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Öztekin S, Hooning MJ, van Deurzen CHM, Dietvorst AMHP, Drooger JC, Kitzen JJEM, Martens JWM, van der Padt-Pruijsten A, Vastbinder MB, Zuetenhorst H, Heemskerk-Gerritsen BAM, Jager A. The effect of (neo)adjuvant chemotherapy on long-term survival outcomes in patients with invasive lobular breast cancer treated with endocrine therapy: A retrospective cohort study. Cancer 2024; 130:927-935. [PMID: 37985357 DOI: 10.1002/cncr.35125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite histological and molecular differences between invasive lobular carcinoma (ILC) and invasive carcinoma of no special type, according to national treatment guidelines no distinction is made regarding the use of (neo)adjuvant chemotherapy. Studies on the long-term outcome of chemotherapy in patients with ILC are scarce and show inconclusive results. METHODS All patients with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative ILC with an indication for chemotherapy treated with adjuvant endocrine therapy were selected from the Erasmus Medical Center Breast Cancer database. Cox proportional hazards models were used to estimate the effect of chemotherapy on recurrence-free survival (RFS), breast cancer-specific survival (BCSS), and overall survival (OS). RESULTS A total of 520 patients were selected, of whom 379 were treated with chemotherapy and 141 were not. Patients in the chemotherapy group were younger (51 vs. 61 years old; p < .001), had a higher T status (T3+, 33% vs. 14%; p < .001), and more often had lymph node involvement (80% vs. 49%; p < .001) in comparison to the no-chemotherapy group. After adjusting for confounders, chemotherapy treatment was not associated with better RFS (hazard ratio [HR], 1.20; 95% confidence interval [CI], 0.63-2.31), BCSS (HR, 1.24; 95% CI, 0.60-2.58), or OS (HR, 0.97; 95% CI, 0.56-1.66). This was also reflected by adjusted Cox survival curves in the chemotherapy versus no-chemotherapy group for RFS (75% vs. 79%), BCSS (80% vs. 84%), and OS (72% vs. 71%). CONCLUSIONS Chemotherapy is not associated with improved RFS, BCSS, or OS for patients with ER+/HER2- ILC treated with adjuvant endocrine therapy and with an indication for chemotherapy.
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Affiliation(s)
- Selin Öztekin
- Department of Medical Oncology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, the Netherlands
| | - Maartje J Hooning
- Department of Medical Oncology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, the Netherlands
| | | | - Anne-Marie H P Dietvorst
- Department of Medical Oncology, Breast Cancer Center South Holland South, Van Weel Bethesda Hospital, Dirksland, the Netherlands
| | - Jan C Drooger
- Department of Medical Oncology, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, the Netherlands
| | - Jos J E M Kitzen
- Department of Medical Oncology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - John W M Martens
- Department of Medical Oncology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, the Netherlands
| | | | - Mijntje B Vastbinder
- Department of Medical Oncology, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Hanneke Zuetenhorst
- Department of Medical Oncology, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | | | - Agnes Jager
- Department of Medical Oncology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, the Netherlands
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2
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Verschoor N, Bos MK, de Kruijff IE, Van MN, Kraan J, Drooger JC, Zuetenhorst JM, Wilting SM, Sleijfer S, Jager A, Martens JWM. Trastuzumab and first-line taxane chemotherapy in metastatic breast cancer patients with a HER2-negative tumor and HER2-positive circulating tumor cells: a phase II trial. Breast Cancer Res Treat 2024:10.1007/s10549-023-07231-4. [PMID: 38291268 DOI: 10.1007/s10549-023-07231-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/11/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE HER2 overexpressing circulating tumor cells (CTCs) are observed in up to 25% of HER2-negative metastatic breast cancer patients. Since targeted anti-HER2 therapy has drastically improved clinical outcomes of patients with HER2-positive breast cancer, we hypothesized that patients with HER2 overexpressing CTCs might benefit from the addition of trastuzumab to chemotherapy. METHODS In this single-arm, phase II trial, patients with HER2-positive CTCs received trastuzumab as addition to first-line treatment with taxane chemotherapy. Patients with detectable CTCs but without HER2 overexpression that received taxane chemotherapy only, were used as control group. The primary outcome measure was progression-free rate at 6 months (PFR6), with a target of 80%. In November 2022, the study was terminated early due to slow patient accrual. RESULTS 63 patients were screened, of which eight patients had HER2-positive CTCs and were treated with trastuzumab. The median number of CTCs was 15 per 7.5 ml of blood (range 1-131) in patients with HER2-positive CTCs, compared to median 5 (range 1-1047) in the control group. PFR6 was 50% in the trastuzumab group and 54% in the taxane monotherapy group, with no significant difference in median PFS (8 versus 9 months, p = 0.51). CONCLUSION No clinical benefit of trastuzumab was observed, although this study was performed in a limited number of patients. Additionally, we observed a strong correlation between the number of evaluable CTCs and the presence of HER2-positive CTCs. We argue that randomized studies investigating agents that are proven to be solely effective in the HER2-positive patient group in patients with HER2-positive CTCs and HER2-negative tissue are currently infeasible. Several factors contribute to this impracticality, including the need for more stringent thresholds, and the rapidly evolving landscape of cancer treatments.
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Affiliation(s)
- Noortje Verschoor
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Manouk K Bos
- Department of Internal Medicine, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | - Ingeborg E de Kruijff
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mai N Van
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jaco Kraan
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jan C Drooger
- Department of Internal Medicine, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | - Johanna M Zuetenhorst
- Department of Medical Oncology, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands
| | - Saskia M Wilting
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - John W M Martens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Verschoor N, de Weerd V, Van MN, Kraan J, Smid M, Heijns JB, Drooger JC, Zuetenhorst JM, van der Padt-Pruijsten A, Jager A, Sleijfer S, Martens JWM, Wilting SM. Tumor-agnostic ctDNA levels by mFAST-SeqS in first-line HR-positive, HER2 negative metastatic breast cancer patients as a biomarker for survival. NPJ Breast Cancer 2023; 9:61. [PMID: 37452019 PMCID: PMC10349058 DOI: 10.1038/s41523-023-00563-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
This prospective cohort study reports aneuploidy score by mFast-SeqS as a strong prognostic marker in MBC patients. mFAST-SeqS is an affordable and easily implementable method for the assessment of total ctDNA levels and, as such, provides an alternative prognostic tool. One mixed cohort (cohort A, n = 45) starting any type of treatment in any line of therapy and one larger cohort (cohort B, n = 129) consisting of patients starting aromatase inhibitors (AI) as first-line therapy were used. mFAST-SeqS was performed using plasma of blood in which CTCs (CellSearch) were enumerated. The resulting aneuploidy score was correlated with categorized CTC count and associated with outcome. The aneuploidy score was significantly correlated with CTC count, but discordance was observed in 31.6% when applying cut-offs of 5. In both cohorts, aneuploidy score was a significant prognostic marker for both PFS and OS. In the Cox regression models, the HR for aneuploidy score for PFS was 2.52 (95% CI: 1.56-4.07), and the HR for OS was 2.37 (95% CI: 1.36-4.14). Results presented here warrant further investigations into the clinical utility of this marker in MBC patients.
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Affiliation(s)
- Noortje Verschoor
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Vanja de Weerd
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mai N Van
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jaco Kraan
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marcel Smid
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joan B Heijns
- Department of Medical Oncology, Amphia, Breda, The Netherlands
| | - Jan C Drooger
- Department of Medical Oncology, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | - Johanna M Zuetenhorst
- Department of Medical Oncology, Franciscus Gasthuis & Vlietland, Rotterdam/ Schiedam, the Netherlands
| | | | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - John W M Martens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Saskia M Wilting
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Buijs SM, Hoop EOD, Braal CL, van Rosmalen MM, Drooger JC, van Rossum-Schornagel QC, Vastbinder MB, Koolen SLW, Jager A, Mathijssen RHJ. The impact of endoxifen-guided tamoxifen dose reductions on endocrine side-effects in patients with primary breast cancer. ESMO Open 2023; 8:100786. [PMID: 36753991 PMCID: PMC10024121 DOI: 10.1016/j.esmoop.2023.100786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Tamoxifen is important in the adjuvant treatment of hormone-sensitive breast cancer and substantially reduces recurrence; however, almost 50% of patients are non-compliant mainly due to side-effects. The aim of this study was to investigate whether endoxifen-guided tamoxifen dose reduction could lead to fewer side-effects. MATERIALS AND METHODS Effects of tamoxifen dose reduction were investigated in patients with bothersome side-effects and endoxifen levels ≥32 nM and compared to patients with side-effects who remained on tamoxifen 20 mg. Endocrine symptoms and health-related quality of life (HR-QOL) were assessed after 3 months with the Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) questionnaire. RESULTS Tamoxifen dose was reduced in 20 patients, 17 of whom were assessable for side-effect analyses. A clinically relevant improvement of >6 points was observed in endocrine symptoms and HR-QOL in 41% and 65% of the patients, respectively. In total, there was a significant and clinically relevant improvement in endocrine symptoms [5.7, 95% confidence interval (CI) -0.5-11.5] and HR-QOL (8.2, 95% CI 0.9-15.4) after dose reduction. This was not seen in patients whose doses were not reduced (n = 60). In 21% of patients, endoxifen dropped slightly below the 16-nM threshold (12.8, 15.5, 15.8, 15.9 nM). CONCLUSIONS Endoxifen-guided dose reduction of tamoxifen significantly improved tamoxifen-related side-effects and HR-QOL. Nearly 80% of patients remained above the most conservative endoxifen threshold.
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Affiliation(s)
- S M Buijs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - E Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - C L Braal
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M M van Rosmalen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - J C Drooger
- Department of Medical Oncology, Breast Cancer Center South Holland South, Ikazia Hospital, Rotterdam, The Netherlands
| | | | - M B Vastbinder
- Department of Internal Medicine, IJsselland Hospital, Capelle aan den Ijssel, Rotterdam, The Netherlands
| | - S L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Owusuaa C, van der Padt-Pruijsten A, Drooger JC, Heijns JB, Dietvorst AM, Janssens-van Vliet ECJ, Nieboer D, Aerts JGJV, van der Heide A, van der Rijt CCD. Development of a Clinical Prediction Model for 1-Year Mortality in Patients With Advanced Cancer. JAMA Netw Open 2022; 5:e2244350. [PMID: 36449290 PMCID: PMC9713606 DOI: 10.1001/jamanetworkopen.2022.44350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE To optimize palliative care in patients with cancer who are in their last year of life, timely and accurate prognostication is needed. However, available instruments for prognostication, such as the surprise question ("Would I be surprised if this patient died in the next year?") and various prediction models using clinical variables, are not well validated or lack discriminative ability. OBJECTIVE To develop and validate a prediction model to calculate the 1-year risk of death among patients with advanced cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter prospective prognostic study was performed in the general oncology inpatient and outpatient clinics of 6 hospitals in the Netherlands. A total of 867 patients were enrolled between June 2 and November 22, 2017, and followed up for 1 year. The primary analyses were performed from October 9 to 25, 2019, with the most recent analyses performed from June 19 to 22, 2022. Cox proportional hazards regression analysis was used to develop a prediction model including 3 categories of candidate predictors: clinician responses to the surprise question, patient clinical characteristics, and patient laboratory values. Data on race and ethnicity were not collected because most patients were expected to be of White race and Dutch ethnicity, and race and ethnicity were not considered as prognostic factors. The models' discriminative ability was assessed using internal-external validation by study hospital and measured using the C statistic. Patients 18 years and older with locally advanced or metastatic cancer were eligible. Patients with hematologic cancer were excluded. MAIN OUTCOMES AND MEASURES The risk of death by 1 year. RESULTS Among 867 patients, the median age was 66 years (IQR, 56-72 years), and 411 individuals (47.4%) were male. The 1-year mortality rate was 41.6% (361 patients). Three prediction models with increasing complexity were developed: (1) a simple model including the surprise question, (2) a clinical model including the surprise question and clinical characteristics (age, cancer type prognosis, visceral metastases, brain metastases, Eastern Cooperative Oncology Group performance status, weight loss, pain, and dyspnea), and (3) an extended model including the surprise question, clinical characteristics, and laboratory values (hemoglobin, C-reactive protein, and serum albumin). The pooled C statistic was 0.69 (95% CI, 0.67-0.71) for the simple model, 0.76 (95% CI, 0.73-0.78) for the clinical model, and 0.78 (95% CI, 0.76-0.80) for the extended model. A nomogram and web-based calculator were developed to support clinicians in adequately caring for patients with advanced cancer. CONCLUSIONS AND RELEVANCE In this study, a prediction model including the surprise question, clinical characteristics, and laboratory values had better discriminative ability in predicting death among patients with advanced cancer than models including the surprise question, clinical characteristics, or laboratory values alone. The nomogram and web-based calculator developed for this study can be used by clinicians to identify patients who may benefit from palliative care and advance care planning. Further exploration of the feasibility and external validity of the model is needed.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Jan C. Drooger
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, the Netherlands
| | - Joan B. Heijns
- Department of Internal Medicine, Amphia, Breda, the Netherlands
| | - Anne-Marie Dietvorst
- Department of Internal Medicine, Van Weel Bethesda Hospital, Dirksland, the Netherlands
| | | | - Daan Nieboer
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joachim G. J. V. Aerts
- Department of Pulmonary Diseases, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
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Bouwer NI, Steenbruggen TG, Rier HN, Kitzen JJEM, Smorenburg CH, van Bekkum ML, de Jong PC, Drooger JC, Holterhues C, Kofflard MJM, Boersma E, Sonke GS, Levin M, Jager A. The effect of trastuzumab on cardiac function in patients with
HER2
‐positive metastatic breast cancer and reduced baseline left ventricular ejection fraction. Int J Cancer 2022; 151:616-622. [PMID: 35403708 PMCID: PMC9320802 DOI: 10.1002/ijc.34024] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/20/2022] [Accepted: 03/04/2022] [Indexed: 11/11/2022]
Abstract
We investigated the effect of trastuzumab on cardiac function in a real‐world historic cohort of patients with HER2‐positive metastatic breast cancer (MBC) with reduced baseline left ventricular ejection fraction (LVEF). Thirty‐seven patients with HER2‐positive MBC and baseline LVEF of 40% to 49% were included. Median LVEF was 46% (interquartile range [IQR] 44%‐48%) and median follow‐up was 18 months (IQR 9‐34 months). During this period, the LVEF did not worsen in 24/37 (65%) patients, while 13/37 (35%) patients developed severe cardiotoxicity defined as LVEF <40% with median time to severe cardiotoxicity of 7 months (IQR 4‐10 months) after beginning trastuzumab. Severe cardiotoxicity was reversible (defined as LVEF increase to a value <5%‐points below baseline value) in 7/13 (54%) patients, partly reversible (defined as absolute LVEF increase ≥10%‐points from nadir to a value >5%‐points below baseline) in 3/13 (23%) patients and irreversible (defined as absolute LVEF increase <10%‐points from nadir and to a value >5%‐points below baseline) in 3/13 (23%) patients. Likelihood of reversibility was numerically higher in patients who received cardio‐protective medications (CPM), including ACE‐inhibitors, beta‐blockers and angiotensine‐2 inhibitors, compared to those who did not receive any CPM (71% vs 13%, P = .091). Sixty‐five percent of patients who received trastuzumab for HER2‐positive MBC did not develop severe cardiotoxicity during a median follow‐up of 18 months, despite having a compromised baseline LVEF. If severe cardiotoxicity occurred, it was at least partly reversible in more than two‐thirds of the cases. Risks and benefits of trastuzumab use should be balanced carefully in this vulnerable population.
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Affiliation(s)
- Nathalie I Bouwer
- Department of Internal Medicine Albert Schweitzer Hospital Dordrecht
- Department of Cardiology Albert Schweitzer Hospital Dordrecht
| | | | - Hánah N Rier
- Department of Medical Oncology, Erasmus MC Cancer Institute Rotterdam
| | - Jos JEM Kitzen
- Department of Internal Medicine Albert Schweitzer Hospital Dordrecht
| | | | | | - Paul C de Jong
- Department of Medical Oncology Sint Antonius Hospital Utrecht
| | - Jan C Drooger
- Department of Medical Oncology, Breast Cancer Center South Holland South Ikazia Hospital Rotterdam
| | | | | | - Eric Boersma
- Department of Cardiology, Erasmus MC University Medical Centre Rotterdam Rotterdam
| | - Gabe S Sonke
- Department of Medical Oncology the Netherlands Cancer Institute Amsterdam
| | - Mark‐David Levin
- Department of Internal Medicine Albert Schweitzer Hospital Dordrecht
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute Rotterdam
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7
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Bouwer NI, Steenbruggen TG, Rier HN, Kitzen JJEM, Smorenburg CH, Van Bekkum ML, Tije AJT, De Jong PC, Drooger JC, Holterhues C, Kofflard MJM, Boersma E, Sonke GS, Levin MD, Jager A. Abstract PS13-21: Cardiac function in patients receiving trastuzumab for HER2+ metastatic breast cancer with left ventricular ejection fraction<50% at baseline. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps13-21] [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
Research objectives and rationale Trastuzumab greatly enhances the efficacy of treatment in HER2+ metastatic breast cancer (MBC). Due to its potential to induce cardiomyopathy, however, trastuzumab is contraindicated in patients with baseline left ventricular ejection fraction (LVEF) <50%, although this criterion is sometimes waived. We investigated the effect of trastuzumab on the cardiac function in a real-world cohort of patients with HER2+ MBC with a reduced baseline LVEF, i.e. baseline LVEF <50%. Methods We collected data on patients with HER2+ MBC who received at least one cycle of trastuzumab-based treatment between 2000 and 2014 in eight Dutch hospitals. Eligible patients had baseline LVEF 40-50%. Data were retrospectively collected from medical files using case record forms. Primary endpoint was severe cardiotoxicity defined as LVEF <40%. We also investigated whether severe cardiotoxicity was reversible. Reversibility was defined as any LVEF increase to a value <5% below baseline value and irreversibility as any absolute LVEF increase <10% from lowest value to >5% below baseline. Exploratory, we compared the incidence of severe cardiotoxicity in patients with and without cardioprotective medication at start trastuzumab. Results Of the 758 patients identified with HER2+ MBC, 41 patients were included with a LVEF <50% at start of trastuzumab treatment. The median LVEF at start was 46% with an interquartile range (IQR) of 42-48%. The median duration of trastuzumab treatment was 14 months (IQR 8-32 months). During this period, 16 patients (39%) developed severe cardiotoxicity. The median time to severe cardiotoxicity was 7 months (IQR 4-10 months). Severe cardiotoxicity was reversible in 6 patients (43%), partly reversible in 4 patients (29%) and irreversible in 4 patients (29%). Two patients were lost-to-follow-up. Of the 6 patients with reversible severe cardiotoxicity, trastuzumab treatment was continued in 2 patients (33%), interrupted <6 months in 1 patient (17%) and discontinued in 3 patients (50%). Of the 4 patients with irreversible severe cardiotoxicity, trastuzumab treatment was interrupted in 1 patient (25%) and discontinued in the other 3 patients (75%). In total, 12 patients (29%) received cardioprotective medications, i.e. beta-blocker (n=4), ACE inhibitor (n=4) or both (n=4), at start of trastuzumab treatment. In patients who received cardioprotective medications at start trastuzumab severe cardiotoxicity was less often observed compared to patients who did not received cardioprotective medications at start of trastuzumab (17% vs 48%, p=0.059, Table). Conclusion In our cohort of patients with HER2+ MBC, trastuzumab could be safely administered in 61% without developing severe cardiotoxicity despite an impaired LVEF at the start of trastuzumab treatment. Severe cardiotoxicity was (partly) reversible in about two thirds of the cases. Risks and benefits of trastuzumab use in this vulnerable population must be balanced carefully. The use of cardioprotective medications at start of trastuzumab treatment might reduce the risk of developing severe cardiotoxicity.
Clinical characteristics of patients with and without cardioprotective medication from start trastuzAll patients (n=41)Patients with cardioprotective medication from start trastuzumab (n=12)Patients without cardioprotective medication fromStart trastuzumab (n=29)P-valueSevere cardiotoxicitya, n (%)16 (39)2 (17)14 (48)0.059Time to cardiotoxicity, months [IQR]7 [3 - 12]6 [not reached - 8]8 [4 - 11]0.515Reversibilityb, n (%)No4 (29)1 (8)3 (10)0.260Partial4 (29)0 (0)4 (14)Yes6 (43)0 (0)6 (21)Trastuzumab treatment , n (%)Continued27 (66)7 (58)20 (69)0.796Interrupted6 (15)2 (17)4 (14)Discontinued8 (20)3 (25)5 (17)LVEF, median % (IQR)Baseline46 [42 - 48]47 [44 - 49]46 [43 - 48]0.177Nadir42 [33 - 45]43 [40 - 47]40 [32 - 45]0.322Highest53 [50 - 57]52 [50 - 57]53 [49 - 58]0.761Difference nadir and highest13 [9 - 20]11 [7 - 19]13 [10 - 21]0.464Cardiac symptoms, n (%)16 (39)4 (33)12 (41)0.515
Citation Format: Nathalie I Bouwer, Tessa G Steenbruggen, Hanah N Rier, Jos JEM Kitzen, Carolien H Smorenburg, Marlies L Van Bekkum, Albert J Ten Tije, Paul C De Jong, Jan C Drooger, Cynthia Holterhues, Marcel JM Kofflard, Eric Boersma, Gabe S Sonke, Mark-David Levin, Agnes Jager. Cardiac function in patients receiving trastuzumab for HER2+ metastatic breast cancer with left ventricular ejection fraction<50% at baseline [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-21.
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Affiliation(s)
| | | | - Hanah N Rier
- 1Albert Schweitzer Hospital, Dordrecht, Netherlands
| | | | | | | | | | | | | | | | | | | | - Gabe S Sonke
- 2Netherlands Cancer Institute, Amsterdam, Netherlands
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8
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Steenbruggen TG, Bouwer NI, Smorenburg CH, Rier HN, Jager A, Beelen K, Ten Tije AJ, de Jong PC, Drooger JC, Holterhues C, Kitzen JJEM, Levin MD, Sonke GS. Radiological complete remission in HER2-positive metastatic breast cancer patients: what to do with trastuzumab? Breast Cancer Res Treat 2019; 178:597-605. [PMID: 31493033 DOI: 10.1007/s10549-019-05427-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients with HER2-positive metastatic breast cancer (MBC) treated with trastuzumab may experience durable tumor response for many years. It is unknown if patients with durable radiological complete remission (rCR) can discontinue trastuzumab. We analyzed clinical characteristics associated with rCR and overall survival (OS) in a historic cohort of patients with HER2-positive MBC and studied the effect of stopping trastuzumab in case of rCR. METHODS We included patients with HER2-positive MBC treated with first or second-line trastuzumab-based therapy in eight Dutch hospitals between 2000 and 2014. Data were collected from medical records. We used multivariable regression models to identify independent prognostic factors for rCR and OS. Time-to-progression after achieving rCR for patients who continued and stopped trastuzumab, and breast cancer-specific survival were also evaluated. RESULTS We identified 717 patients with a median age of 53 years at MBC diagnosis. The median follow-up was 109 months (IQR 72-148). The strongest factor associated with OS was achievement of rCR, adjusted hazard ratio 0.27 (95% CI 0.18-0.40). RCR was observed in 72 patients (10%). The ten-year OS estimate for patients who achieved rCR was 52 versus 7% for patients who did not achieve rCR. Thirty patients with rCR discontinued trastuzumab, of whom 20 (67%) are alive in ongoing remission after 78 months of median follow-up since rCR. Of forty patients (58%) who continued trastuzumab since rCR, 13 (33%) are in ongoing remission after 68 months of median follow-up. Median time-to-progression in the latter group was 14 months. CONCLUSIONS Achieving rCR is the strongest predictor for improved survival in patients with HER2-positive MBC. Trastuzumab may be discontinued in selected patients with ongoing rCR. Further research is required to identify patients who have achieved rCR and in whom trastuzumab may safely be discontinued.
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Affiliation(s)
- T G Steenbruggen
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - N I Bouwer
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - C H Smorenburg
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - H N Rier
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - A Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - K Beelen
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - A J Ten Tije
- Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | - P C de Jong
- Department of Medical Oncology, Sint Antonius Hospital, Utrecht, Utrecht, The Netherlands
| | - J C Drooger
- Department of Medical Oncology, Ikazia Hospital, Rotterdam, The Netherlands
| | - C Holterhues
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - J J E M Kitzen
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - M -D Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - G S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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9
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Steenbruggen TG, Bouwer NI, Smorenburg CH, Rier HN, Jager A, Beelen KJ, ten Tije AJ, de Jong PC, Drooger JC, Holterhues C, Horlings HM, Sanders J, Levin MD, Sonke GS. Abstract P6-17-19: What to do with trastuzumab therapy after achieving radiological complete remission (rCR) in HER2+ metastatic breast cancer (MBC)? Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p6-17-19] [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
Intro MBC is generally considered incurable, but patients with HER2+ disease treated with trastuzumab do relatively well and some have an exceptional durable response and survive over 10 years. We analyzed the clinical-pathological characteristics associated with long-term survival in patients with HER2+ MBC treated with trastuzumab. In addition, we studied the effect of stopping trastuzumab in case of rCR.
Methods We included all patients with HER2+ MBC treated with first- or second-line trastuzumab-based palliative therapy between January 2000 and December 2014 in 8 Dutch hospitals (Netherlands Cancer Institute, Erasmus Medical Center, Albert Schweitzer Hospital, Reinier de Graaf Hospital, Amphia Hospital, St. Antonius Hospital, Ikazia Hospital, Haga Hospital). Patients were identified through the Netherlands Cancer Registry and linkage with the institutes' tumor registries. Data was collected from medical records using case record forms. Primary endpoint was overall survival (OS), defined as first-date of MBC until death due to any cause. Kaplan-Meier survival estimates were calculated and multivariable Cox-regression models used to identify prognostic factors for improved survival. Time to progression (TTP) after achieving rCR for patients who continued and stopped trastuzumab and breast cancer specific survival were secondary outcomes.
Results We included 744 patients (median age 53, range 24-87). Median follow-up (FU) was 109 months (range 0-178). Clinical factors associated with improved survival in multivariable analyses were single-organ metastases, ER-positivity, no skin or liver metastases, no prior trastuzumab, local therapy of metastatic disease and achievement of rCR. In line with our first single center analyses1, achievement of rCR was the strongest predictor of improved survival (multivariable HR 0.30, 95%CI 0.20-0.46). RCR was observed in 71 patients (10%), of whom 60 had been treated with trastuzumab and chemotherapy, 9 with trastuzumab and hormonal therapy, and 2 with hormonal therapy. In patients with rCR the estimated 10-year OS was 53% versus 7% in patients who did not achieve rCR (p<0.001).
Thirty patients stopped trastuzumab after achieving rCR. Median time between onset of rCR and last gift of trastuzumab in these patients was 6 months (0-132). Twenty-one patients (70%) remain in complete remission after a median FU of 75 months (range 54-90) since onset of rCR. Nine patients experienced disease progression after a median time of 14 months (range 9-62) since last gift of trastuzumab. Of these, 8 patients died due to MBC and one again achieved an ongoing rCR. Out of 39 patients who continued trastuzumab after achieving rCR, 12 are in ongoing remission after a median FU of 71 months (range 51-91). In this group median TTP was 14 months (range 5-23).
Conclusion Achieving rCR is strongly associated with long-term survival in patients with HER2+ MBC. Seventy percent of patients who stopped trastuzumab after achieving rCR remained in remission, suggesting this can be an attractive approach in selected patients. External validation of these findings is required, however, as well as additional analyses to characterize the patients -and their tumors- who achieved rCR.
1 Steenbruggen, CancerRes 2017
Citation Format: Steenbruggen TG, Bouwer NI, Smorenburg CH, Rier HN, Jager A, Beelen KJ, ten Tije AJ, de Jong PC, Drooger JC, Holterhues C, Horlings HM, Sanders J, Levin M-D, Sonke GS. What to do with trastuzumab therapy after achieving radiological complete remission (rCR) in HER2+ metastatic breast cancer (MBC)? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-19.
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Affiliation(s)
- TG Steenbruggen
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - NI Bouwer
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - CH Smorenburg
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - HN Rier
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - A Jager
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - KJ Beelen
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - AJ ten Tije
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - PC de Jong
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - JC Drooger
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - C Holterhues
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - HM Horlings
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - J Sanders
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - M-D Levin
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
| | - GS Sonke
- The Netherlands Cancer Institute, Amsterdam, Noord-Holland, Netherlands; Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, Netherlands; Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, Netherlands; Reinier de Graaf Hospital, Delft, Zuid-Holland, Netherlands; Amphia Hospital, Breda, Brabant, Netherlands; Sint Antonius Hospital, Utrecht, Netherlands; Ikazia Hospital, Rotterdam, Zuid-Holland, Netherlands; Haga Hospital, The Hague, Zuid-Holland, Netherlands
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Rier HN, Levin MD, van Rosmalen J, Bos MMEM, Drooger JC, de Jong P, Portielje JEA, Elsten EMP, Ten Tije AJ, Sleijfer S, Jager A. First-Line Palliative HER2-Targeted Therapy in HER2-Positive Metastatic Breast Cancer Is Less Effective After Previous Adjuvant Trastuzumab-Based Therapy. Oncologist 2017; 22:901-909. [PMID: 28533475 PMCID: PMC5553959 DOI: 10.1634/theoncologist.2016-0448] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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] [Received: 11/11/2016] [Accepted: 03/09/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Survival of patients with human epidermal growth receptor 2 (HER2)-positive metastatic breast cancer (MBC) has improved dramatically since trastuzumab has become available, although the disease eventually progresses in most patients. This study investigates the outcome (overall survival [OS] and time to next treatment [TNT]) in MBC patients pretreated with trastuzumab in the adjuvant setting (TP-group) compared with trastuzumab-naïve patients (TN-group) in order to investigate the possibility of trastuzumab resistance. PATIENTS AND METHODS Patients treated with first-line HER2-targeted-containing chemotherapy were eligible for the study. A power analysis was performed to estimate the minimum size of the TP-group. OS and TNT were estimated using Kaplan-Meier curves and multivariable Cox proportional hazards models. RESULTS Between January 1, 2000, and June 1, 2014, 469 patients were included, of whom 82 were in the TP-group and 387 were in the TN-group. Median OS and TNT were significantly worse in the TP-group compared with the TN-group (17 vs. 30 months, adjusted hazard ratio [HR] 1.84 [1.15-2.96], p = .01 and 7 vs. 13 months, adjusted HR 1.65 [1.06-2.58], p = .03) after adjustment for age, year of diagnosis, disease-free interval, hormone receptor status, metastatic site, and cytotoxic regimens. CONCLUSION First-line trastuzumab-containing treatment regimens are less effective in patients with failure of adjuvant trastuzumab compared with trastuzumab-naïve patients and might be due to trastuzumab resistance. The impact of trastuzumab resistance on the response on dual HER2 blockade with trastuzumab and pertuzumab and how resistance mechanisms can be used in the optimization of HER2-targeted treatment lines need further investigation. IMPLICATIONS FOR PRACTICE Evidence on the efficacy of palliative trastuzumab-based therapy after failure of trastuzumab in the adjuvant setting is limited because of a minority of patients treated with adjuvant trastuzumab in clinical trials. In this study, less clinical benefit of palliative trastuzumab-based therapy was observed in patients relapsing after adjuvant trastuzumab compared with no adjuvant trastuzumab treatment. Subgroup analyses and multivariable analyses revealed that this was independent of possible confounding factors, including adjuvant taxane-treatment. This might suggest a clinically meaningful impaired efficacy of trastuzumab after previous, in this case adjuvant, trastuzumab therapy. These results could have implications for treatment decision-making after short progression-free intervals on trastuzumab-containing regimens in the palliative setting.
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Affiliation(s)
- Hánah N Rier
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Monique M E M Bos
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Jan C Drooger
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Medical Oncology, Ikazia Hospital, Rotterdam, The Netherlands
| | - Paul de Jong
- Department of Internal Medicine, Sint Antonius Hospital, Utrecht, The Netherlands
| | | | | | | | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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11
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van den Tempel N, Odijk H, van Holthe N, Naipal K, Raams A, Eppink B, van Gent DC, Hardillo J, Verduijn GM, Drooger JC, van Rhoon GC, Smedts DHPM, van Doorn HC, Boormans JL, Jager A, Franckena M, Kanaar R. Heat-induced BRCA2 degradation in human tumours provides rationale for hyperthermia-PARP-inhibitor combination therapies. Int J Hyperthermia 2017; 34:407-414. [PMID: 28705099 DOI: 10.1080/02656736.2017.1355487] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Hyperthermia (40-44 °C) effectively sensitises tumours to radiotherapy by locally altering tumour biology. One of the effects of heat at the cellular level is inhibition of DNA repair by homologous recombination via degradation of the BRCA2-protein. This suggests that hyperthermia can expand the group of patients that benefit from PARP-inhibitors, a drug exploiting homologous recombination deficiency. Here, we explore whether the molecular mechanisms that cause heat-mediated degradation of BRCA2 are conserved in cell lines from various origins and, most importantly, whether, BRCA2 protein levels can be attenuated by heat in freshly biopted human tumours. EXPERIMENTAL DESIGN Cells from four established cell lines and from freshly biopsied material of cervical (15), head- and neck (9) or bladder tumours (27) were heated to 42 °C for 60 min ex vivo. In vivo hyperthermia was studied by taking two biopsies of the same breast or cervical tumour: one before and one after treatment. BRCA2 protein levels were measured by immunoblotting. RESULTS We found decreased BRCA2-levels after hyperthermia in all established cell lines and in 91% of all tumours treated ex vivo. For tumours treated with hyperthermia in vivo, technical issues and intra-tumour heterogeneity prevented obtaining interpretable results. CONCLUSIONS This study demonstrates that heat-mediated degradation of BRCA2 occurs in tumour material directly derived from patients. Although BRCA2-degradation may not be a practical biomarker for heat deposition in situ, it does suggest that application of hyperthermia could be an effective method to expand the patient group that could benefit from PARP-inhibitors.
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Affiliation(s)
- Nathalie van den Tempel
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Hanny Odijk
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Netteke van Holthe
- b Department of Radiation Oncology , Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Kishan Naipal
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Anja Raams
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Berina Eppink
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Dik C van Gent
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Jose Hardillo
- c Department of Otolaryngology and Head and Neck Surgery , Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Gerda M Verduijn
- b Department of Radiation Oncology , Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Jan C Drooger
- d Department of Medical Oncology , Ikazia Hospital , Rotterdam , The Netherlands
| | - Gerard C van Rhoon
- b Department of Radiation Oncology , Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Dineke H P M Smedts
- e Department of Gynaecological Oncology , Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Helena C van Doorn
- e Department of Gynaecological Oncology , Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Joost L Boormans
- f Department of Urology , Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Agnes Jager
- g Department of Medical Oncology , Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Martine Franckena
- b Department of Radiation Oncology , Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Roland Kanaar
- a Department of Molecular Genetics , Cancer Genomics Centre Netherlands Erasmus University Medical Centre , Rotterdam , The Netherlands
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Drooger JC, Akdeniz D, Pignol JP, Koppert LB, McCool D, Seynaeve CM, Hooning MJ, Jager A. Adjuvant radiotherapy for primary breast cancer in BRCA1 and BRCA2 mutation carriers and risk of contralateral breast cancer with special attention to patients irradiated at younger age. Breast Cancer Res Treat 2016; 154:171-80. [PMID: 26467044 PMCID: PMC4621694 DOI: 10.1007/s10549-015-3597-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/05/2015] [Indexed: 12/04/2022]
Abstract
The purpose of this study was to estimate the influence of adjuvant radiotherapy for primary breast cancer (BC) on the risk of contralateral BC (CBC) in BRCA1 or BRCA2(BRCA1/2) mutation carriers, with special attention to patients irradiated at age younger than 40 years. Additionally, tendencies in locoregional treatments and rates of contralateral risk-reducing mastectomy over time were explored. In this retrospective cohort study, 691 BRCA1/2-associated BC patients treated between 1980 and 2013 were followed from diagnosis until CBC or censoring event including ipsilateral BC recurrence, distant metastasis, contralateral risk-reducing mastectomy, other invasive cancer diagnosis, death, or loss to follow up. Hazard ratios (HR) for CBC associated with radiotherapy were estimated using Cox regression. Median follow-up time was 8.6 years [range 0.3–34.3 years]. No association between radiotherapy for primary BC and risk of CBC was found, neither in the total population (HR 0.82, 95 % CI 0.45–1.49) nor in the subgroup of patients younger than 40 years at primary diagnosis (HR 1.36, 95 % CI 0.60–3.09). During follow-up, the number of patients at risk decreased substantially since a large proportion of patients were censored after contralateral risk-reducing mastectomy or BC recurrence. Over the years, increasing preference for mastectomy without radiotherapy compared to breast-conserving surgery with radiotherapy was found ranging from less than 30 % in 1995 to almost 50 % after 2010. The rate of contralateral risk-reducing mastectomy increased over the years from less than 40 % in 1995 to more than 60 % after 2010. In this cohort of BRCA1/2-associated BC patients, no association between radiotherapy for primary BC and risk of CBC was observed in the total group, nor in the patients irradiated before the age of 40 years. The number of patients at risk after 10 and 15 years of follow-up, however, was too small to definitively exclude harmful effects of adjuvant radiotherapy.
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Affiliation(s)
- Jan C. Drooger
- />Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
- />Department of Medical Oncology, Ikazia Hospital, Rotterdam, The Netherlands
| | - Delal Akdeniz
- />Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Jean-Philippe Pignol
- />Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B. Koppert
- />Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Danielle McCool
- />Division of Molecular Pathology and Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Caroline M. Seynaeve
- />Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Maartje J. Hooning
- />Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Agnes Jager
- />Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
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13
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Drooger JC, van Tinteren H, de Groot SM, Ten Tije AJ, de Graaf H, Portielje JEA, Jager A, Honkoop A, Linn SC, Kroep JR, Erdkamp FLG, Hamberg P, Imholz ALT, van Rossum-Schornagel QC, Heijns JB, van Leeuwen-Stok AE, Sleijfer S. A randomized phase 2 study exploring the role of bevacizumab and a chemotherapy-free approach in HER2-positive metastatic breast cancer: The HAT study (BOOG 2008-2003), a Dutch Breast Cancer Research Group trial. Cancer 2016; 122:2961-70. [PMID: 27315546 DOI: 10.1002/cncr.30141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 02/20/2016] [Revised: 04/11/2016] [Accepted: 04/25/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND To explore the role of bevacizumab and a chemotherapy-free approach, the authors evaluated the combination of bevacizumab, trastuzumab, and paclitaxel (HAT) and the regimen of trastuzumab and bevacizumab (HA) with the addition of paclitaxel after progression (HA-HAT) as first-line treatment for patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer. METHODS In a noncomparative phase 2 trial, patients were randomized between HAT and HA-HAT. The primary endpoint was the progression-free rate at 1 year (1-year PFR). In the HA-HAT group, progression-free survival (PFS) was separately established for HA (PFS1) and HAT (PFS2). RESULTS Eighty-four patients received HAT (n = 39) or HA-HAT (n = 45). The 1-year PFR was 74.4% (95% confidence interval [CI], 61.8%-89.4%) and 62.2% (95% CI, 49.6%-89.4%) in the HAT and HA-HAT arms, respectively. The median PFS was 19.8 months (95% CI, 14.9-25.6 months) in the HAT arm and 19.6 months (95% CI, 12.0-32.0 months) in the HA-HAT arm. In the HA-HAT arm, the median PFS1 was 10.4 months (95% CI, 6.2-15.0 months), and the median PFS2 was 8.2 months (95% CI, 7.0-12.6 months). The number and severity of adverse events were comparable between the arms. CONCLUSIONS Both HAT and HA-HAT have promising activity in patients with HER2-positive metastatic breast cancer. In particular, starting with only targeted agents and delaying chemotherapy is worth further exploration. Cancer 2016;122:2961-2970. © 2016 American Cancer Society.
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Affiliation(s)
- Jan C Drooger
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute and Cancer Genomics Netherlands, Rotterdam, the Netherlands. .,Department of Medical Oncology, Ikazia Hospital, Rotterdam, the Netherlands.
| | - Harm van Tinteren
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Steffen M de Groot
- Comprehensive Cancer Center of the Netherlands, Amsterdam, the Netherlands
| | - Albert J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Breda, the Netherlands
| | - Hiltje de Graaf
- Department of Medical Oncology, Leeuwarden Medical Center, Leeuwarden, the Netherlands
| | | | - Agnes Jager
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute and Cancer Genomics Netherlands, Rotterdam, the Netherlands
| | - Aafke Honkoop
- Department of Medical Oncology, Isala Clinic, Zwolle, the Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frans L G Erdkamp
- Department of Medical Oncology, Orbis Medical Center, Sittard, the Netherlands
| | - Paul Hamberg
- Department of Medical Oncology, Sint Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Alex L T Imholz
- Department of Medical Oncology, Deventer Hospital, Deventer, the Netherlands
| | | | - Joan B Heijns
- Department of Medical Oncology, Amphia Hospital, Breda, the Netherlands
| | | | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute and Cancer Genomics Netherlands, Rotterdam, the Netherlands
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Drooger JC, Heemskerk-Gerritsen BAM, Smallenbroek N, Epskamp C, Seynaeve CM, Jager A. Toxicity of (neo)adjuvant chemotherapy for BRCA1- and BRCA2-associated breast cancer. Breast Cancer Res Treat 2016; 156:557-566. [PMID: 27060914 PMCID: PMC4837227 DOI: 10.1007/s10549-016-3777-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/30/2016] [Indexed: 01/16/2023]
Abstract
Treatment with (neo)adjuvant chemotherapy for breast cancer, as currently given, causes cell damage by induction of double-strand DNA breaks. Because BRCA1 and BRCA2 proteins play a role in the repair of DNA damage, the efficacy of (neo)adjuvant chemotherapy may be increased in BRCA1/2-associated breast cancer patients. As a downside, acute chemotherapy-related toxicity may also be increased. We selected all female patients who were treated at the Erasmus MC Cancer Institute, with (neo)adjuvant chemotherapy for primary or locoregional recurrence of breast cancer (PBC/LR) between January 1, 2004 and December 31, 2014. The primary outcome was the relative total dose intensity (RTDI), calculated for anthracyclines and taxanes separately. Secondary outcomes were the occurrence of febrile neutropenia, delay in chemotherapy administration, and switch to another chemotherapy regimen due to toxicity. In total, 701 patients treated for PBC/LR were eligible for data analyses, among which 85 BRCA1/2 mutation carriers (n = 67 BRCA1 and n = 18 BRCA2). The mean RTDI for anthracyclines was not significantly different between both groups (98.7 % in the BRCA1/2, 96.6 % in the sporadic group, p = 0.27). Also the mean RTDI for taxanes was not significantly different between the groups (93.6 % in the BRCA1/2-associated, 90.0 % in the sporadic group, p = 0.12). Linear regression analysis revealed no significant effect of BRCA1/2 mutation carriership on the RTDIs. No significant differences were found in the percentages of patients presenting with febrile neutropenia, having a delay in chemotherapy administration or switching to an altered chemotherapy regimen. Additionally, the odds ratios showed no significant effect of BRCA1/2 mutation carriership on the secondary outcome variables. (Neo)adjuvant chemotherapy-related toxicity was not different between BRCA1/2-associated and sporadic breast cancer patients suggesting that the DNA damage repair mechanism of non-cancer cells with only one normal copy of either the BRCA1 or BRCA2 gene is sufficiently functional to handle acute chemotherapy-associated toxicity.
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Affiliation(s)
- Jan C Drooger
- Department of Medical Oncology, Erasmus MC Cancer Institute and Cancer Genomics Netherlands, PO Box 5201, 3008, AE, Rotterdam, The Netherlands. .,Department of Medical Oncology, Ikazia Hospital, Rotterdam, The Netherlands.
| | - Bernadette A M Heemskerk-Gerritsen
- Department of Medical Oncology, Erasmus MC Cancer Institute and Cancer Genomics Netherlands, PO Box 5201, 3008, AE, Rotterdam, The Netherlands
| | - Nyrée Smallenbroek
- Department of Medical Oncology, Erasmus MC Cancer Institute and Cancer Genomics Netherlands, PO Box 5201, 3008, AE, Rotterdam, The Netherlands
| | - Cynthia Epskamp
- Department of Medical Oncology, Erasmus MC Cancer Institute and Cancer Genomics Netherlands, PO Box 5201, 3008, AE, Rotterdam, The Netherlands.,Department of Internal Medicine, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Caroline M Seynaeve
- Department of Medical Oncology, Erasmus MC Cancer Institute and Cancer Genomics Netherlands, PO Box 5201, 3008, AE, Rotterdam, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute and Cancer Genomics Netherlands, PO Box 5201, 3008, AE, Rotterdam, The Netherlands
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15
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Drooger JC, Jager A, Lam MH, den Boer MD, Sleijfer S, Mathijssen RH, de Bruijn P. Development and validation of an UPLC–MS/MS method for the quantification of tamoxifen and its main metabolites in human scalp hair. J Pharm Biomed Anal 2015; 114:416-25. [DOI: 10.1016/j.jpba.2015.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/08/2015] [Accepted: 06/10/2015] [Indexed: 12/13/2022]
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16
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Drooger JC, van Pelt-Sprangers JM, Leunis C, Jager A, de Jongh FE. Neutrophil-guided dosing of anthracycline-cyclophosphamide-containing chemotherapy in patients with breast cancer: a feasibility study. Med Oncol 2015; 32:113. [PMID: 25772511 PMCID: PMC4357644 DOI: 10.1007/s12032-015-0550-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/23/2015] [Indexed: 11/30/2022]
Abstract
The aim of this study was to investigate whether neutrophil-guided dose escalation of anthracycline-cyclophosphamide-containing chemotherapy (ACC) for breast cancer is feasible, in order to optimize outcome. Breast cancer patients planned for 3-weekly ACC were enrolled in this study. The first treatment cycle was administered in a standard BSA-adjusted dose. The absolute neutrophil count was measured at baseline and at day 8, 11 and 15 after administration of ACC. For patients with none or mild (CTC grade 0-2) neutropenia and no other dose-limiting toxicity, we performed a 10-25 % dose escalation of the second cycle with the opportunity to a further 10-25 % dose escalation of the third cycle. Thirty patients were treated in the adjuvant setting with either FE100C (n = 23) or AC (n = 4), or in the palliative setting with FAC (n = 3). Two out of 23 patients (9 %) treated with FEC did not develop grade 3-4 neutropenia after the first treatment cycle. Dose escalation was performed in these two patients (30 % in one and 15 % in the other patient). During dose escalation, there were no complications like febrile neutropenia. No patients treated with FAC or AC could be escalated, since all of them developed grade 3-4 neutropenia. We conclude that asymptomatic grade 3-4 neutropenia is likely to be achieved in the majority of patients with breast cancer treated with ACC according to presently advocated BSA-based dose levels. Escalation of currently advocated ACC doses without G-CSF, with a target of grade 3-4 neutropenia, is feasible, but only possible in a small proportion of patients. EudraCT 2010-020309-33.
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Affiliation(s)
- Jan C Drooger
- Department of Internal Medicine, Ikazia Hospital, PO Box 5009, 3008 AA, Rotterdam, The Netherlands,
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17
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Drooger JC, Hooning MJ, Seynaeve CM, Baaijens MHA, Obdeijn IM, Sleijfer S, Jager A. Diagnostic and therapeutic ionizing radiation and the risk of a first and second primary breast cancer, with special attention for BRCA1 and BRCA2 mutation carriers: a critical review of the literature. Cancer Treat Rev 2014; 41:187-96. [PMID: 25533736 DOI: 10.1016/j.ctrv.2014.12.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [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: 09/01/2014] [Revised: 11/26/2014] [Accepted: 12/01/2014] [Indexed: 12/15/2022]
Abstract
Occurrence of breast cancer is a well-known long-term side effect of ionizing radiation (both diagnostic and therapeutic). The radiation-induced breast cancer risk increases with longer follow-up, higher radiation dose and younger age of exposure. The risk for breast cancer following irradiation for lymphomas is well known. Although data regarding the carcinogenic risk of adjuvant radiotherapy for a primary breast cancer are sparse, an increased risk is suggested with longer follow-up mainly when exposed at younger age. Particularly, patients with a BRCA1/2 mutation might be more sensitive for the deleterious effects of ionizing radiation due to an impaired capacity of repairing double strand DNA breaks. This might have consequences for the use of mammography in breast cancer screening, as well as the choice between breast conserving therapy including radiotherapy and mastectomy at primary breast cancer diagnosis in young BRCA1/2 mutation carriers. Good data regarding this topic, however, are scarce, mainly due to constraints in the design of performed studies. In this review, we will discuss the current literature on the association between ionizing radiation and developing breast cancer, with particular attention to patients with a BRCA1/2 mutation.
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Affiliation(s)
- Jan C Drooger
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Medical Oncology, PO Box 5201, 3008 AE Rotterdam, The Netherlands; Ikazia Hospital, Department of Internal Medicine, PO Box 3008 AA, Rotterdam, The Netherlands.
| | - Maartje J Hooning
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Medical Oncology, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Caroline M Seynaeve
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Medical Oncology, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Margreet H A Baaijens
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Radiotherapy, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Inge Marie Obdeijn
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Radiology, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Medical Oncology, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Agnes Jager
- Erasmus MC Cancer Institute and Cancer Genomics Netherlands, Department of Medical Oncology, PO Box 5201, 3008 AE Rotterdam, The Netherlands
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18
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Abstract
The bone is the most common site to which breast cancer metastasises. Recently, denosumab, a fully human monoclonal antibody that binds to receptor activator of nuclear factor kappa-B ligand (RANKL) has been developed as a new targeted bone therapy. In a large randomized phase III study with a head-to-head comparison of denosumab to zoledronic acid in patients with bone metastases of breast cancer, denosumab significantly delayed the time to first skeletal related event. In the adjuvant setting denosumab significantly increased bone mineral density compared to placebo in a phase III study in patients treated with aromatase inhibitors. Preclinical data suggest an effect of denosumab on tumour growth and even on carcinogenesis. This review describes the current indications for denosumab in the various settings of breast cancer treatment, with special attention for efficacy, short and long term toxicity and other relevant issues for clinical practice. Furthermore possible and necessary future research questions are proposed.
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Affiliation(s)
- Jan C Drooger
- Erasmus MC Cancer Institute, Department of Medical Oncology, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands.
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19
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Drooger JC, Dees A, Swaak AJG. ANCA-Positive Patients: The Influence of PR3 and MPO Antibodies on Survival Rate and The Association with Clinical and Laboratory Characteristics. Open Rheumatol J 2009; 3:14-7. [PMID: 19461938 PMCID: PMC2684710 DOI: 10.2174/1874312900903010014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [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: 01/23/2009] [Revised: 02/16/2009] [Accepted: 02/19/2009] [Indexed: 12/02/2022] Open
Abstract
Objectives: To compare the survival rate, and the clinical and laboratory characteristics in patients, characterized by the presence of certain anti-neutrophil cytoplasmic auto-antibodies (ANCAs). Methods: In a retrospective observational study, we analyzed the data of all patients with a positive ANCA test between 1995 and 2005 at our hospital. Based on serology patients were divided in three subgroups (ANCA-Proteinase 3 (PR3), ANCA-Myeloperoxidase (MPO) and atypical ANCA), irrespective of the diagnosis. Patient survival was compared by Kaplan Meier survival analysis. Differences in clinical and laboratory characteristics between the groups of specific ANCAs were determined. Results: Fifty-four ANCA-positive patients were analyzed. Eighteen of these patients were ANCA-PR3-positive, 17 were ANCA-MPO-positive and 19 had a atypical ANCA. A random control group was created of matched ANCA negative patients. Average follow-up time was 52 months. The calculated five year survival rate in respectively the ANCA-PR3- positive group, the ANCA-MPO-positive group, the atypical ANCA group and the ANCA-negative group was 45%, 81%, 90% and 100%. (P = 0.012, Wilcoxon test). A higher mean leukocyte count, a higher mean erythrocyte sedimentation rate and more fever was observed in the ANCA-PR3-positive group compared to the ANCA-MPO-positive group. Conclusions: A remarkable lower survival rate was observed in ANCA-PR3-positive patients compared to ANCA-MPO-positive patients. We also demonstrated that patients characterized by the presence of a defined ANCA differ in clinical and laboratory characteristics.
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Affiliation(s)
- J C Drooger
- Departments of Internal Medicine and Rheumatology, Ikazia Hospital, Postbus 5009, 3008 AA, Rotterdam, The Netherlands
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20
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Drooger JC, Troe JWM, Borsboom GJJM, Hofman A, Mackenbach JP, Moll HA, Snijders RJM, Verhulst FC, Witteman JCM, Steegers EAP, Joung IMA. Ethnic differences in prenatal growth and the association with maternal and fetal characteristics. Ultrasound Obstet Gynecol 2005; 26:115-22. [PMID: 16038011 DOI: 10.1002/uog.1962] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES The objectives of this study were to determine ethnic differences in prenatal growth and to examine their association with differences in maternal and fetal characteristics such as maternal height, weight, age, parity and fetal gender. METHODS A total of 1494 women from Rotterdam, The Netherlands, with a low-risk pregnancy who participated in a population-based cohort study, the Generation R Study, were offered three ultrasound examinations during pregnancy. Multilevel modeling was applied to determine ethnic differences in (estimated) fetal weight (including birth weight) and in the separate biometric variables that were used to calculate the estimated fetal weight (abdominal circumference, head circumference and femur length). Additionally the association of ethnic differences with maternal and fetal characteristics (i.e. maternal weight, height, age, parity and fetal gender) was studied. RESULTS Turkish, Cape Verdian, Surinamese-Creole and Surinamese-Hindustani women had on average smaller fetuses than the native Dutch women. The differences became more pronounced towards term. In the Turkish group the differences were no longer statistically significant when adjusted for maternal weight, height, age, parity and fetal gender. In the Cape Verdian, Surinamese-Creole and Surinamese-Hindustani groups the differences decreased after adjustment (31%, 16% and 39%, respectively). CONCLUSIONS This study shows that there are ethnic differences in fetal growth, which to a large extent may be attributed to differences in maternal weight, height, age and parity. For some ethnic groups, however, additional factors are involved, as differences remain significant after correction for fetal and maternal characteristics.
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Affiliation(s)
- J C Drooger
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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