1
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Moffat GT, Kong W, MacKay HJ, McGee J, Booth CM, Ethier JL. Real-world outcomes associated with bevacizumab combined with chemotherapy in platinum-resistant ovarian Cancer. Gynecol Oncol 2024; 184:51-56. [PMID: 38281412 DOI: 10.1016/j.ygyno.2024.01.027] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/08/2024] [Accepted: 01/18/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The addition of bevacizumab to chemotherapy for platinum-resistant (PL-R) ovarian cancer (OC) improved progression-free (PFS) but not overall survival (OS) in clinical trials. We explored real-world outcomes in Ontario, Canada, and compared survival in the pre- and post-bevacizumab era. METHODS Administrative databases were utilized to identify all patients treated with bevacizumab for PL-R OC. Time on treatment (ToT) was used as surrogate for PFS. Median OS was determined using the Kaplan-Meier method. Factors associated with ToT/OS were identified using a Cox proportional hazard model. A before and after comparative effectiveness analysis was performed to determine mOS for patients treated pre- and post-bevacizumab approval. RESULTS From 2017 to 2019, 176 patients received bevacizumab. Median ToT was 3 months and OS was 11 months. Sixty-four percent received liposomal doxorubicin and 34% received paclitaxel. ToT (6 vs 3 months; HR 0.44; p < 0.0001) and OS (14 vs 9 months; HR 0.45; p = 0.0089) were longer with bevacizumab/paclitaxel. OS was not significantly different pre- and post-bevacizumab funding (8 vs 9 months; HR 1.01; 0.937). Median OS increased for those receiving paclitaxel (6 vs 11 months), but those in the post group were younger, more likely to have undergone primary surgery and had less co-morbidities. CONCLUSION Real-world outcomes with bevacizumab in PL-R OC are inferior to those in the pivotal clinical trial. Survival has not significantly improved since funding became publicly available, indicating a substantial efficacy-effectiveness gap between trial and real-world outcomes. Median OS and ToT were significantly better when bevacizumab was given with paclitaxel.
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Affiliation(s)
- Gordon Taylor Moffat
- Division of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Weidong Kong
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Helen J MacKay
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jacob McGee
- Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Josee-Lyne Ethier
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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2
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Ethier JL, Kong W, MacKay HJ, McGee J, Booth CM. Real-world outcomes associated with use of front-line bevacizumab in ovarian cancer. J Cancer Policy 2023; 36:100421. [PMID: 37030536 DOI: 10.1016/j.jcpo.2023.100421] [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] [Received: 01/09/2023] [Revised: 03/22/2023] [Accepted: 04/05/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND In the pivotal ICON7 study, addition of bevacizumab to front-line treatment of ovarian cancer (OC) significantly improved overall survival (OS) (p=0.03) in a high-risk subgroup of patients with suboptimally debulked/unresectable stage III or IV disease, leading to approval in Ontario, Canada in March 2016. Here we describe utilization of bevacizumab for front-line, high-risk OC and determine outcomes in routine clinical practice. METHODS Provincial administrative databases were utilized to identify all patients treated with front-line bevacizumab following its approval. Median OS (mOS) was determined using the Kaplan-Meier method. Factors associated with OS were identified using a Cox proportional hazard model. A comparative effectiveness analysis was performed to determine mOS pre- (2006-2016) and post- (2016-2019) approval. RESULTS From March 2016 to October 2019, 282 patients received bevacizumab. Mean age was 64 years old, and 58% had stage IV disease. Median survival was 29 months and was longer in stage III (37 months) compared to stage IV disease (28 months). In a comparative effectiveness analysis of patients with stage IV serous OC, post-approval uptake of bevacizumab was low (23%). Median OS was similar pre (26 months) and post (27 months) approval (HR 0.92, 0.75-1.12, p=0.383). CONCLUSIONS Survival in real-world patients treated with front-line bevacizumab is shorter than in pivotal clinical trials. Survival in stage IV serous patients has not significantly improved post public reimbursement of bevacizumab. This analysis was limited by poor uptake, however mOS was similar in patients who did and did not receive bevacizumab.
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Affiliation(s)
- Josee-Lyne Ethier
- Department of Oncology, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada.
| | - Weidong Kong
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Helen J MacKay
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jacob McGee
- Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
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3
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MacKay HJ. Abstract IA006: Endocrine therapy and ER/PR combinations. Clin Cancer Res 2021. [DOI: 10.1158/1557-3265.endomet20-ia006] [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
Endocrine therapy is the “original” targeted therapy in endometrial cancer (EC). Despite over 60 years experience with this treatment modality we have yet to answer some key questions including which women derive benefit and how do we identify them? Despite a high proportion of ECs being ER and/or PR positive, endocrine therapy is only associated with modest benefit. Greater understanding of ER and PR biology may help identify patient populations who will derive benefit and assist in optimizing this approach. Favourable toxicity profiles and multiple pathway interactions suggest the potential for combining endocrine and other targeted agents. We discuss the preliminary data and hypothesize on potential strategies to accelerate the pace of development in this area.
Citation Format: Helen J. MacKay. Endocrine therapy and ER/PR combinations [abstract]. In: Proceedings of the AACR Virtual Special Conference: Endometrial Cancer: New Biology Driving Research and Treatment; 2020 Nov 9-10. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(3_Suppl):Abstract nr IA006.
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Affiliation(s)
- Helen J. MacKay
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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4
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Komorowski AS, MacKay HJ, Pezo RC. Quality of adverse event reporting in phase III randomized controlled trials of breast and colorectal cancer: A systematic review. Cancer Med 2020; 9:5035-5050. [PMID: 32452660 PMCID: PMC7367648 DOI: 10.1002/cam4.3095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/13/2019] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022] Open
Abstract
Background Clinical trial reports often emphasize efficacy over harms, leading to misinterpretation of the risk‐to‐benefit ratio of new therapies. Clear and sufficiently detailed reporting of methods and results is especially important in the abstracts of trial reports, as readers often base their assessment of a trial on such information. In this study, we evaluated the quality of adverse event (AE) reporting and abstract quality in phase III randomized controlled trials (RCTs) of systemic therapies in breast and colorectal cancer. Methods Medline, EMBASE, Cochrane Database of RCTs, and Cochrane Database of Systematic Reviews were searched from November 2005 to September 2018. Phase III RCTs evaluating systemic therapies in breast or colorectal cancer were included. Each article was independently reviewed by two investigators using a standardized data extraction form based on guidelines developed by the Consolidated Standards of Reporting Trials (CONSORT) group. Descriptive statistics, bivariate analysis, and multivariable linear regression were used to analyze data. All statistical tests were two‐sided. Results Of 166 RCTs identified, 99.4% reported harms in the manuscript body, and 59.6% reported harms in the abstract. Reporting was restricted to severe harms in 15.6% of RCTs. Statistical comparison of AE rates went unreported in 59.0% of studies. Information regarding AEs leading to dose reductions, treatment discontinuations, or study withdrawals went unreported in 59.3%, 18.7%, and 86.8% of studies, respectively. Recently published RCTs (P = .009) and those sponsored at least partially by for‐profit companies (P = .003) had higher abstract quality scores. Conclusions Breast and colorectal cancer phase III RCTs inadequately report CONSORT‐compliant AE data. Improved guideline adherence and abstract reporting is required to properly weigh benefits and harms of new oncologic therapies. Systematic Review Registration Number CRD42019140673.
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Affiliation(s)
- Adam S Komorowski
- Division of Medical Microbiology, McMaster University, Hamilton, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Helen J MacKay
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rossanna C Pezo
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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MacKay HJ, Freixinos VR, Fleming GF. Therapeutic Targets and Opportunities in Endometrial Cancer: Update on Endocrine Therapy and Nonimmunotherapy Targeted Options. Am Soc Clin Oncol Educ Book 2020; 40:1-11. [PMID: 32239967 DOI: 10.1200/edbk_280495] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Worldwide, the incidence of endometrial cancer is increasing. Although the prognosis remains good for patients diagnosed with early-stage disease, for those diagnosed with recurrent or metastatic disease, options have been limited, and prognosis is short. Optimizing and identifying new well-tolerated treatments for women living with endometrial cancer is a top priority. A new era is dawning where we are starting to see the integration of clinically relevant genomic and pathologic data to inform and refine treatment strategies for women with endometrial cancer. Here, we focus on reviewing nonimmunotherapy-based targeted treatment options and emerging directions for women with endometrial cancer.
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Affiliation(s)
- Helen J MacKay
- Division of Medical Oncology & Hematology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | | | - Gini F Fleming
- Section of Hematology-Oncology, Department of Medicine, The University of Chicago, Chicago, IL
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Komorowski AS, Warner E, MacKay HJ, Sahgal A, Pritchard KI, Jerzak KJ. Incidence of Brain Metastases in Nonmetastatic and Metastatic Breast Cancer: Is There a Role for Screening? Clin Breast Cancer 2019; 20:e54-e64. [PMID: 31447286 DOI: 10.1016/j.clbc.2019.06.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 12/16/2018] [Revised: 03/24/2019] [Accepted: 06/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines recommend against screening breast cancer patients for asymptomatic brain metastases. Because brain metastases are a major cause of morbidity and mortality from breast cancer, we undertook a literature review to ascertain whether there might be a role for brain metastases screening in high-risk patient subgroups. MATERIALS AND METHODS A literature search was conducted on the OvidSP platform in the MedLine database, using MeSH terms and subject headings related to breast cancer, brain metastases, and incidence. The search was conducted without language or publication restrictions, and included articles indexed from January 1, 2006 to June 10, 2018. Experimental and observational studies that reported the incidence of brain metastases in patients with nonmetastatic or metastatic breast cancer were included. RESULTS One hundred seventy studies were identified, with 33 included in the final analysis. Among nonmetastatic breast cancer patients, incidence of brain metastases as site of first recurrence per year of median follow-up ranged from 0.1% to 3.2%. Although incidence of brain metastases was much higher among the metastatic breast cancer population overall, it was particularly high among metastatic HER2-overexpressing (HER2+) and triple-negative populations, ranging between 22% and 36% for the former, and 15%-37% for the latter in the absence of screening. CONCLUSION In patients with nonmetastatic breast cancer, screening for asymptomatic brain metastases cannot currently be justified. However, due to the high incidence of brain metastases among patients with metastatic HER2+ and triple-negative breast cancer, studies to determine the value of screening for brain metastases should be undertaken in these subgroups.
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Affiliation(s)
- Adam S Komorowski
- Division of Medical Microbiology, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Warner
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Helen J MacKay
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen I Pritchard
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Katarzyna J Jerzak
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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7
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Provencher DM, Gallagher CJ, Parulekar WR, Ledermann JA, Armstrong DK, Brundage M, Gourley C, Romero I, Gonzalez-Martin A, Feeney M, Bessette P, Hall M, Weberpals JI, Hall G, Lau SK, Gauthier P, Fung-Kee-Fung M, Eisenhauer EA, Winch C, Tu D, MacKay HJ. OV21/PETROC: a randomized Gynecologic Cancer Intergroup phase II study of intraperitoneal versus intravenous chemotherapy following neoadjuvant chemotherapy and optimal debulking surgery in epithelial ovarian cancer. Ann Oncol 2018; 29:431-438. [PMID: 29186319 PMCID: PMC6658709 DOI: 10.1093/annonc/mdx754] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background The purpose of this multistage, adaptively, designed randomized phase II study was to evaluate the role of intraperitoneal (i.p.) chemotherapy following neoadjuvant chemotherapy (NACT) and optimal debulking surgery in women with epithelial ovarian cancer (EOC). Patients and methods We carried out a multicenter, two-stage, phase II trial. Eligible patients with stage IIB-IVA EOC treated with platinum-based intravenous (i.v.) NACT followed by optimal (<1 cm) debulking surgery were randomized to one of the three treatment arms: (i) i.v. carboplatin/paclitaxel, (ii) i.p. cisplatin plus i.v./i.p. paclitaxel, or (iii) i.p. carboplatin plus i.v./i.p. paclitaxel. The primary end point was 9-month progressive disease rate (PD9). Secondary end points included progression-free survival (PFS), overall survival (OS), toxicity, and quality of life (QOL). Results Between 2009 and 2015, 275 patients were randomized; i.p. cisplatin containing arm did not progress beyond the first stage of the study after failing to meet the pre-set superiority rule. The final analysis compared i.v. carboplatin/paclitaxel (n = 101) with i.p. carboplatin, i.v./i.p. paclitaxel (n = 102). The intention to treat PD9 was lower in the i.p. carboplatin arm compared with the i.v. carboplatin arm: 24.5% (95% CI 16.2% to 32.9%) versus 38.6% (95% CI 29.1% to 48.1%) P = 0.065. The study was underpowered to detect differences in PFS: HR PFS 0.82 (95% CI 0.57-1.17); P = 0.27 and OS HR 0.80 (95% CI 0.47-1.35) P = 0.40. The i.p. carboplatin-based regimen was well tolerated with no reduction in QOL or increase in toxicity compared with i.v. administration alone. Conclusion In women with stage IIIC or IVA EOC treated with NACT and optimal debulking surgery, i.p. carboplatin-based chemotherapy is well tolerated and associated with an improved PD9 compared with i.v. carboplatin-based chemotherapy. Clinical trial number clinicaltrials.gov, NCT01622543.
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Affiliation(s)
- D M Provencher
- Institut du Cancer de Montréal, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | | | - W R Parulekar
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - J A Ledermann
- University College London Cancer Institute, London, UK
| | - D K Armstrong
- Johns Hopkins University School of Medicine, Baltimore, USA
| | - M Brundage
- Cancer Centre of Southeastern Ontario, Kingston, Canada
| | - C Gourley
- Edinburgh Cancer Research UK Centre, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - I Romero
- Secretaria del Área Clínica de Oncología Ginecológica, Instituto Valenciano de Oncología, València
| | | | - M Feeney
- University College London Cancer Institute, London, UK
| | - P Bessette
- Gynecologic Oncology Division, Centre Hospitalier de l'Université de Montréal, Sherbrooke, Canada
| | - M Hall
- Department of Obstetrics and Gynaecology, Mount Vernon Cancer Centre, Northwood, UK
| | - J I Weberpals
- Division of Gynaecologic Oncology, The Ottawa Hospital, Ottawa, Canada
| | - G Hall
- Leeds Institute of Cancer and Pathology, St James's University Hospital, Leeds, UK
| | - S K Lau
- Division of Gynecologic Oncology, Segal Cancer Center, SMBD Jewish General Hospital, McGill University, Montréal, Canada
| | - P Gauthier
- Gynecologic Oncology Division, Centre Hospitalier de l'Université de Montréal, Sherbrooke, Canada
| | - M Fung-Kee-Fung
- Division of Gynaecologic Oncology, The Ottawa Hospital, Ottawa, Canada
| | - E A Eisenhauer
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - C Winch
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - D Tu
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - H J MacKay
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.
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8
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Provencher DM, Gallagher CJ, Parulekar WR, Ledermann JA, Armstrong DK, Brundage M, Gourley C, Romero I, Gonzalez-Martin A, Feeney M, Bessette P, Hall M, Weberpals JI, Hall G, Lau SK, Gauthier P, Fung-Kee-Fung M, Eisenhauer EA, Winch C, Tu D, MacKay HJ. OV21/PETROC: a randomized Gynecologic Cancer Intergroup phase II study of intraperitoneal versus intravenous chemotherapy following neoadjuvant chemotherapy and optimal debulking surgery in epithelial ovarian cancer. Ann Oncol 2018. [PMID: 29186319 DOI: 10.1093/annonc/mdx754] [] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background The purpose of this multistage, adaptively, designed randomized phase II study was to evaluate the role of intraperitoneal (i.p.) chemotherapy following neoadjuvant chemotherapy (NACT) and optimal debulking surgery in women with epithelial ovarian cancer (EOC). Patients and methods We carried out a multicenter, two-stage, phase II trial. Eligible patients with stage IIB-IVA EOC treated with platinum-based intravenous (i.v.) NACT followed by optimal (<1 cm) debulking surgery were randomized to one of the three treatment arms: (i) i.v. carboplatin/paclitaxel, (ii) i.p. cisplatin plus i.v./i.p. paclitaxel, or (iii) i.p. carboplatin plus i.v./i.p. paclitaxel. The primary end point was 9-month progressive disease rate (PD9). Secondary end points included progression-free survival (PFS), overall survival (OS), toxicity, and quality of life (QOL). Results Between 2009 and 2015, 275 patients were randomized; i.p. cisplatin containing arm did not progress beyond the first stage of the study after failing to meet the pre-set superiority rule. The final analysis compared i.v. carboplatin/paclitaxel (n = 101) with i.p. carboplatin, i.v./i.p. paclitaxel (n = 102). The intention to treat PD9 was lower in the i.p. carboplatin arm compared with the i.v. carboplatin arm: 24.5% (95% CI 16.2% to 32.9%) versus 38.6% (95% CI 29.1% to 48.1%) P = 0.065. The study was underpowered to detect differences in PFS: HR PFS 0.82 (95% CI 0.57-1.17); P = 0.27 and OS HR 0.80 (95% CI 0.47-1.35) P = 0.40. The i.p. carboplatin-based regimen was well tolerated with no reduction in QOL or increase in toxicity compared with i.v. administration alone. Conclusion In women with stage IIIC or IVA EOC treated with NACT and optimal debulking surgery, i.p. carboplatin-based chemotherapy is well tolerated and associated with an improved PD9 compared with i.v. carboplatin-based chemotherapy. Clinical trial number clinicaltrials.gov, NCT01622543.
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Affiliation(s)
- D M Provencher
- Institut du Cancer de Montréal, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | | | - W R Parulekar
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - J A Ledermann
- University College London Cancer Institute, London, UK
| | - D K Armstrong
- Johns Hopkins University School of Medicine, Baltimore, USA
| | - M Brundage
- Cancer Centre of Southeastern Ontario, Kingston, Canada
| | - C Gourley
- Edinburgh Cancer Research UK Centre, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - I Romero
- Secretaria del Área Clínica de Oncología Ginecológica, Instituto Valenciano de Oncología, València
| | | | - M Feeney
- University College London Cancer Institute, London, UK
| | - P Bessette
- Gynecologic Oncology Division, Centre Hospitalier de l'Université de Montréal, Sherbrooke, Canada
| | - M Hall
- Department of Obstetrics and Gynaecology, Mount Vernon Cancer Centre, Northwood, UK
| | - J I Weberpals
- Division of Gynaecologic Oncology, The Ottawa Hospital, Ottawa, Canada
| | - G Hall
- Leeds Institute of Cancer and Pathology, St James's University Hospital, Leeds, UK
| | - S K Lau
- Division of Gynecologic Oncology, Segal Cancer Center, SMBD Jewish General Hospital, McGill University, Montréal, Canada
| | - P Gauthier
- Gynecologic Oncology Division, Centre Hospitalier de l'Université de Montréal, Sherbrooke, Canada
| | - M Fung-Kee-Fung
- Division of Gynaecologic Oncology, The Ottawa Hospital, Ottawa, Canada
| | - E A Eisenhauer
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - C Winch
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - D Tu
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, Canada
| | - H J MacKay
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.
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MacKay HJ, Levine DA, Bae-Jump VL, Bell DW, McAlpine JN, Santin A, Fleming GF, Mutch DG, Nephew KP, Wentzensen N, Goodfellow PJ, Dorigo O, Nijman HW, Broaddus R, Kohn EC. Moving forward with actionable therapeutic targets and opportunities in endometrial cancer: NCI clinical trials planning meeting report on identifying key genes and molecular pathways for targeted endometrial cancer trials. Oncotarget 2017; 8:84579-84594. [PMID: 29137450 PMCID: PMC5663622 DOI: 10.18632/oncotarget.19961] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022] Open
Abstract
The incidence and mortality rates from endometrial cancer are increasing. There have been no new drugs approved for the treatment of endometrial cancer in decades. The National Cancer Institute, Gynecologic Cancer Steering Committee identified the integration of molecular and/or histologic stratification into endometrial cancer management as a top strategic priority. Based on this, they convened a group of experts to review the molecular data in this disease. Here we report on the actionable opportunities and therapeutic directions identified for incorporation into future clinical trials.
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Affiliation(s)
- Helen J. MacKay
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Douglas A. Levine
- Division of Gynecologic Cancer, Department of OB/GYN, NYU Langone Laura and Isaac Perlmutter Cancer Center, New York, NY, United States
| | - Victoria L. Bae-Jump
- Division of Gynecologic Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, CA, United States
| | - Daphne W. Bell
- Reproductive Cancer Genetics Section, Cancer Genetics and Comparative Genomics Branch, National Human Genome Research Institute/NIH, MSC 8000, Bethesda, ML, United States
| | - Jessica N. McAlpine
- University of British Columbia & BC Cancer Agency, Division of Gynecologic Oncology, Vancouver, British Columbia, Canada
| | - Alessandro Santin
- Department of Gynecology, Obstetrics and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Gini F. Fleming
- Section of Hematology-Oncology, Department of Medicine, The University of Chicago, Chicago, IL, United States
| | - David G. Mutch
- Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Kenneth P. Nephew
- Medical Sciences Program, Indiana University School of Medicine, Bloomington, IN, United States
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, ML, United States
| | - Paul J. Goodfellow
- James Comprehensive Cancer Center and The Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH, United States
| | - Oliver Dorigo
- Division Gynecologic Oncology, Department of Obstetrics and Gynecology, Stanford, CA, United States
| | - Hans W. Nijman
- Department of Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Russell Broaddus
- Department of Pathology, Unit 85, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Elise C. Kohn
- Clinical Investigations Branch of The Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, ML, United States
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10
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Affiliation(s)
| | - Helen J. MacKay
- Odette Cancer Centre, Sunnybrook Health Sciences, Toronto, Ontario, Canada
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11
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Van Gool IC, Stelloo E, Nout RA, Nijman HW, Edmondson RJ, Church DN, MacKay HJ, Leary A, Powell ME, Mileshkin L, Creutzberg CL, Smit VTHBM, Bosse T. Prognostic significance of L1CAM expression and its association with mutant p53 expression in high-risk endometrial cancer. Mod Pathol 2016; 29:174-81. [PMID: 26743472 DOI: 10.1038/modpathol.2015.147] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/12/2015] [Indexed: 02/07/2023]
Abstract
Studies in early-stage, predominantly low- and intermediate-risk endometrial cancer have demonstrated that L1 cell adhesion molecule (L1CAM) overexpression identifies patients at increased risk of recurrence, yet its prognostic significance in high-risk endometrial cancer is unclear. To evaluate this, its frequency, and the relationship of L1CAM with the established endometrial cancer biomarker p53, we analyzed the expression of both markers by immunohistochemistry in a pilot series of 116 endometrial cancers (86 endometrioid, 30 non-endometrioid subtype) with high-risk features (such as high tumor grade and deep myometrial invasion) and correlated results with clinical outcome. We used The Cancer Genome Atlas (TCGA) endometrial cancer series to validate our findings. Using the previously reported cutoff of 10% positive staining, 51/116 (44%) tumors were classified as L1CAM-positive, with no significant association between L1CAM positivity and the rate of distant metastasis (P=0.195). However, increasing the threshold for L1CAM positivity to 50% resulted in a reduction of the frequency of L1CAM-positive tumors to 24% (28/116), and a significant association with the rate of distant metastasis (P=0.018). L1CAM expression was strongly associated with mutant p53 in the high-risk and TCGA series (P<0.001), although a substantial fraction (36% of endometrioid, 10% of non-endometrioid morphology) of p53-mutant endometrial cancers displayed <10% L1CAM positivity. Moreover, 30% of p53-wild-type non-endometrioid endometrial cancers demonstrated diffuse L1CAM staining, suggesting p53-independent mechanisms of L1CAM overexpression. In conclusion, the previously proposed threshold for L1CAM positivity of >10% does not predict prognosis in high-risk endometrial cancer, whereas an alternative threshold (>50%) does. L1CAM expression is strongly, but not universally, associated with mutant p53, and may be strong enough for clinical implementation as prognostic marker in combination with p53. The high frequency of L1CAM expression in high-risk endometrial cancers suggests that it may also be a promising therapeutic target in this tumor subset.
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Affiliation(s)
- Inge C Van Gool
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen Stelloo
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans W Nijman
- Department of Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard J Edmondson
- Institute of Cancer Sciences, University of Manchester, St Marys Hospital, Manchester, UK
| | - David N Church
- Molecular and Population Genetics Laboratory, The Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.,Oxford Cancer Centre, Churchill Hospital, Oxford, UK
| | - Helen J MacKay
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Leary
- Department of Medicine, Gynecology Unit, Gustave Roussy, Villejuif, France
| | - Melanie E Powell
- Department of Clinical Oncology, Barts Health NHS Trust, London, UK
| | - Linda Mileshkin
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
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Stelloo E, Bosse T, Nout RA, MacKay HJ, Church DN, Nijman HW, Leary A, Edmondson RJ, Powell ME, Crosbie EJ, Kitchener HC, Mileshkin L, Pollock PM, Smit VT, Creutzberg CL. Refining prognosis and identifying targetable pathways for high-risk endometrial cancer; a TransPORTEC initiative. Mod Pathol 2015; 28:836-44. [PMID: 25720322 DOI: 10.1038/modpathol.2015.43] [Citation(s) in RCA: 301] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 01/10/2023]
Abstract
This study aimed to investigate whether molecular analysis can be used to refine risk assessment, direct adjuvant therapy, and identify actionable alterations in high-risk endometrial cancer. TransPORTEC, an international consortium related to the PORTEC3 trial, was established for translational research in high-risk endometrial cancer. In this explorative study, routine molecular analyses were used to detect prognostic subgroups: p53 immunohistochemistry, microsatellite instability and POLE proofreading mutation. Furthermore, DNA was analyzed for hotspot mutations in 13 additional genes (BRAF, CDKNA2, CTNNB1, FBXW7, FGFR2, FGFR3, FOXL2, HRAS, KRAS, NRAS, PIK3CA, PPP2R1A, and PTEN) and protein expression of ER, PR, PTEN, and ARID1a was analyzed. Rates of distant metastasis, recurrence-free, and overall survival were calculated using the Kaplan-Meier method and log-rank test. In total, samples of 116 high-risk endometrial cancer patients were included: 86 endometrioid; 12 serous; and 18 clear cell. For endometrioid, serous, and clear cell cancers, 5-year recurrence-free survival rates were 68%, 27%, and 50% (P=0.014) and distant metastasis rates 23%, 64%, and 50% (P=0.001), respectively. Four prognostic subgroups were identified: (1) a group of p53-mutant tumors; (2) microsatellite instable tumors; (3) POLE proofreading-mutant tumors; and (4) a group with no specific molecular profile (NSMP). In group 3 (POLE-mutant; n=14) and group 2 (microsatellite instable; n=19) patients, no distant metastasis occurred, compared with 50% distant metastasis rate in group 1 (p53-mutant; n=36) and 39% in group 4 (NSMP; P<0.001). Five-year recurrence-free survival was 93% and 95% for group 3 (POLE-mutant) and group 2 (microsatellite instable) vs 42% (group 1, p53-mutant) and 52% (group 4, NSMP; P<0.001). Targetable FBXW7 and FGFR2 mutations (6%), alterations in the PI3K-AKT pathway (60%) and hormone receptor positivity (45%) were frequently found. In conclusion, molecular analysis of high-risk endometrial cancer identifies four distinct prognostic subgroups, with potential therapeutic implications. High frequencies of targetable alterations were identified and may serve as targets for individualized treatment.
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Affiliation(s)
- Ellen Stelloo
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Remi A Nout
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Helen J MacKay
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
| | - David N Church
- Molecular and Population Genetics Laboratory, The Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Hans W Nijman
- Department of Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alexandra Leary
- Department of Medicine, Gynecology Unit, Gustave Roussy, Villejuif, France
| | - Richard J Edmondson
- Institute of Cancer Sciences, University of Manchester, St Marys Hospital, Manchester, UK
| | - Melanie E Powell
- Department of Clinical Oncology, Barts Health NHS Trust, London, UK
| | - Emma J Crosbie
- Institute of Cancer Sciences, University of Manchester, St Marys Hospital, Manchester, UK
| | - Henry C Kitchener
- Institute of Cancer Sciences, University of Manchester, St Marys Hospital, Manchester, UK
| | - Linda Mileshkin
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Pamela M Pollock
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Vincent T Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carien L Creutzberg
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Ferguson SE, Aronson M, Pollett A, Eiriksson LR, Oza AM, Gallinger S, Lerner-Ellis J, Alvandi Z, Bernardini MQ, MacKay HJ, Mojtahedi G, Tone AA, Massey C, Clarke BA. Performance characteristics of screening strategies for Lynch syndrome in unselected women with newly diagnosed endometrial cancer who have undergone universal germline mutation testing. Cancer 2014; 120:3932-9. [PMID: 25081409 DOI: 10.1002/cncr.28933] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [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: 04/25/2014] [Accepted: 06/20/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immunohistochemistry (IHC) for mismatch repair protein expression, microsatellite instability (MSI) testing, tumor morphology, and family history were compared to determine which screening strategy is superior in identifying Lynch syndrome (LS) in unselected women with newly diagnosed endometrial cancer (EC) who have undergone universal germline mutation testing. METHODS A prospective cohort study was performed that recruited women with newly diagnosed EC. Participants completed a family history assessment with molecular characterization of EC with IHC and MSI testing and EC assessment for LS-associated morphologic features and underwent universal germline mutation testing for mutations in the mismatch repair pathway. The sensitivity, specificity, and positive and negative predictive values were compared between the screening strategies. RESULTS A total of 118 (65%) of 182 consecutive women with EC participated. Of these, 34 women (29%) had tumors that were IHC deficient and 27 women (23%; N = 117) had tumors that were positive for MSI. Twenty women (17%) met IHC criteria and 16 women (15.2%, N = 105) met family history criteria based on Ontario Ministry of Health Criteria for the genetic assessment for LS. Seven women (5.9%) had a germline mutation: 4 had MLH1 (mutL homolog 1), 2 had MSH6 (mutS homolog 6), and 1 had MSH2 (mutS homolog 2). IHC in women aged <60 years had the best performance characteristics, with a sensitivity of 100%, a specificity of 86.1%, a positive predictive value of 58.3%, and a negative predictive value of 100%. Family history and tumor morphology both had the lowest sensitivity at 71.4%. Overall tumor morphology had the poorest performance, with a specificity of 42.1%. CONCLUSIONS The mutation rate of 5.9% was higher than expected in this unselected cohort of women with EC. The superior screening strategy to identify women presenting with EC is universal IHC screening in women aged <60 years.
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Affiliation(s)
- Sarah E Ferguson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada
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