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Kirkham AA, King K, Joy AA, Pelletier AB, Mackey JR, Young K, Zhu X, Meza-Junco J, Basi SK, Hiller JP, Brkin T, Michalowski B, Pituskin E, Paterson DI, Courneya KS, Thompson RB, Prado CM. Rationale and design of the Diet Restriction and Exercise-induced Adaptations in Metastatic breast cancer (DREAM) study: a 2-arm, parallel-group, phase II, randomized control trial of a short-term, calorie-restricted, and ketogenic diet plus exercise during intravenous chemotherapy versus usual care. BMC Cancer 2021; 21:1093. [PMID: 34629067 PMCID: PMC8504029 DOI: 10.1186/s12885-021-08808-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An underlying cause of solid tumor resistance to chemotherapy treatment is diminished tumor blood supply, which leads to a hypoxic microenvironment, dependence on anaerobic energy metabolism, and impaired delivery of intravenous treatments. Preclinical data suggest that dietary strategies of caloric restriction and low-carbohydrate intake can inhibit glycolysis, while acute exercise can transiently enhance blood flow to the tumor and reduce hypoxia. The Diet Restriction and Exercise-induced Adaptations in Metastatic Breast Cancer (DREAM) study will compare the effects of a short-term, 50% calorie-restricted and ketogenic diet combined with aerobic exercise performed during intravenous chemotherapy treatment to usual care on changes in tumor burden, treatment side effects, and quality of life. METHODS Fifty patients with measurable metastases and primary breast cancer starting a new line of intravenous chemotherapy will be randomly assigned to usual care or the combined diet and exercise intervention. Participants assigned to the intervention group will be provided with food consisting of 50% of measured calorie needs with 80% of calories from fat and ≤ 10% from carbohydrates for 48-72 h prior to each chemotherapy treatment and will perform 30-60 min of moderate-intensity cycle ergometer exercise during each chemotherapy infusion, for up to six treatment cycles. The diet and exercise durations will be adapted for each chemotherapy protocol. Tumor burden will be assessed by change in target lesion size using axial computed tomography (primary outcome) and magnetic resonance imaging (MRI)-derived apparent diffusion coefficient (secondary outcome) after up to six treatments. Tertiary outcomes will include quantitative MRI markers of treatment toxicity to the heart, thigh skeletal muscle, and liver, and patient-reported symptoms and quality of life. Exploratory outcome measures include progression-free and overall survival. DISCUSSION The DREAM study will test a novel, short-term diet and exercise intervention that is targeted to mechanisms of tumor resistance to chemotherapy. A reduction in lesion size is likely to translate to improved cancer outcomes including disease progression and overall survival. Furthermore, a lifestyle intervention may empower patients with metastatic breast cancer by actively engaging them to play a key role in their treatment. TRIAL REGISTRATION ClinicalTrials.gov, NCT03795493 , registered 7 January, 2019.
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Affiliation(s)
- Amy A Kirkham
- Faculty of Kinesiology & Physical Education, University of Toronto, 422, 100 Devonshire Pl, Toronto, ON, M5S 2C9, Canada.
| | - Karen King
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Anil A Joy
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | | | - John R Mackey
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Kelvin Young
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Xiaofu Zhu
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Judith Meza-Junco
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Sanraj K Basi
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Julie Price Hiller
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Tina Brkin
- Cross Cancer Institute, Edmonton, AB, Canada
| | | | - Edith Pituskin
- Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
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2
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Clemons M, Fergusson D, Joy AA, Thavorn K, Meza-Junco J, Hiller JP, Mackey J, Ng T, Zhu X, Ibrahim MFK, Sienkiewicz M, Saunders D, Vandermeer L, Pond G, Basulaiman B, Awan A, Pitre L, Nixon NA, Hutton B, Hilton JF. A multi-centre study comparing granulocyte-colony stimulating factors to antibiotics for primary prophylaxis of docetaxel-cyclophosphamide induced febrile neutropenia. Breast 2021; 58:42-49. [PMID: 33901921 PMCID: PMC8095051 DOI: 10.1016/j.breast.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Primary febrile neutropenia (FN) prophylaxis with ciprofloxacin or granulocyte-colony stimulating factors (G-CSF) is recommended with docetaxel-cyclophosphamide (TC) chemotherapy for early-stage breast cancer (EBC). A pragmatic randomised trial compared the superiority of G-CSF to ciprofloxacin and a cost-utility analysis were conducted. METHODS EBC patients receiving TC chemotherapy were randomised to ciprofloxacin or G-CSF. The primary outcome was a composite of FN and non-FN treatment-related hospitalisation. Secondary outcomes included; rates of FN, non-FN treatment-related hospitalisation, chemotherapy dose reductions/delays/discontinuations. Primary analysis was performed with the intention to treat population. Cost-utility analyses were conducted from the Canadian public payer perspective. RESULTS 458 eligible patients were randomised: 228 to ciprofloxacin and 230 to G-CSF. For the primary endpoint there was non-statistically significant difference (Risk difference = -6.7%, 95%CI = -13.5%-0.1%, p = 0.061) between ciprofloxacin patients (46,20.2%) and G-CSF (31,13.5%). Patients receiving ciprofloxacin were more likely to experience FN (36/228, 15.8% vs 13/230, 5.7%) than patients receiving G-CSF (p < 0.001). Non-FN treatment-related hospitalisation occurred in 40/228 (17.5%) of ciprofloxacin patients vs 28/230 (12.2%) of G-CSF patients (p = 0.12). There were no differences in other secondary outcomes. G-CSF was associated with an incremental cost-effectiveness ratio of C$1,760,796 per one quality-adjusted life year gained. CONCLUSION The primary endpoint of superiority of G-CSF over ciprofloxacin was not demonstrated. While there were reduced FN rates with G-CSF, there were no differences in chemotherapy dose delays/reductions or discontinuations. With the commonly used willingness to pay value of C$50,000/QALY, G-CSF use was not cost-effective compared to ciprofloxacin and deserves scrutiny from the payer perspective.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Anil A Joy
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Judith Meza-Junco
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Julie Price Hiller
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - John Mackey
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Terry Ng
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Xiaofu Zhu
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Mohammed F K Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Marta Sienkiewicz
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Gregory Pond
- Department of Oncology, McMaster University, Hamilton, Canada
| | - Bassam Basulaiman
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Lacey Pitre
- Department of Oncology, Northeast Cancer Centre, Sudbury, Canada
| | - Nancy A Nixon
- Division of Medical Oncology, Department of Oncology, University of Alberta, Tom Baker Cancer Centre, Calgary, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - John F Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Mittendorf EA, Lu B, Melisko M, Price Hiller J, Bondarenko I, Brunt AM, Sergii G, Petrakova K, Peoples GE. Efficacy and Safety Analysis of Nelipepimut-S Vaccine to Prevent Breast Cancer Recurrence: A Randomized, Multicenter, Phase III Clinical Trial. Clin Cancer Res 2019; 25:4248-4254. [PMID: 31036542 DOI: 10.1158/1078-0432.ccr-18-2867] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/31/2018] [Accepted: 04/19/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE In phase I/II studies, nelipepimut-S (NP-S) plus GM-CSF vaccine was well tolerated and effectively raised HER2-specific immunity in patients with breast cancer. Results from a prespecified interim analysis of a phase III trial assessing NP-S + GM-CSF are reported. PATIENTS AND METHODS This multicenter, randomized, double-blind phase III study enrolled females ≥18 years with T1-T3, HER2 low-expressing (IHC 1+/2+), node-positive breast cancer in the adjuvant setting. Patients received 1,000 μg NP-S + 250 μg GM-CSF or placebo + GM-CSF monthly for 6 months, then every 6 months through 36 months. The primary objective was disease-free survival (DFS). Protocol-specified imaging occurred annually. New abnormalities were categorized as recurrence events; biopsy confirmation was not mandated. The interim analysis was conducted as specified in the protocol after 73 DFS events. RESULTS A total of 758 patients (mean age 51.8 years) were randomized. Adverse events were similar between groups; most common were injection-associated: erythema (84.3%), induration (55.8%), and pruritus (54.9%). There was no significant between-arms difference in DFS events at interim analysis at median follow-up (16.8 months). In the NP-S arm, imaging detected 54.1% of recurrence events in asymptomatic patients versus 29.2% in the placebo arm (P = 0.069). CONCLUSIONS NP-S was well tolerated. There was no significant difference in DFS events between NP-S and placebo. Use of mandated annual scans and image-detected recurrence events hastened the interim analysis contributing to early trial termination.
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Affiliation(s)
- Elizabeth A Mittendorf
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Biao Lu
- Independent Statistical Contractor, San Ramon, California
| | - Michelle Melisko
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Julie Price Hiller
- Division of Medical Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Igor Bondarenko
- Department of Oncology and Medical Radiology, Dnipropetrovsk State Medical Academy, Dnipropetrovsk, Ukraine
| | - Adrian Murray Brunt
- Cancer Centre, University Hospitals of North Midlands and Keele University, Stoke-on-Trent, United Kingdom
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Chu MP, Hecht JR, Slamon D, Wainberg ZA, Bang YJ, Hoff PM, Sobrero A, Qin S, Afenjar K, Houe V, King K, Koski S, Mulder K, Hiller JP, Scarfe A, Spratlin J, Huang YJ, Khan-Wasti S, Chua N, Sawyer MB. Association of Proton Pump Inhibitors and Capecitabine Efficacy in Advanced Gastroesophageal Cancer: Secondary Analysis of the TRIO-013/LOGiC Randomized Clinical Trial. JAMA Oncol 2017; 3:767-773. [PMID: 27737436 DOI: 10.1001/jamaoncol.2016.3358] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Capecitabine is an oral cytotoxic chemotherapeutic commonly used across cancer subtypes. As with other oral medications though, it may suffer from drug interactions that could impair its absorption. Objective To determine if gastric acid suppressants such as proton pump inhibitors (PPIs) may impair capecitabine efficacy. Design, Setting, and Participants This secondary analysis of TRIO-013, a phase III randomized trial, compares capecitabine and oxaliplatin (CapeOx) with or without lapatinib in 545 patients with ERBB2/HER2-positive metastatic gastroesophageal cancer (GEC); patients were randomized 1:1 between CapeOx with or without lapatinib. Proton pump inhibitor use was identified by medication records. Progression-free survival (PFS) and overall survival (OS) were compared between patients treated with PPIs vs patients who were not. Specific subgroups were accounted for, such as younger age (<60 years), Asian ethnicity, female sex, and disease stage (metastatic/advanced) in multivariate Cox proportional hazards modeling. The TRIO-013 trial accrued and randomized patients between June 2008 and January 2012; this analysis took place in January 2014. Interventions Patients were divided based on PPI exposure. Main Outcomes and Measures Primary study outcome was PFS and OS between patients treated with PPIs vs patients who were not. Secondary outcomes included disease response rates and toxicities. Results Of the 545 patients with GEC (median age, 60 years; 406 men [74%]) included in the study, 229 received PPIs (42.0%) and were evenly distributed between arms. In the placebo arm, PPI-treated patients had poorer median PFS, 4.2 vs 5.7 months (hazard ratio [HR], 1.55; 95% CI, 1.29-1.81, P < .001); OS, 9.2 vs 11.3 months (HR, 1.34; 95% CI, 1.06-1.62; P = .04); and disease control rate (83% vs 72%; P = .02) vs patients not treated with PPIs. In multivariate analysis considering age, race, disease stage, and sex, PPI-treated patients had poorer PFS (HR, 1.68; 95% CI, 1.42-1.94; P < .001) and OS (HR, 1.41; 95% CI, 1.11-1.71; P = .001). In patients treated with CapeOx and lapatinib, PPIs had less effect on PFS (HR, 1.08; P = .54) and OS (HR, 1.26; P = .10); however, multivariate analysis in this group demonstrated a significant difference in OS (HR, 1.38; 95% CI, 1.06-1.66; P = .03). Conclusions and Relevance Proton pump inhibitors negatively effected capecitabine efficacy by possibly raising gastric pH levels, leading to altered dissolution and absorption. These results are consistent with previous erlotinib and sunitinib studies. Whether PPIs affected lapatinib is unclear given concurrent capecitabine. Given capecitabine's prevalence in treatment breast cancer and colon cancer, further studies are under way. Trial Registration clinicaltrials.gov Identifier: NCT00680901.
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Affiliation(s)
- Michael P Chu
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - J Randolph Hecht
- Jonsson Comprehensive Cancer Center, Department of Clinical and Translational Research, University of California-Los Angeles, Los Angeles
| | - Dennis Slamon
- Jonsson Comprehensive Cancer Center, Department of Clinical and Translational Research, University of California-Los Angeles, Los Angeles
| | - Zev A Wainberg
- Jonsson Comprehensive Cancer Center, Department of Clinical and Translational Research, University of California-Los Angeles, Los Angeles
| | - Yung-Jue Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Paulo M Hoff
- Instituto do Cancer do Estado de Sao Paulo, Universidade de Sao Paolo, Sao Paolo, Brazil
| | - Alberto Sobrero
- IRCCS Ospedale San Martino IST, Medical Oncology, Largo Benzi 10 Genova, 16132, Italy
| | - Shukui Qin
- Department of Oncology, The 81 Hospital of the Chinese People's Liberation Army, Nanjing, China
| | - Karen Afenjar
- Project Management, Translational Research in Oncology (TRIO), Paris, France
| | - Vincent Houe
- Department of Biostatistics, TRIO, Paris, France
| | - Karen King
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Sheryl Koski
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Karen Mulder
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Julie Price Hiller
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Andrew Scarfe
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Jennifer Spratlin
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Yingjie J Huang
- Department of Research and Development Projects, Clinical Platforms and Sciences, GlaxoSmithKline (GSK), Middlesex, United Kingdom
| | - Saba Khan-Wasti
- Department of Research and Development Projects, Clinical Platforms and Sciences, GlaxoSmithKline (GSK), Middlesex, United Kingdom
| | - Neil Chua
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
| | - Michael B Sawyer
- Cross Cancer Institute, Department of Oncology, Edmonton, Alberta, Canada
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Standeven L, Price Hiller J, Mulder K, Zhu G, Ghosh S, Spratlin JL. Impact of a dedicated cancer center surveillance program on guideline adherence for patients with stage II and III colorectal cancer. Clin Colorectal Cancer 2012; 12:103-12. [PMID: 23153862 DOI: 10.1016/j.clcc.2012.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 09/28/2012] [Accepted: 09/28/2012] [Indexed: 01/20/2023]
Abstract
UNLABELLED Surveillance after curative treatment for stage II/III colorectal cancer identifies surgically resectable disease and improves survival. We evaluated adherence to guidelines and outcomes for 408 patients enrolled in an innovative follow-up program at our cancer center. We found that a dedicated intensive surveillance program can impact adherence to guidelines for patients with colorectal cancer. BACKGROUND Our aims were to evaluate adherence to guidelines on colorectal cancer surveillance and outcomes for patients enrolled in an innovative follow-up program at our cancer center. PATIENTS AND METHODS A retrospective chart review was conducted at the Cross Cancer Institute in Edmonton, Canada. Patients with stage II/III colorectal cancer who completed treatment and who entered into the program from December 1, 2007, to December 31, 2009, were identified. The minimum standard of care follow-up was defined as (1) carcinoembryonic antigen (CEA) testing every 120 days for 3 years; (2) computed tomography of chest, abdomen, and pelvis at 10 to 14 months and 22 to 26 months after surgery; and (3) colonoscopy within 14 months of surgery. RESULTS A total of 408 patients met inclusion criteria. Two hundred (49.0%) patients were adherent to all 3 components of surveillance. Among all patients, 57 (14.0%) were nonadherent to computed tomography imaging, 135 (33.1%) were nonadherent to colonoscopy, and 96 (23.5%) were nonadherent to CEA testing. Determinants of nonadherence are described. In total, 192 (47.2%) patients had an abnormal surveillance investigation that led to 307 follow-up events. After a median of 1.6 years, 69 (16.9%) patients had documented tumor recurrence. Sixty-one (88.4%) of these 69 patients had recurrence diagnosed via surveillance, and 31 (44.9%) patients were considered potentially resectable. CONCLUSIONS Our study demonstrated an improvement in CEA testing since the program began; however, adherence rates for all components are not yet optimal. Alterations to surveillance program management are outlined. Further investigation will determine whether intense follow-up improves patient survival locally.
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Affiliation(s)
- Leah Standeven
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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