Impact of sex on the efficacy and safety of panitumumab plus fluorouracil and folinic acid versus fluorouracil and folinic acid alone as maintenance therapy in RAS WT metastatic colorectal cancer (mCRC). Subgroup analysis of the PanaMa-study (AIO-KRK-0212)

BACKGROUND

Clinical trials in metastatic colorectal cancer (mCRC) are usually conducted irrespective of sex. Sex-associated differences relating to safety and efficacy in the treatment of mCRC, however, are gaining interest.

METHODS

PanaMa investigated the efficacy of panitumumab (Pmab) plus fluorouracil and folinic acid (FU/FA) versus FU/FA alone after induction therapy with six cycles of FU/FA and oxaliplatin plus Pmab in patients with RAS wild-type mCRC. In this post hoc analysis, the study population was stratified for sex. Evaluated efficacy endpoints during maintenance treatment were progression-free survival (PFS, primary endpoint of the trial), overall survival (OS) and objective response rate during maintenance therapy. Safety endpoints were rates of any grade and grade 3/4 adverse events during maintenance therapy.

RESULTS

In total, 165 male and 83 female patients were randomized and treated. Male and female patients showed numerically better objective response rates with Pmab, without reaching statistical significance. Male patients derived a significant benefit from the addition of Pmab to maintenance treatment with regard to PFS [hazard ratio (HR) 0.63; 95% confidence interval (CI) 0.45-0.88; P = 0.006] that was not observed in female patients (HR 0.85; 95% CI 0.53-1.35; P = 0.491). The better PFS for male patients treated with Pmab did not translate into improved OS (HR 0.85; 95% CI 0.55-1.30; P = 0.452). Female patients showed numerically improved OS when treated with Pmab. There was no difference in the total of grade ≥3 adverse events during maintenance regarding sex (P = 0.791). Female patients, however, had a higher rate of any grade nausea, diarrhea and stomatitis.

CONCLUSIONS

In the PanaMa trial, the addition of Pmab to maintenance treatment of RAS wild-type mCRC with FU/FA improved the outcome in terms of the primary endpoint (PFS) particularly in male patients. Female patients did not show the same benefit while experiencing higher rates of adverse events. Our results support the development of sex-specific protocols.

Study protocol of the FIRE-8 (AIO-KRK/YMO-0519) trial: a prospective, randomized, open-label, multicenter phase II trial investigating the efficacy of trifluridine/tipiracil plus panitumumab versus trifluridine/tipiracil plus bevacizumab as first-line treatment in patients with metastatic colorectal cancer

Background

Initial systemic therapy for patients with metastatic colorectal cancer (mCRC) is usually based on two- or three-drug chemotherapy regimens with fluoropyrimidine (5-fluorouracil (5-FU) or capecitabine), oxaliplatin and/or irinotecan, combined with either anti-VEGF (bevacizumab) or, for RAS wild-type (WT) tumors, anti-EGFR antibodies (panitumumab or cetuximab). Recommendations for patients who are not eligible for intensive combination therapies are limited and include fluoropyrimidine plus bevacizumab or single agent anti-EGFR antibody treatment. The use of a monochemotherapy concept of trifluridine/ tipiracil in combination with monoclonal antibodies is not approved for first-line therapy, yet. Results from the phase II TASCO trial evaluating trifluridine/ tipiracil plus bevacicumab in first-line treatment of mCRC patients and from the phase I/II APOLLON trial investigating trifluridine/ tipiracil plus panitumumab in pre-treated mCRC patients suggest favourable activity and tolerability of these new therapeutic approaches.

Methods

FIRE-8 (NCT05007132) is a prospective, randomized, open-label, multicenter phase II study which aims to evaluate the efficacy of first-line treatment with trifluridine/tipiracil (35 mg/m² body surface area (BSA), orally twice daily on days 1–5 and 8–12, q28 days) plus either the anti-EGFR antibody panitumumab (6 mg/kg body weight, intravenously on day 1 and 15, q28 days) [arm A] or (as control arm) the anti-VEGF antibody bevacizumab (5 mg/kg body weight, intravenously on day 1 and 15, q28 days) [arm B] in RAS WT mCRC patients. The primary objective is to demonstrate an improved objective response rate (ORR) according to RECIST 1.1 from 30% (control arm) to 55% with panitumumab. With a power of 80% and a two-sided significance level of 0.05, 138 evaluable patients are needed. Given an estimated drop-out rate of 10%, 153 patients will be enrolled.

Discussion

To the best of our knowledge, this is the first phase II trial to evaluate the efficacy of trifluridine/tipiracil plus panitumumab in first-line treatment of RAS WT mCRC patients. The administration of anti-EGFR antibodies rather than anti-VEGF antibodies in combination with trifluridine/tipiracil may result in an increased initial efficacy.

Trial registration

EU Clinical Trials Register (EudraCT) 2019-004223-20. Registered October 22, 2019, ClinicalTrials.govNCT05007132. Registered on August 12, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09892-8.

Dynamic molecular analysis and clinical correlates of tumor evolution within a phase II trial of panitumumab-based therapy in metastatic colorectal cancer

Background

Mutations in rat sarcoma (RAS) genes may be a mechanism of secondary resistance in epidermal growth factor receptor inhibitor-treated patients. Tumor-tissue biopsy testing has been the standard for evaluating mutational status; however, plasma testing of cell-free DNA has been shown to be a more sensitive method for detecting clonal evolution.

Materials and methods

Archival pre- and post-treatment tumor biopsy samples from a phase II study of panitumumab in combination with irinotecan in patients with metastatic colorectal cancer (mCRC) that also collected plasma samples before, during, and after treatment were analyzed for emergence of mutations during/post-treatment by next-generation sequencing and BEAMing.

Results

The rate of emergence of tumor tissue RAS mutations was 9.5% by next-generation sequencing (n = 21) and 6.3% by BEAMing (n = 16). Plasma testing of cell-free DNA by BEAMing revealed a mutant RAS emergence rate of 36.7% (n = 39). Exploratory outcomes analysis of plasma samples indicated that patients who had emergent RAS mutations at progression had similar median progression-free survival to those patients who remained wild-type at progression. Serial analysis of plasma samples showed that the first detected emergence of RAS mutations preceded progression by a median of 3.6 months (range, −0.3 to 7.5 months) and that there did not appear to be a mutant RAS allele frequency threshold that could predict near-term outcomes.

Conclusions

This first prospective analysis in mCRC showed that serial plasma biopsies are more inclusive than tissue biopsies for evaluating global tumor heterogeneity; however, the clinical utility of plasma testing in mCRC remains to be further explored.

ClinicalTrials.gov Identifier

NCT00891930

Abstract P1-11-10: Efficacy of NEPA as antiemetic prophylaxis in breast cancer patients receiving highly or moderately emetogenic chemotherapy – Interim results of a German prospective, non-interventional study

Background

The oral fixed dose combination of netupitant and palonosetron NEPA has been approved for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) in cancer patients receiving cisplatin-based highly emetogenic (HEC) or moderately emetogenic chemotherapy (MEC). The primary objective of the prospective, non-interventional study (NIS) AkyPRO is the evaluation of quality of life in adults receiving MEC or HEC and NEPA for CINV prevention. Secondary endpoints are efficacy and safety of NEPA. Here we present an interim analysis of NEPA efficacy in the subgroup of breast cancer patients, who represent the largest subgroup (66%) of enrolled patients. Since September 2015, 2427 patients have been enrolled, of whom 986 are breast cancer patients.

Methods

The NIS has been designed to evaluate NEPA in 2,500 cancer patients receiving single day or two day MEC or HEC. QoL is recorded by FLIE questionnaires. Efficacy (complete response (CR, no vomiting, no rescue medication)), additional medication, and adverse events are recorded in patient diaries over three consecutive chemotherapy cycles. Additionally, physicians report their efficacy assessments of NEPA online, using an eCRF.

Results

At the cut-off date November 11, 2017, 2427 patients had been enrolled in the study. For the interim analysis 986 breast cancer patients were evaluated who had been fully documented in the eCRF at the cut-off date.

95% had an ECOG performance status of 0 or 1. 51% received adjuvant, 44% neoadjuvant, and 5% palliative chemotherapy. 80% of patients received HEC, mostly (79%) anthracycline/cyclophosphamide (AC) combinations. Of the women receiving MEC, the majority were treated with carboplatin-based regimens (9%). 7% of patients received other MEC regimens.

81.4-82.8 % of patients reported CR in cycles 1-3 and more than 93% of patients reported no emesis during the 3 treatment cycles covered in the patient diaries. No significant nausea was reported by 62.7-64.2% of patients.

Physicians rated the efficacy of the antiemetic prophylaxis with NEPA using the 4 categories very good, good, satisfactory, and poor. In cycles 1 and 2, more than 89% of physicians rated the efficacy of NEPA very good or good. In cycle 3, 90.6% rated it very good or good. In addition to reporting CR, nausea and emesis episodes in their patient diaries, patients used the same 4 categories to assess the efficacy of NEPA at the end of each treatment cycle. Efficacy assessments of physicians and patients were very similar, with 87% of patients choosing very good or good in cycle 1 compared to 89% of physicians.

NEPA was well tolerated. Low-grade constipation (14.9%) and insomnia (8.3%) were the most frequent treatment-related adverse event.

Conclusion

In this real life study, NEPA was effective in the prevention of CINV in the subgroup of breast cancer patients receiving HEC or MEC. The efficacy assessments by patients and physicians were comparable, with approximately 90% good or very good efficacy for 3 consecutive cycles. More than 93% of patients reported no emesis and more than 81% reported CR during the 5 days post-chemotherapy during all 3 cycles. The study is ongoing.

Citation Format: Schilling J, Hielscher C, Hanusch C, Kurbacher C, Busch S, Karthaus M. Efficacy of NEPA as antiemetic prophylaxis in breast cancer patients receiving highly or moderately emetogenic chemotherapy – Interim results of a German prospective, non-interventional study [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 P1-11-10.

Abstract P6-11-05: NEPA for CINV prevention in highly or moderately emetogenic chemotherapy – interim results of a German non-interventional study on quality of life and efficacy

Background

Inadequately controlled chemotherapy-induced nausea and vomiting (CINV) has a significant impact on the quality of life and daily functioning of cancer patients. Despite international antiemetic guidelines (ASCO, NCCN, MASCC/ESMO), CINV remains a problem for patients, especially in the delayed phase after chemotherapy application. International guidelines recommend a triple combination of 5-HT3- and NK1-receptor antagonist (RA) and dexamethasone given on day 1 for patients receiving HEC including anthracycline / cyclophosphamide (AC)-containing chemotherapy. The MASCC/ESMO guidelines recommend the triple regimen on day 1 also for patients receiving carboplatin-based MEC.

NEPA, a fixed dose combination of the NK1-RA netupitant and the 5-HT3-RA palonosetron, has been approved for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) in cancer patients receiving cisplatin-based highly emetogenic (HEC) or moderately emetogenic chemotherapy (MEC).

Objectives

The primary objective of this prospective, non-interventional study is the evaluation of quality of life (QoL) in adult cancer patients receiving NEPA for CINV prevention in MEC or HEC. Secondary endpoints are efficacy and safety of NEPA.

Methods

The study is planned to enroll 2,500 cancer patients receiving single or two day MEC or HEC in German oncology centers. NEPA is prescribed in accordance with the marketing authorization. QoL is recorded in FLIE questionnaires. Efficacy, determined as complete response (CR, no vomiting, no rescue medication), additional medication, and adverse events are recorded in patient diaries and e-CRF. Three consecutive chemotherapy cycles must be documented.

Results

At the cut-off date 31 May 2017, 1,959 patients had been included. 86.3% of patients were female, with a median age of 57 years. 94.1% of patients had an ECOG Performance Status of 0 or 1. 67.4% of patients had breast cancer. 47% of patients received adjuvant, 31.7% received neoadjuvant chemotherapy.

At the cut-off date 31.05.2017, efficacy, assessed by physicians on a 4 point scale, was rated very good or good for 1,656 (89.7%), 1,540 (90.0%) and 1,469 (91.8%) patients in cycle 1, 2 and 3, respectively. The overall efficacy assessments of physicians and patients were very similar with approximately 90 % of good or very good efficacy of NEPA. Quality of life data as analyzed by 24 March 2017: Less than 10% of patients experienced reduced quality of life, with 90.8%, 92.1% and 90.8% reporting no impact on daily life due to vomiting for HEC in cycle 1, 2 and 3 and 92.1%, 91.7% and 93.6% for MEC. Nausea was harder to control. 64.0%-65.2% of the patients receiving HEC reporting no impact on daily life by nausea and 61.1% - 65.0% of the patients receiving MEC.

Conclusions

NEPA was very effective in the CINV-prevention in patients receiving HEC or MEC, with more than 90% of patients reporting no impact on daily life by vomiting. The study is ongoing.

Citation Format: Schilling J, Klare P, Heilmann V, Wülfing P, Karthaus M. NEPA for CINV prevention in highly or moderately emetogenic chemotherapy – interim results of a German non-interventional study on quality of life and efficacy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-11-05.

Diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients: guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Fever may be the only clinical symptom at the onset of infection in neutropenic cancer patients undergoing myelosuppressive chemotherapy. A prompt and evidence-based diagnostic and therapeutic approach is mandatory. A systematic search of current literature was conducted, including only full papers and excluding allogeneic hematopoietic stem cell transplant recipients. Recommendations for diagnosis and therapy were developed by an expert panel and approved after plenary discussion by the AGIHO. Randomized clinical trials were mainly available for therapeutic decisions, and new diagnostic procedures have been introduced into clinical practice in the past decade. Stratification into a high-risk versus low-risk patient population is recommended. In high-risk patients, initial empirical antimicrobial therapy should be active against pathogens most commonly involved in microbiologically documented and most threatening infections, including Pseudomonas aeruginosa, but excluding coagulase-negative staphylococci. In patients whose expected duration of neutropenia is more than 7 days and who do not respond to first-line antibacterial treatment, specifically in the absence of mold-active antifungal prophylaxis, further therapy should be directed also against fungi, in particular Aspergillus species. With regard to antimicrobial stewardship, treatment duration after defervescence in persistently neutropenic patients must be critically reconsidered and the choice of anti-infective agents adjusted to local epidemiology. This guideline updates recommendations for diagnosis and empirical therapy of fever of unknown origin in adult neutropenic cancer patients in light of the challenges of antimicrobial stewardship.

Abstract P2-11-01: Non interventional study with netupitant/ palonosetron (NEPA) as CINV prophylaxis in highly or moderately emetogenic chemotherapy

Background

Nausea and Vomiting due to cancer therapy is still a problem for patients and physicians and therefore an ongoing item of research in oncology. International antiemetic guidelines (ASCO, NCCN, MASCC/ESMO) have been published and new drugs are introduced into the market. The fixed oral combination of the NK1-receptor antagonist (RA) netupitant and the 5-HT3-RA palonosetron (NEPA) was recently approved in US and EU for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) in cancer patients receiving cisplatin-based highly emetogenic (HEC) or moderately emetogenic chemotherapy (MEC). The MASCC guidelines 2016 recommend a triple combination of 5-HT3- and NK1-RA and dexamethasone given on day 1 for patients receiving HEC, anthracycline / cyclophosphamide (AC)-containing chemotherapy as well as for carboplatin-based MEC for the prevention of chemotherapy-induced nausea and vomiting (CINV).

Objectives

The primary endpoint of this non interventional study is the evaluation of quality of life in adult cancer patients receiving NEPA for CINV prevention in MEC or HEC. Secondary endpoints are efficacy and safety of NEPA.

Methods

This non-interventional study evaluates CINV prophylaxis with NEPA and QoL in 2500 cancer patients receiving single day or two day MEC or HEC in an ambulatory setting in German cancer hospitals and specialized cancer practices. NEPA is prescribed in accordance with the EU marketing authorization. Quality of life is recorded by FLIE questionnaires. Efficacy - measured as complete response (CR, no vomiting, no rescue medication) –as well as additional medication, safety and adverse events (AEs) are documented by an online questionnaire filled by the physician and a patient diary. 3 consecutive chemotherapy cycles are documented online using the ODM QuaSi documentation system. All specifications in the online documentation must be verifiable.

Results

700 patients from 175 centers (93 gynaecologic oncology, 79 medical oncology, 3 urologic oncology) are included to date. The majority of patients were women (88.7%). 71% of all patients had breast cancer. 92.6% had an ECOG performance status of 0-1. 77.6% received (neo)adjuvant chemotherapy. Most common chemotherapy regimens were AC-based regimens (53.9%), carboplatin-based regimens (15.9%) and cisplatin-based regimens (12%).

Efficacy data are available for 486 patients in cycle 1 and 350 patients over 3 cycles. During 3 consecutive chemotherapy cycles, 89% of patients had a CR on day 1 as recorded by patient diaries. In the delayed phase (days 2-5), 85% of patients had a CR. 93% recorded no vomiting during the entire 5 days at risk following chemotherapy and 69% reported no or only mild nausea. > 90% of the medical staff rated the efficacy of the CINV-prophylaxis with NEPA as good or very good over 3 cycles.

Adverse events (AE), mostly constipation were rare and mild and only of grade 1 or 2. No serious AEs were observed.

Summary

NEPA is a safe and efficacious option for the prophylaxis of nausea and vomiting in highly and moderately emetogenic chemotherapy.

Citation Format: Schilling JP, Karthaus M, Klare P, Guth D, Ortner PA. Non interventional study with netupitant/ palonosetron (NEPA) as CINV prophylaxis in highly or moderately emetogenic chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-11-01.

A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients

BACKGROUND

Central venous catheter (CVC)-related bloodstream infections (CRBSI) are a frequent cause of morbidity and mortality in patients with chemotherapy-induced neutropenia. Chlorhexidine containing catheter securement dressings may prevent CRBSI.

PATIENTS AND METHODS

A multicenter randomized, controlled trial was conducted at 10 German hematology departments. We compared chlorhexidine-containing dressings with non-chlorhexidine control dressings in neutropenic patients. The primary end point was the incidence of definite CRBSI within the first 14 days (dCRBSI14) of CVC placement. Secondary end points included combined incidence of definite or probable CRBSI within 14 days (dpCRBSI14), overall (dpCRBSI), incidence of unscheduled dressing changes and adverse events.

RESULTS

From February 2012 to September 2014, 613 assessable patients were included in the study. The incidence of dCRBSI14 was 2.6% (8/307) in the chlorhexidine and 3.9% (12/306) in the control group (P = 0.375). Both dpCRBSI14 and dpCRBSI were significantly less frequent in the study group with dpCRBSI14 in 6.5% (20/307) of the chlorhexidine group when compared with 11% (34/306) in the control group (P = 0.047), and dpCRBSI in 10.4% (32/307) versus 17% (52/306), respectively (P = 0.019). The frequency of dressing intolerance with cutaneous and soft tissue abnormalities at the contact area was similar in both groups (12.4% and 11.8%; P = 0.901).

CONCLUSIONS

Although the trial failed its primary end point, the application of chlorhexidine containing catheter securement dressings reduces the incidence of definite or probable CRBSI in neutropenic patients.

CLINICAL TRIALS NUMBER

NCT01544686 (Clinicaltrials.gov).

Prophylaxis of infectious complications with colony-stimulating factors in adult cancer patients undergoing chemotherapy-evidence-based guidelines from the Infectious Diseases Working Party AGIHO of the German Society for Haematology and Medical Oncology (DGHO)

BACKGROUND

Current evidence on myelopoietic growth factors is difficult to overview for the practicing haematologist/oncologist. International guidelines are sometimes conflicting, exclude certain patient groups, or cannot directly be applied to the German health system. This guideline by the Infectious Diseases Working Party (AGIHO) of the German Society of Haematology and Medical Oncology (DGHO) gives evidence-based recommendations for the use of G-CSF, pegylated G-CSF, and biosimilars to prevent infectious complications in cancer patients undergoing chemotherapy, including those with haematological malignancies.

METHODS

We systematically searched and evaluated current evidence. An expert panel discussed the results and recommendations. We then compared our recommendations to current international guidelines.

RESULTS

We summarised the data from eligible studies in evidence tables, developed recommendations for different entities and risk groups.

CONCLUSION

Comprehensive literature search and expert panel consensus confirmed many key recommendations given by international guidelines. Evidence for growth factors during acute myeloid leukaemia induction chemotherapy and pegfilgrastim use in haematological malignancies was rated lower compared with other guidelines.

A randomized phase III study evaluating the efficacy and safety of NEPA, a fixed-dose combination of netupitant and palonosetron, for prevention of chemotherapy-induced nausea and vomiting following moderately emetogenic chemotherapy

BACKGROUND

Antiemetic guidelines recommend co-administration of agents that target multiple molecular pathways involved in emesis to maximize prevention and control of chemotherapy-induced nausea and vomiting (CINV). NEPA is a new oral fixed-dose combination of 300 mg netupitant, a highly selective NK1 receptor antagonist (RA) and 0.50 mg palonosetron (PALO), a pharmacologically and clinically distinct 5-HT3 RA, which targets dual antiemetic pathways.

PATIENTS AND METHODS

This multinational, randomized, double-blind, parallel group phase III study (NCT01339260) in 1455 chemotherapy-naïve patients receiving moderately emetogenic (anthracycline-cyclophosphamide) chemotherapy evaluated the efficacy and safety of a single oral dose of NEPA versus a single oral dose (0.50 mg) of PALO. All patients also received oral dexamethasone (DEX) on day 1 only (12 mg in the NEPA arm and 20 mg in the PALO arm). The primary efficacy end point was complete response (CR: no emesis, no rescue medication) during the delayed (25-120 h) phase in cycle 1.

RESULTS

The percentage of patients with CR during the delayed phase was significantly higher in the NEPA group compared with the PALO group (76.9% versus 69.5%; P = 0.001), as were the percentages in the overall (0-120 h) (74.3% versus 66.6%; P = 0.001) and acute (0-24 h) (88.4% versus 85.0%; P = 0.047) phases. NEPA was also superior to PALO during the delayed and overall phases for all secondary efficacy end points of no emesis, no significant nausea and complete protection (CR plus no significant nausea). NEPA was well tolerated with a similar safety profile as PALO.

CONCLUSIONS

NEPA plus a single dose of DEX was superior to PALO plus DEX in preventing CINV following moderately emetogenic chemotherapy in acute, delayed and overall phases of observation. As a fixed-dose antiemetic drug combination, NEPA along with a single dose of DEX on day 1 offers guideline-based prophylaxis with a convenient, single-day treatment.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

Abstract P3-09-01: NEPA, a fixed-dose combination of netupitant and palonosetron, prevents chemotherapy-induced nausea and vomiting (CINV) more effectively and reduces the impact on daily living for breast cancer patients compared with palonosetron

Background:

Breast cancer (BC) patients receiving anthracycline-cyclophosphamide (AC) chemotherapy (CT) are at risk for developing CINV due not only to the emetogenicity of the CT but also to young age and gender. As recommended by international antiemetic guidelines, targeting multiple molecular pathways involved in emesis related to AC is important for maximizing control of CINV and improving the functional status of BC patients during CT. NEPA is a fixed-dose combination of netupitant (NETU), a highly-selective NK1 receptor antagonist (RA), and palonosetron (PALO), a pharmacologically distinct 5-HT3 RA, that targets dual antiemetic pathways with a convenient single day dose.

Methods:

This was a multinational, randomized, double-blind, phase 3 study evaluating the efficacy and safety of a single oral dose of NEPA (NETU 300 mg + PALO 0.50 mg) versus a single oral 0.50 mg dose of PALO in chemotherapy-naïve patients receiving AC. All patients received oral dexamethasone (DEX) on day 1 (12 mg NEPA arm; 20 mg PALO arm). The primary efficacy endpoint was complete response (CR: no emesis, no rescue medication) in the delayed phase, 25-120h after CT. The Functional Living Index-Emesis (FLIE) questionnaire with a 5-day recall period was used to assess the impact of CINV on patients’ daily lives as a secondary endpoint. The FLIE consists of 9 nausea-specific (nausea domain) and 9 vomiting-specific (vomiting domain) items that address the effect of nausea and vomiting on daily life. Each item is scored on a 7-point 100 mm visual analog scale with anchors of “none/not at all” and “a great deal”. The proportion of patients with an average item score >6 reflecting “no impact on daily life” (NIDL) (ie, total FLIE score >108, nausea/vomiting domain score >54) was compared for NEPA vs PALO using a Cochran-Maentel-Haenszel test stratified by age class and region.

Results:

1455 patients with a mean age of 54 were randomized to receive NEPA or PALO. Treatment groups were similar; 98% were females with BC (97%).

As previously reported (ASCO 2013), NEPA showed superior CR rates compared to PALO for the acute 0-24h (88% vs 85%; p = 0.047), delayed (77% vs 70%; p = 0.001) and overall 0-120h (74% vs 67%; p = 0.001) phases.

A greater proportion of NEPA-treated patients reported NIDL for nausea, vomiting and combined domains compared to PALO.

% Patients with NIDL (Overall 0-120h)NEPA (N = 724)PALO (N = 725)p-valueNausea domain72%66%0.015Vomiting domain90%84%0.001Overall combined79%72%0.0056 patients excluded who did not receive AC or study drug

The adverse event (AE) profile was comparable between groups. Most frequently reported treatment-related AEs for NEPA and PALO, respectively, were headache (3.3%, 3.0%) and constipation (2.1%, 2.1%).

Conclusions:

In this large Phase 3 study of predominantly females with BC receiving AC, NEPA was superior to PALO in preventing CINV and reducing the negative impact of CINV on patients’ daily lives. As a fixed-dose antiemetic drug combination including an NK1 RA and 5-HT3 RA, NEPA offers improved efficacy over PALO alone, with a convenient single-day dose, and oral DEX only on day 1.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-01.

Diagnosis of invasive fungal infections in hematology and oncology--guidelines from the Infectious Diseases Working Party in Haematology and Oncology of the German Society for Haematology and Oncology (AGIHO)

Invasive fungal infections (IFIs) are a primary cause of morbidity and mortality in patients with hematological malignancies. Establishing a definite diagnosis of IFI in immunocompromised patients is particularly challenging and time consuming, but delayed initiation of antifungal treatment increases mortality. The limited overall outcome has led to the strategy of initiating either 'empirical' or 'preemptive' antifungal therapy before the final diagnosis. However, diagnostic procedures have been vastly improved in recent years. Particularly noteworthy is the introduction of newer imaging techniques and non-culture methods, including antigen-based assays, metabolite detection and molecular detection of fungal DNA from body fluid samples. Though varying widely in cancer patients, the risk of IFI is highest in those with allogeneic stem cell transplantation and those with acute leukemia. The AGIHO presents recommendations for the diagnosis of IFIs with risk-adapted screening concepts for febrile episodes in patients with haemato-oncological disorders.

Gemcitabine (G) and cisplatin (C) as first-line treatment of metastatic breast cancer (MBC): Results of phase II trial

273

Background: G has been studied in combination with a variety of agents known to be active in cancer. G has a mild toxicity profile. GC is active in various advanced tumors. Splitting of C dose (D 1 + d8) is better tolerated and can be a good alternative to once a cycle in pts with advanced breast cancer. This phase II trial evaluates G (1000 mg/m2) C (35 mg/ m2) d1+8 repeated every 21 d in the 1st-line treatment of metastatic breast cancer (MBC). The primary objective of the study was to determine the objective tumor response rate (ORR) of 1st-line GC in patients with metastatic breast cancer.The one-stage design tested the null hypothesis that the true response rate for this population should be equal to 50% for efficacy. Overall survival (OS), time to progression (TTP) and toxicity were evaluated.

Methods: 70 female MBC pts with the median age of 49.8 ys (range 29.6-80.0) were enrolled. Tumor assessment was performed every other cycle by standard criteria including CT or MRI. 67 pts received a total of 310 cycles GC, out of these 54 pts were evaluable for efficacy.

Results: Complete and partial responses were observed in 7/54 (13.0%) and 19/54 (35.2%) evaluable pts, respectively with an overall response of 48.2%. Disease stabilization was noticed in 19/54 (35.2%) pts. Progression was observed in 5/54 (9.3%) pts. TTP was 33.9 weeks (95% CI, 23.9-48.0). OS was 84.0 weeks (95% CI, 58.6-119.3). 1-year overall survival rate was 68.4% (95% CI, 53.6-79.3%). Hematological toxicity G4 was neutropenia in 14.9% (10/67), and no G4 thrombocytopenia. Hypotension G4 (1.5%) was the only severe non-hematological toxicity.

Conclusions: GC in the first-line treatment of MBC, demonstrated a substantial overall response rate and had a good toxicity profile. GC is a suitable option for first-line MBC in selected pts.

Prophylaxis and treatment of invasive aspergillosis with voriconazole, posaconazole and caspofungin: review of the literature

Major progress for the management of invasive aspergillosis has come from the introduction of new antifungals since the late 1990s. Although mortality of invasive aspergillosis remains as high as 30-50%. Backbone of management are prophylaxis, early diagnosis and early initiation of antifungals for reduction of invasive aspergillosis related mortality. Randomized trials have been undertaken for the prophylaxis as well as treatment of invasive aspergillosis in the last two decades. Posaconazole is recommended for prophylaxis against aspergillosis in patients treated for acute myelogenous leukemia, myelodysplastic syndrome or patients with graft versus host disease after allogeneic transplantation. Efficacy has been shown for first-line therapy of invasive aspergillosis with voriconazole and liposomal amphotericin B. Gastrointestinal resorption for the azoles posaconazole, voriconazole and itraconazole differ considerably. While oral voriconazole resportion is reduced when taken with food, posaconazole has to be taken with fatty food for optimal intestinal resorption. Beside all advances in the management of invasive aspergillosis important questions remain unresolved. This article reviews the current state of prophylaxis and treatment of invasive aspergillosis and points out clinicians unmet needs.

Current issues in the clinical management of invasive candida infections--the AGIHO, DMykG, ÖGMM and PEG web-based survey and expert consensus conference 2009

The objectives of this study were to identify unsolved issues in the management of invasive candidiasis, identify controversies and achieve consensus. The German Speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMykG e.V.) asked other German infectious diseases (ID) and mycological societies to submit unsolved issues concerning the diagnosis and treatment of fungal infections. Based on these contributions, a digital web-based questionnaire of 12 questions on Candida infections was designed to be completed by experts of the participating societies. Controversial results were identified by a mathematical model and were discussed at a consensus conference during the 43rd Annual Meeting of the DMykG e.V. in Cologne, Germany. Forty-two individuals completed the questionnaire. Analysis showed a strong consensus on treatment indications, choice of antifungals for clinical situations, handling of central venous catheters, duration of treatment and role of susceptibility testing. Opinions diverged on: initial treatment of haemodynamically stable neutropenic and haemodynamically unstable non-neutropenic patients, step down to oral treatment and the differential role of the echinocandins. These questions were presented for discussion at the expert consensus conference. In three of four questions, consensus was achieved. A two-step approach - web-based survey plus classical panel discussion - allows to capture expeditiously the opinions of a large and diverse group of individuals, to identify controversial issues and to resolve them in a personal, interactive setting. Thus, expert consensus was achieved on nine of 12 important questions on how to treat invasive candidiasis.

A randomized, double-blind, placebo-controlled trial for prevention of oxaliplatin-induced neuropathy symptoms with pregabalin

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Background: Sensorial peripheral neuropathy (PNP) is a major limitation for pts receiving oxaliplatin-based ctx for CRC. Pregabalin is widely used for treatment of oxaliplatin-induced PNP. We evaluated the efficacy of pregabalin vs. placebo for the prevention of paresthesia from the onset of oxaliplatin-based ctx over each cycle.

Methods: Rd, db, placebo-controlled study in adult CRC pts with ECOG 0-2 to undergo a new oxaliplatin/5-FU/FA-based ctx. Pts were excluded if they had neuropathic pain or other of painful paresthesia prior to baseline. Paresthesia, dysesthesia, and pain were rated on a numerical scale (NRS 0-10) every day. Primary endpoint was the time of onset of persistent symptoms (NRS >4).

Results: Of the 69 screened pts, 64 were randomized and 61 received study medication (32 pregabalin vs. 29 placebo). Pts were balanced in both arms regarding age, sex, stage, and ctx. There were no differences between both treatment groups for all PNP parameters at any cycle. One pt in both arms developed paresthesia (5.3%) after 9 cycles of ctx, 1 pt had persistent pain (placebo arm). During the follow-up period persistent paresthesic, dysesthesic, and persistent pain developed in 2 vs. 1, 2 vs. 2, and 0 vs. 2 pts, respectively. The study was terminated after a blinded data review found that there were very few events of persistent symptoms, which was then confirmed an interim analysis. Nausea and anorexia were the most frequently reported AE in both groups.

Conclusions: The results of this study, which was terminated early at interim analysis, is that too few patients developed persistent symptoms to allow any meaningful treatment difference for prevention of neuropathic pain related to oxaliplatin by pregabalin. There remains an unmet need for oxaliplatin-induced PNP with new trial design issues in this field urgently needed.

No significant financial relationships to disclose.

Interdisciplinary management of EGFR-inhibitor-induced skin reactions: a German expert opinion

BACKGROUND

Anti-epidermal growth factor receptor treatment strategies, i.e. monoclonal antibodies such as cetuximab and panitumumab, or epidermal growth factor receptor (EGFR) small molecule tyrosine kinase inhibitors, such as erlotinib and gefitinib, have expanded the treatment options for different tumor types. Dermatologic toxic effects are the most common side-effects of EGFR inhibitor therapy. They can profoundly affect the patient's quality of life.

PURPOSE

The aim of this study was to provide interdisciplinary expert recommendations on how to treat patients with skin reactions undergoing anti-EGFR treatment.

MATERIAL AND METHODS

An expert panel from Germany with expertise in medical oncology, dermatology or clinical pharmacology was convened to develop expert recommendations based on published peer-reviewed literature.

RESULTS

The expert recommendations for the state-of-the-art treatment of skin reactions induced by EGFR inhibitor therapy include recommendations for diagnostics and grading as well as grade-specific and stage-adapted treatment approaches and preventive measures. It was concluded that EGFR-inhibitor-related dermatologic reactions should always be treated combining basic care of the skin and a specific therapy adapted to stage and grade of skin reaction. For grade 2 and above, specific treatment recommendations for early- and later-stage skin reactions induced by EGFR-inhibitor therapy were proposed.

CONCLUSION

This paper presents a German national expert opinion for the treatment of skin reactions in patients receiving EGFR inhibitor therapy.

Current aspects of invasive candidiasis and aspergillosis in adult intensive care patients

Sepsis is a leading cause of death in the intensive care unit (ICU), with Candida spp. in the forefront among the important pathogens. As recent studies have shown, survival outcome is strongly influenced by adequate antifungal therapy at an early stage that is often delayed by the time lag associated with microbiological diagnosis. Risk factor-based prediction models have a high negative predictive value, but positive prediction of candidaemia in the individual patient remains elusive. New antigen- or DNA-based methods for early diagnosis still await clinical validation. Their routine use is hampered by methodological issues. Species distribution of invasive Candida isolates in the ICU appears to be influenced primarily by age, previous hospitalisation and colonising species. In the context of the importance of adequate first-line treatment, recent guidelines favour the use of echinocandins in critically ill patients with symptoms evoking high suspicion of invasive candidiasis. This is supported by robust clinical trial data, a few interactions and low toxicity. Fluconazole is characterised by reduced activity against some important Candida species, elevated rates of persistent infection seen in comparative trials. Amphotericin B deoxycholate should be considered obsolete in ICU patients because of its high toxicity. Invasive aspergillosis (IA) is a rare devastating infection in the general ICU population, but some centres have reported elevated incidences and underdiagnosis as determined in autopsy-controlled studies. Treatment with mould-active agents such as voriconazole must be initiated early in patients with suspected IA.

Updated analysis of a phase II study (20060314) of panitumumab (pmab) with FOLFIRI as first-line treatment of patients (pts) with metastatic colorectal cancer (mCRC)

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Background: The fully human anti-epidermal growth factor receptor monoclonal antibody pmab, has proven monotherapy activity in chemotherapy refractory mCRC pts with wild-type KRAS-expressing tumors. This first-line, single-arm phase II study is prospectively evaluating whether KRAS status predicts response to treatment when pmab is combined with FOLFIRI. Methods: In this ongoing study, pts with histologically confirmed mCRC (no prior systemic treatment) and ECOG PS 0–2 were enrolled at 36 sites across Europe. Pmab (6mg/kg) and FOLFIRI are administered every 2 weeks. The primary endpoint is objective response rate; secondary endpoints include disease control rate, duration of response, time to response, progression-free survival, time to progression and safety. Results: Data cut-off for the initial interim analysis was 27 June 08 and pending approval of protocol amendment 2, the cut off date for 16 week response rate is 15 Oct 08. Of the 154 pts enrolled, 68% are male; median age is 64 yrs (range, 21–84) and the majority (95%) of pts had ECOG PS 0–1. All pts have received at least one cycle of study treatment; 18% of pts have received ≤2 cycles of full combination therapy and the median number of cycles received is 6. At time of data cut-off, 112 patients (73%) were still receiving at least one element of combination therapy and 29% had stopped treatment with pmab. The most common reason for discontinuing treatment was disease progression (10%). Median follow-up time was 14.3 weeks for all enrolled pts. A total of 97% of patients had experienced at least one adverse event (any grade) and 55% of patients had experienced a grade 3/4 adverse event. There were four reported grade 5 events (hematemesis, rectal hemorrhage, vena cava thrombosis, general physical health deterioration). At time of interim analysis, tissue samples for KRAS analysis are available for approximately 80% of patients. Conclusions: Combining pmab with FOLFIRI in the first-line setting appears to be a well-tolerated regimen. Response rate at 16 weeks in the overall population and by KRAS status and updated safety will be presented.

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Unexpected toxicity (UT) and opportunistic infections (OI) after rituximab-containing therapy for non-Hodgkin's lymphoma (NHL)

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Background: Rituximab (R) is increasingly used for the treatment of B-NHL. Most adverse events are mild to moderate. In rare cases, however, R may be associated with severe UT and OI. Methods: The records of consecutive pts treated at 2 institutions from 01/06 to 12/08 with R-containing chemotherapy or R-maintenance therapy (R-M) for NHL were analyzed for severe UT and OI. UT was considered as related to R if it could not be explained otherwise. Results: 99 pts were included in the cohort study. Pts received a median of 6 cycles (range 1 - 18) of R. A total of 517 cycles of R were evaluable for OI or UT. 7 of 99 pts (7%) (2 females, 5 males) with a median age of 69.5 yrs (range 41–76) experienced UT (n=4) or OI (n=3). UT consisted of interstitial pneumonitis (IP) in 2 pts after 8 and 6 cycles of R-CHOP for diffuse large cell lymphoma (DLCL), a case of congestive heart failure (NYHA III°) after 6x R-CHOP + 2x R-M for follicular lymphoma (FL) and a case of grade 4 pancytopenia lasting for 22 days following 2x R-FC for chronic lymphocytic leukemia. IP completely resolved after initiation of prednisone (n=1) or under empiric antimicrobial therapy (n=1). Congestive heart failure improved under appropriate therapy and the pt received 2 more cycles of R-M. Pancytopenia slowly recovered under therapy with G-CSF, R was terminated. OI consisted of pneumocystis jirovecii pneumonia after 5x R-CHOP-14 for DLCL, Epstein-Barr-virus (EBV)-associated hepatitis after 5x R-CHOP-21 for relapsed FL and generalized herpes zoster following 6x R-bendamustine (RB) + 1x R-M for recurrent BALT-lymphoma. R was restarted in the latter 2 pts. Infections resolved under antimicrobial therapy. EBV-hepatitis improved spontaneously. Moreover, 2 pts were transferred to us for therapy of enterovirus-induced encephalitis after 6x R-CHOP-21 + 2x R-M for FL (n=1) and cerebral toxoplasmosis in a pt heavily pretreated with R-containing therapy for relapsed mantle cell lymphoma (n=1). Conclusions: Severe UT and OI are rare but potentially fatal complications. Awareness of UT/OI, rapid diagnostic proceedings and, whenever possible, initiation of therapy are essential. In selected cases reexposure of R may be feasible.

No significant financial relationships to disclose.

Epidermal growth factor receptor (EGFR) inhibitor–related skin toxicity: Review of interim data from a phase II study (20060314) of panitumumab (pmab) with FOLFIRI in the first-line treatment of metastatic colorectal cancer (mCRC)

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Background: Skin toxicity that can impact quality of life as well as treatment adherence is commonly associated with EGFR therapy. Despite their particular importance in terms of making decisions regarding supportive care, time to onset and maximum grade of skin toxicity are seldom reported. Pmab is a fully human monoclonal antibody directed against the EGFR with demonstrated monotherapy activity in patients (pts) with wild-type KRAS expressing, chemotherapy refractory, mCRC. Methods: In this single-arm study, first-line pts with histologically confirmed mCRC were enrolled to receive pmab (6mg/kg) and FOLFIRI every 2 weeks. This trial is ongoing to evaluate the primary endpoint of objective response rate and secondary endpoints including disease control rate, duration of response, time to response, progression-free survival, time to progression and other safety aspects. The focus of this abstract is skin toxicity. Results: Cutoff for the initial interim analysis was 27 June 2008. Of the 154 pts enrolled, 68% are male; median age is 64 years (range 21–84) and 95% of pts had ECOG PS 0–1. A total of 97% of pts had experienced at least one adverse event (any grade) and 55% of pts had experienced a grade 3/4 event. Grade 3/4 skin and subcutaneous toxicities were observed in 20% of pts ( Table ). Median time to first cutaneous toxicity and median time to most severe toxicity were 9 (95%CI, 7–13) and 14 (95%CI, 13–16) days, respectively. The most severe toxicity was grade 4 in one pt. Conclusions: Combining pmab with FOLFIRI in the first-line setting is a well-tolerated regimen. Skin toxicity was observed in 92% of patients; onset, incidence, and severity of which appears to be comparable to published data. Management of skin toxicities will be presented.

[Table: see text]

[Table: see text]

Renal safety of sustained pemetrexed (P)/platinum treatment for advanced malignant mesothelioma (MM)

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Background: MM is a very rare and aggressive neoplasm with a short life expectancy. Standard care of MM is P + cisplatinum (DDP). The optimal duration of chemotherapy(ctx) for MM is undetermined. The feasibility of maintenance with P/DDP has not been reported. A major obstacle to sustained P/DDP for MM is renal safety beside neurotoxicity. At present, there are no data regarding renal safety in pts receiving ≥ 6 cycles of P/DDP in MM. Methods: We evaluated long term renal function of P(500 mg/m2)/DDP(75 mg/m2) for MM prospectively. Ctx on d1 was repeated on d22 until disease progression or toxicity. Pts with impairment of renal function (creatinine-clearance <60 ml/min) switched to P/carboplatin (CP) AUC 5 for further ctx. P ctx was stopped if creatinine-clearance (CrCl) <45 ml/min. Routine folinic acid and vitamine B12 was administered to prevent AE. Study endpoint was long term renal function for sustained therapy of P/DDP followed by P/CP and/or P-mono. Results: Between 12/02 and 05/06 86 consecutive MM pts were treated. Staging revealed peritoneal MM in 19, and pleural MM in 67 pts. Five pts did not receive ctx. First-line ctx was P/DDP in 66 pts (prior s-crea 0.85; SD 0.17) given a mean of 4.9 cyles (range 1–11) for a mean of 120 d (21–397 d) and a mean of 138 mg DDP/cycle. 28 pts received CP/P sequentially for further maintenance up to 27 cycles (mean 6.4). A change from P/DDP to P/CP was necessary due to a worsening renal function in all of those pts. Mean s-crea/CrCl prior to DDP ctx in those pts was 0.87 mg/dl (SD 0.17)/96.0 ml/min (SD 26) and 1.01 mg/dl (SD 0.29)/73.4 ml/min (SD 22) at the end of P/DDP. Mean given CP dose was 425 mg/cycle (range 175 - 725 mg). Pts subsequently receiving P/CP had a s-crea of 1.16 mg/dl (CrCl 73.4 ml/min) prior to ctx that did not change during P/CP (1.13 mg/dl/CrCl 73.2 ml/min). 13 pts received P- mono with a mean of 8 cycles (1–26) subsequently. Renal function showed a s-crea(CrCl) of 1.13 mg/dl (71.2 ml/min) prior and 1.11 mg/dl (70.8 ml/min) at the end of P ctx. Conclusions: Long term maintenance P/DDP of MM is limited by renal impairment due to DDP, while subsequent P/CP or P-mono was feasible and not associated with further deterioration of renal function. Further trials with sustained P/CP or P ctx for MM are warranted to evaluate the efficacy of maintenance for advanced MM.

No significant financial relationships to disclose.