Abstract P1-13-01: Final results of the ASG1-3 study, a randomized phase III study comparing a standard dose chemotherapy with epirubicin/cyclophosphamide and paclitaxel with a dose dense regimen with epirubicin and paclitaxel

Background

Dose dense chemotherapy (DDT) has shown improvements of disease-free survival (DFS) and overall survival for primary breast cancer patients with a high risk of relapse. There are much less data about the effect of DDT in patients with intermediate risk of recurrence (1-3 positive axillary lymph nodes). Aim of this prospectively randomized trial was to investigate the superiority of a DDT schedule over a standard chemotherapy (ST) in primary breast cancer patients with 1-3 positive axillary lymph nodes.

Methods

The ASG1-3 study is a prospectively randomized, open label phase III study of the Adjuvant Study Group of the NOGGO association. Patients were eligible for the trial, if they had a primary invasive breast cancer (pT1-3) with 1-3 positive axillary lymph nodes and no evidence of distant metastases. Patients were randomized to an adjuvant therapy with either 4 cycles epirubicin (90mg/m2 body surface area, BSA) and cyclophosphamide (600mg/m2 BSA) q3w, followed by 4 cycles of paclitaxel (175mg/m2 BSA) referred to as ST or to a therapy with 4 cycles of epicubicin (120 mg/m2 BSA) q2w and primary G-CSF support followed by 4 cycles of paclitaxel (175mg/m2 BSA) q2w and primary G-CSF support referred to as DDT. Trastuzumab was not given in this study. The study was designed to show an increase of 70% DFS (ST) to 80% DFS (DDT) 5 years after randomization. Comparisons were conducted using Kaplan Meier estimates, log rank tests and Cox regression analyses. In an exploratory way, subgroup analyses were performed for HER2, hormone receptor status and grading using Cox regression models with interaction terms.

Results

A total of 936 patients were eligible for survival analysis, of which 465 were randomized to ST and 471 to DDT from 2001 to 2004. Patient characteristics were mainly well balanced, with patients being 52.5/52.1 years old, 71.9/78.1% being hormone receptor positive, 24.4/24.6% being HER2 positive and 38.6/38.8% having a tumor grade of 3 in the ST arm and DDT arm respectively. 53 events occurred after ST and 46 after DDT. Adjusted hazard ratio (HR) was 0.87 (95%CI: 0.57-1.35; p=0.54). 5 year DFS rates were 85% (ST) vs. 87% (DDT). Hematological toxicities were the most common grade 3 or 4 adverse events. Grade 3/4 neutropenia occurred in 57.2 vs. 28.0%, grade 3/4 anemia in 15.3% vs. 17.1% and grade 3 /4 pain symptoms were seen in 13.2 vs. 12.4% of the patients in the ST arm vs. DDT arm respectively. Other grade 3/4 toxicities were less frequent than 10%. Subgroup analysis showed a significant interaction (p<0.001) between HER2 status and randomization arm with regard to DFS. In HER2 negative patients the HR was 1.53 (95%CI: 0.91-2.59), whereas in HER2 positive patients the HR was 0.22 (95%CI: 0.09-0.55). Patients with HER2 positive disease and DDT had a similar prognosis like HER2 negative patients.

Conclusion

In the overall population a statistically significant improvement of DFS could not be shown for the DDT arm. In patients with HER2 positive breast cancer DDT chemotherapy improved the disease-free survival to a prognosis which was similar to patients with HER2 negative disease.

Citation Format: Fasching PA, Eggemann H, Krocker J, Häberle L, Volz B, Kleine-Tebbe A, Blohmer J-U, Kittel K, Hufnagel M, Janni W, Emons G, Simon E, Köhler U, Thomssen C, Kohls A, Beckmann MW, Hielscher C, Krabisch P, Zeiser T, Brodkorb T, Baier F, Nabieva N, Kellner S, Untch M, Stadie S, Budner M, Breitbach G-P, Keller M, Stickeler E, Kühn T, Tolkmitt M, Belau AK, Schmidt M, Ulm K, Kümmel S. Final results of the ASG1-3 study, a randomized phase III study comparing a standard dose chemotherapy with epirubicin/cyclophosphamide and paclitaxel with a dose dense regimen with epirubicin and paclitaxel [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 P1-13-01.

Randomised trial: survival benefit and safety of adjuvant dose-dense chemotherapy for node-positive breast cancer

We evaluated the survival benefit, safety, feasibility, and tolerability of dose-dense (DD) adjuvant chemotherapy with epirubicin and paclitaxel for women with node-positive primary breast cancer. Randomised patients (n=216) received DD or conventional-schedule (CS) chemotherapy. Dose-dense regimen patients (n=108) received epirubicin 90 mg m⁻² plus paclitaxel 175 mg m⁻² in four 14-day cycles, then cyclophosphamide 600 mg m⁻², methotrexate 40 mg m⁻², and fluorouracil 600 mg m⁻² (CMF 600/40/600) in three 14-day cycles, plus filgrastim 5 μg kg day⁻¹ as growth support in every cycle. Conventional-schedule regimen patients (n=108) received epirubicin 90 mg m⁻² plus cyclophosphamide 600 mg m⁻² in four 21-day cycles, then CMF 600/40/600 in three 21-day cycles, plus filgrastim if required. After a median follow-up of 38.4 months, 71 patients (33%) relapsed or died: DD, 33 patients (15 deaths); CS, 38 patients (22 deaths). Dose dense showed a trend for improved disease-free survival (DFS) and overall survival (OS). Four-year rates of DFS and OS were 64 and 85% for DD, and 58 and 75% for CS. All seven cycles were administered to 208 patients (96%). Rates of cycle delay, discontinuation, dose reduction, and adverse events were similar in both groups. Dose-dense sequential chemotherapy with epirubicin/paclitaxel then CMF, supported by filgrastim, is safe and improves survival for patients with node-positive breast cancer.

Cervical intraepithelial neoplasia--biopsy methods as AIDS for diagnosis and therapy

Between 1977 and 1995, a total of 1610 patients were admitted to hospital with Pap III, IIID, IVa or IVb. The results of 1182 conisations with cervical abrasion and 428 ectocervical surface scrapings with cervical abrasion were evaluated. The percentage of findings of (CIN II was 35.2% for all cases and 23.3% for conisation alone. No atypical findings or CIN I was seen in 13.9% of all conisation cases. The introduction of a second biopsy method (ectocervical surface scraping (ESS) in 1985 resulted in the reduction of cases with a positive histological finding for conisations of (CIN I from 17.7% (1977-1984, n = 468) to 11.3% (1985-1995, n = 714). Evaluation of combined PA and punch biopsy from the ectocervix assisted by colposcopy was performed in 130 cases. Histological correspondence between the methods was seen in 44.6% of the cases. In 22.3% of the patients the highest CIN degree was seen in the biopsy material obtained under colposcopic observation, while in 33.1% of the cases the highest degree of dysplasia was seen in the material obtained by ectocervical surface scraping. Conisation as the sole diagnostic tool can be replaced by combined and simplified biopsy techniques without prejudice to safety. If only PA is performed, the possibility cannot be ruled out that in individual cases an early-stage invasive cervical carcinoma may be overlooked. Conisation performed without evidence of atypical epithelial structures or only CIN I findings must be regarded as over-treatment. For all CIN III cases, however, conisation remains the most important form of therapy.

[Ductal carcinoma of the male breast]

Ductal carcinoma in the breast of a 64-year-old male is reported. Diagnosis, therapy, prognosis and follow-up are discussed. Current standard therapy is ablatio mammae, with axillary lymph node dissection. A decision in respect of chemotherapy depends on the results of staging. A follow-up control of the patients for early detection and therapy of metastasis is recommended. Our data as well as recent data from literature suggest that with respect to TNM Stages in mammary carcinoma, there is no prognostic difference between men and women.

[Breast asymmetry--differential diagnosis and surgical correction]

The problems of asymmetry of the female breast have been exemplified on four cases. Changes in a single breast due to anatomical defects or as a result of an accident, as well as changes due to a large fibroadenoma have been presented. Surgical correction was made after an individual evaluation of each case and included reduction mammoplasty, breast augmentation, lifting and nipple transplantation or reconstruction.