities have not proven to be superior to postsurgical observation alone. Therefore, at present the routine use of adjuvant therapy should be regarded as an investigational approach. Improved clinical trial designs with standardized surgical techniques and the incorporation of newer active drugs are needed. On the contrary, neo-adjuvant chemotherapy has shown promising results as suggested by the final results of UK Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial.