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Leal T, Kotecha R, Ramlau R, Zhang L, Milanowski J, Cobo M, Roubec J, Petruzelka L, Havel L, Kalmadi S, Ward J, Andric Z, Berghmans T, Gerber DE, Kloecker G, Panikkar R, Aerts J, Delmonte A, Pless M, Greil R, Rolfo C, Akerley W, Eaton M, Iqbal M, Langer C. Tumor Treating Fields therapy with standard systemic therapy versus standard systemic therapy alone in metastatic non-small-cell lung cancer following progression on or after platinum-based therapy (LUNAR): a randomised, open-label, pivotal phase 3 study. Lancet Oncol 2023; 24:1002-1017. [PMID: 37657460 DOI: 10.1016/s1470-2045(23)00344-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Tumor Treating Fields (TTFields) are electric fields that disrupt processes critical for cancer cell survival, leading to immunogenic cell death and enhanced antitumour immune response. In preclinical models of non-small-cell lung cancer, TTFields amplified the effects of chemotherapy and immune checkpoint inhibitors. We report primary results from a pivotal study of TTFields therapy in metastatic non-small-cell lung cancer. METHODS This randomised, open-label, pivotal phase 3 study recruited patients at 130 sites in 19 countries. Participants were aged 22 years or older with metastatic non-small-cell lung cancer progressing on or after platinum-based therapy, with squamous or non-squamous histology and ECOG performance status of 2 or less. Previous platinum-based therapy was required, but no restriction was placed on the number or type of previous lines of systemic therapy. Participants were randomly assigned (1:1) to TTFields therapy and standard systemic therapy (investigator's choice of immune checkpoint inhibitor [nivolumab, pembrolizumab, or atezolizumab] or docetaxel) or standard therapy alone. Randomisation was performed centrally using variable blocked randomisation and an interactive voice-web response system, and was stratified by tumour histology, treatment, and region. Systemic therapies were dosed according to local practice guidelines. TTFields therapy (150 kHz) was delivered continuously to the thoracic region with the recommendation to achieve an average of at least 18 h/day device usage. The primary endpoint was overall survival in the intention-to-treat population. The safety population included all patients who received any study therapy and were analysed according to the actual treatment received. The study is registered with ClinicalTrials.gov, NCT02973789. FINDINGS Between Feb 13, 2017, and Nov 19, 2021, 276 patients were enrolled and randomly assigned to receive TTFields therapy with standard therapy (n=137) or standard therapy alone (n=139). The median age was 64 years (IQR 59-70), 178 (64%) were male and 98 (36%) were female, 156 (57%) had non-squamous non-small-cell lung cancer, and 87 (32%) had received a previous immune checkpoint inhibitor. Median follow-up was 10·6 months (IQR 6·1-33·7) for patients receiving TTFields therapy with standard therapy, and 9·5 months (0·1-32·1) for patients receiving standard therapy. Overall survival was significantly longer with TTFields therapy and standard therapy than with standard therapy alone (median 13·2 months [95% CI 10·3-15·5] vs 9·9 months [8·1-11·5]; hazard ratio [HR] 0·74 [95% CI 0·56-0·98]; p=0·035). In the safety population (n=267), serious adverse events of any cause were reported in 70 (53%) of 133 patients receiving TTFields therapy plus standard therapy and 51 (38%) of 134 patients receiving standard therapy alone. The most frequent grade 3-4 adverse events were leukopenia (37 [14%] of 267), pneumonia (28 [10%]), and anaemia (21 [8%]). TTFields therapy-related adverse events were reported in 95 (71%) of 133 patients; these were mostly (81 [85%]) grade 1-2 skin and subcutaneous tissue disorders. There were three deaths related to standard therapy (two due to infections and one due to pulmonary haemorrhage) and no deaths related to TTFields therapy. INTERPRETATION TTFields therapy added to standard therapy significantly improved overall survival compared with standard therapy alone in metastatic non-small-cell lung cancer after progression on platinum-based therapy without exacerbating systemic toxicities. These data suggest that TTFields therapy is efficacious in metastatic non-small-cell lung cancer and should be considered as a treatment option to manage the disease in this setting. FUNDING Novocure.
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Affiliation(s)
- Ticiana Leal
- Winship Cancer Institute at Emory University, Atlanta, GA, USA.
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Rodryg Ramlau
- Poznan University of Medical Sciences, Poznan, Poland
| | - Li Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center (SYSUCC), Guangzhou, China
| | | | - Manuel Cobo
- Medical Oncology Intercenter Unit, Regional and Virgen de la Victoria University Hospitals, IBIMA, Málaga, Spain
| | - Jaromir Roubec
- Nemocnice AGEL Ostrava-Vítkovice, Ostrava, Czech Republic
| | | | | | | | - Jeffrey Ward
- Washington University School of Medicine, St Louis, MO, USA
| | - Zoran Andric
- University Clinical Hospital Centre Bezanijska Kosa, Belgrade, Serbia
| | - Thierry Berghmans
- Jules Bordet Institute, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - David E Gerber
- Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Joachim Aerts
- Department of Pulmonary Medicine, The Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Angelo Delmonte
- IRCCS Istituto Romagnolo per lo Studio dei Tumori Dino Amadori (IRST), Meldola, Italy
| | - Miklos Pless
- Kantonsspital Winterthur, Winterthur, Switzerland
| | - Richard Greil
- Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials (SCRI-CCCIT), Salzburg, Austria; Paracelsus Medical University Salzburg, Salzburg, Austria; Cancer Cluster, Salzburg, Austria
| | - Christian Rolfo
- Center for Thoracic Oncology, Tisch Cancer Institute at Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Wallace Akerley
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | | | - Mussawar Iqbal
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Corey Langer
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Novello S, Maimon N, Stevenson J, Petty W, Ferreira C, Morbeck I, Zer A, Bauman J, Kalmadi S, Xia C, Meloni A, Varrieur T, Awad M. 7MO Sotorasib in KRAS G12C-mutated advanced non-small cell lung cancer (aNSCLC): Overall survival (OS) data from the global expanded access program (EAP study-436). J Thorac Oncol 2023. [DOI: 10.1016/s1556-0864(23)00261-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
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Anadkat MJ, Lacouture M, Friedman A, Horne ZD, Jung J, Kaffenberger B, Kalmadi S, Ovington L, Kotecha R, Abdullah HI, Grosso F. Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region. Front Oncol 2023; 12:975473. [PMID: 36703794 PMCID: PMC9873416 DOI: 10.3389/fonc.2022.975473] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/23/2022] [Indexed: 01/06/2023] Open
Abstract
Tumor Treating Fields (TTFields) are electric fields, delivered via wearable arrays placed on or near the tumor site, that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. As a first-in-class treatment, TTFields therapy is approved for use in newly diagnosed glioblastoma, recurrent glioblastoma, and pleural mesothelioma. Additionally, TTFields therapy is being investigated in non-small cell lung cancer (NSCLC), brain metastases from NSCLC, pancreatic cancer, ovarian cancer, hepatocellular carcinoma, and gastric adenocarcinoma. Because TTFields therapy is well tolerated and delivery is locoregional, there is low risk of additive systemic adverse events (AEs) when used with other cancer treatment modalities. The most common AE associated with TTFields therapy is mild-to-moderate skin events, which can be treated with topical agents and may be managed without significant treatment interruptions. Currently, there are no guidelines for oncologists regarding the management of TTFields therapy-related skin AEs in the thoracic region, applicable for patients with pleural mesothelioma or NSCLC. This publication aims to provide guidance on preventing, minimizing, and managing dermatologic AEs in the thoracic region to help improve patient quality of life and reduce treatment interruptions that may impact outcomes with TTFields therapy.
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Affiliation(s)
- Milan J. Anadkat
- Division of Dermatology, Department of Medicine, Washington University, St. Louis, MO, United States,*Correspondence: Milan J. Anadkat,
| | - Mario Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Adam Friedman
- Division of Dermatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Zachary D. Horne
- Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, United States
| | - Jae Jung
- Department of Dermatology, Norton Healthcare, Louisville, KY, United States
| | | | - Sujith Kalmadi
- Oncology and Haematology Department, Ironwood Cancer & Research Center, Chandler, AZ, United States
| | - Liza Ovington
- Ovington & Associates, Walnutport, PA, United States
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | | | - Federica Grosso
- Mesothelioma Unit, SS Antonio e Biagio General Hospital, Alessandria, Italy
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Kalmadi NR, Brown A, Sharma M, Shtivelband M, Rifkind J, Kalmadi S, Bagai R, Ho E, Clark P, Kellogg C, Khanuja P. Abstract P1-08-18: Impact of gene expression profile testing for lymph node positive (LN+) , hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer (BC) patients on the use of adjuvant chemotherapy in a large community cancer center. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p1-08-18] [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
Background: Use of gene expression profiling (GEP) is considered standard of care, in deciding use of adjuvant chemotherapy in patients with LN negative breast cancer. However, there are limited data for the use of GEP in LN+ disease. Both Mammaprint™ and Oncotype Dx 21 gene recurrence score™ (RS) have been evaluated in LN+ disease, the data are not as robust as in the LN- population. Based on data from the RXPONDER trial and the MINDACT trial, the NCCN has recently recommended the use of Oncotype Dx to help decide the utility and benefit of adjuvant chemotherapy after resection in LN- , Hormone receptor Positive (HR+), HER2 negative (HER2-) breast cancer patients. Because of the potential major impact of these data on patient management and healthcare utilization, we decided to explore the uptake and implementation of this testing at a large community cancer center in order to assess and report real world data pertaining to this novel standard of care. Methods: Database search of the Electronic Medical Records used at Ironwood Cancer Center, revealed 2455 newly diagnosed patients with early stage breast cancer during the period from 1/1/2018 till 6/1/2021. HIPAA deidentified data was extracted with inclusion criteria of newly diagnosed women with LN+ (1-3 nodes), HR+, and Her2- which yielded 403 patients. Demographics & treatment data: Characteristics included menopausal status (Premenopausal 23%, Post Menopausal 77%), Surgery type (mastectomy 44%, breast conservation surgery 56%), size of primary tumor (0-1 cm 16 %, 1-2 cm 28%, 2-5 cm 43%, and > 5 cm 13%), LNs resected (Range 0-37, Median 4), # of LNs +(1-60%, 2-25%, 3-15%), and Tumor Grade (Grade 1-23%, 2-56%, 3-21%). GEP was performed in 62% of the patients. 49% received adjuvant chemotherapy (61% anthracycline based, 39% non anthracycline based). Of the patients tested, 41% received adjuvant chemotherapy. Adjuvant antihormonal therapy included aromatase inhibitors in 86% and Tamoxifen in 14%. 81% of the pre-menopausal patients received complete ovarian suppression. Results: Logistical Regression analysis in a non linear fashion, R2 data and Chi-square analysis was used to test the statistical significance of the observed relationship with respect to the expected relationship. The data was divided into 6 monthly intervals to allow comparison of the uptake of the test and impact on adjuvant chemotherapy decision making. There was a significant increase in GEP profile testing percentages when these intervals were compared across the years (R2 =0.69). Increase in GEP profiling was associated with lower utilization of adjuvant chemotherapy (R2= 0.84). There was a non-significant decline in the use of adjuvant chemotherapy (Chi2 NS, p value 0.22). Menopausal status, grade/size of tumor did not meet the statistical significance for the likelihood of utilization of the test. Currently multivariate analysis is being performed to examine the interplay between the numerous clinical factors on which the data was collected. This analysis will allow us to decide if we can longitudinally explore recurrence rates in each of these subsets. Conclusion: GEP has seen a significant uptake to help with adjuvant chemotherapy decision making in LN + (1-3) patients in the community cancer center setting over the last 4 years. These real world data also showed that increased testing was associated with decreased chemotherapy use which has translated to lowering health care resources and minimizing patient morbidity. Recommendations from the expert guidelines and clinical trial data have helped accelerate the use of this technology in the decision making to undergo adjuvant chemotherapy in the LN+, HR+, HER2- patients with breast cancer.
Citation Format: Nisha Rao Kalmadi, Andrew Brown, Manas Sharma, Mikhail Shtivelband, Joshua Rifkind, Sujith Kalmadi, Rajesh Bagai, Emily Ho, Patricia Clark, Christopher Kellogg, Parvinderjit Khanuja. Impact of gene expression profile testing for lymph node positive (LN+) , hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer (BC) patients on the use of adjuvant chemotherapy in a large community cancer center [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-08-18.
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Affiliation(s)
| | - Andrew Brown
- Arizona College of Osteopathic Medicine, Midwestern University, Mesa, AZ
| | | | | | | | | | | | - Emily Ho
- Ironwood Cancer Center, Chandler, AZ
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Isaacs C, Mahtani R, Lynce F, Sleckman B, Castrellon A, Kalmadi S, Theall KP, Huang X, Bananis E, Rugo HS. Abstract P1-18-13: Efficacy and safety of palbociclib plus endocrine therapy in Black and Hispanic patients with hormone receptor positive/human epidermal growth factor receptor 2-negative advanced breast cancer (HR+/HER2- ABC) participating in the PALOMA trials. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p1-18-13] [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
Background: The PALOMA clinical trials have shown that palbociclib (PAL) plus endocrine therapy (ET) is a safe and effective treatment for HR+/HER2- ABC. However, Black and Hispanic patients are underrepresented in clinical trials and the efficacy and safety of CDK4/6 inhibitors in these populations have not been reported. This post hoc analysis describes the efficacy and safety of PAL + ET in Black and Hispanic patients with HR+/HER2- ABC enrolled in the PALOMA trials. Methods: Postmenopausal patients were treated with letrozole (LET) + PAL on a 125 mg/d, 3/1 weekly schedule or LET alone (PALOMA-1) or LET + placebo (PBO; PALOMA-2) in the 1st line setting. In PALOMA-3, pre/postmenopausal patients were treated with fulvestrant (FUL) + PAL or PBO, with or without a luteinizing hormone releasing hormone agonist, in the ≥1st-line setting. Median progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Treatment-emergent adverse events (AEs) were evaluated according to the National Cancer Institute Common Terminology Criteria for AEs. Results: In PALOMA-2, Black and Hispanic patients comprised 9.8% of the population and had a median age of 58 yrs (PAL + LET arm; n=47) and 54 yrs (PBO + LET arm; n=18). Patients treated with PAL + LET had more visceral disease (62% vs 50%), lung involvement (51% vs 22%), de novo disease (45% vs 22%) and less prior systemics (55% vs 78%) compared to patients treated with PBO + LET. In PALOMA-3, Black and Hispanic patients comprised 9.2% of the population and had a median age of 57 yrs in both the PAL + FUL (n=29) and PBO + FUL (n=19) arms, with baseline characteristics being generally similar between the two arms. PAL+ ET prolonged median PFS in PALOMA-2 and -3 and prolonged median OS in PALOMA-3 compared to PBO + ET (Table 1). In pooled analyses of these patients from PALOMA 1-3 (n=120), the most common grade 3/4 AEs with PAL + ET were neutropenia (57.7%), leukopenia (24.4%), and anemia (3.8%), similar to the rates in the pooled PALOMA 1−3 overall as-treated population (Table 2). None of these grade 3/4 AEs were reported with PBO + ET in the Black/Hispanic subgroup (Table 2). Febrile neutropenia or pulmonary embolism were not reported in either arm. The rate of dose reduction due to AEs was 37.2% with PAL + ET, similar to the rates of dose reduction across the populations in the PALOMA trials (39.4%−42.2%). Conclusion: In Black/Hispanic pts with HR+/HER2- ABC enrolled in the PALOMA-2 and -3 trials, PAL + ET, in the first or greater lines, was an efficacious treatment option with no increased toxicity rates. These findings support the continued use of PAL + ET as a standard of care in these patients. Considering the substantial burden of breast cancer in Black and Hispanic patients, their relatively small representation in the PALOMA trial program highlights the need to increase diversity in clinical trials. Clinical trial identification: Pfizer (NCT00721409, NCT01740427, NCT01942135)
Table 1.Median PFS and OS in the ITT population and Black and Hispanic patients from PALOMA-2 and -3Median (95% CI), moHazard Ratioa (95% CI)PAL + ETPBO + ETPAL + ET vs PBO + ETPFSPALOMA-2ITT [n=666]27.6 (22.4-30.3)14.5 (12.3-17.1)0.56 (0.46-0.69)Black and Hispanic [n=65]27.4 (13.8-NE)13.8 (8.1-30.7)0.61 (0.31-1.2)PALOMA-3ITT [n=521]11.2 (9.5-12.9)4.6 (3.5-5.6)0.50 (0.40-0.62)Black and Hispanic [n=48]11.1 (4.5-12.0)1.9 (1.8-5.7)0.56 (0.28-1.14)OSPALOMA-3ITT [n=521]34.8 (28.8-39.9)28.0 (23.5-33.8)0.79 (0.64-0.97)Black and Hispanic [n=48]35.6 (24.0-58.2)21.0 (14.3-35.4)0.48 (0.23-0.97)ET=endocrine therapy; ITT=intent to treat; NE=not estimable; OS=overall survival; PAL=palbociclib; PBO=placebo; PFS=progression free survival.aEstimated from an unstratified Cox proportional hazards model.
Table 2.Grade 3/4 treatment emergent adverse events in the overall as-treated population and Black and Hispanic subgroup pooled from the PALOMA trialsPooled PALOMAPooled Black/HispanicAE, No. (%)PAL + ET (n=872)ETa (n=471)PAL + ET (n=78)PBO + ET (n=42)Any AE662 (75.9)110 (23.4)53 (67.9)12 (28.6)Neutropenia570 (65.4)5 (1.1)45 (57.7)0Leukopenia233 (26.7)2 (0.4)19 (24.4)0Anemia40 (4.6)9 (1.9)3 (3.8%)0Thrombocytopenia17 (1.9)1 (0.2)1 (1.3%)1 (2.4)Infections45 (5.2)12 (2.5)1 (1.3%)1 (2.4)AE=adverse event; ET=endocrine therapy; PAL=palbociclib; PBO=placebo.aEndocrine therapy with placebo (PALOMA-2 and 3) and without placebo (PALOMA-1).
Citation Format: Claudine Isaacs, Reshma Mahtani, Filipa Lynce, Bethany Sleckman, Aurelio Castrellon, Sujith Kalmadi, Kathy Puyana Theall, Xin Huang, Eustratios Bananis, Hope S. Rugo. Efficacy and safety of palbociclib plus endocrine therapy in Black and Hispanic patients with hormone receptor positive/human epidermal growth factor receptor 2-negative advanced breast cancer (HR+/HER2- ABC) participating in the PALOMA trials [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-18-13.
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Affiliation(s)
- Claudine Isaacs
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Reshma Mahtani
- Sylvester Cancer Center, University of Miami, Deerfield Beach, FL
| | - Filipa Lynce
- Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, MA
| | | | | | | | | | | | | | - Hope S. Rugo
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
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Slingluff CL, Lewis KD, Andtbacka R, Hyngstrom J, Milhem M, Markovic SN, Bowles T, Hamid O, Hernandez-Aya L, Claveau J, Jang S, Philips P, Holtan SG, Shaheen MF, Curti B, Schmidt W, Butler MO, Paramo J, Lutzky J, Padmanabhan A, Thomas S, Milton D, Pecora A, Sato T, Hsueh E, Badarinath S, Keech J, Kalmadi S, Kumar P, Weber R, Levine E, Berger A, Bar A, Beck JT, Travers JB, Mihalcioiu C, Gastman B, Beitsch P, Rapisuwon S, Glaspy J, McCarron EC, Gupta V, Behl D, Blumenstein B, Peterkin JJ. Multicenter, double-blind, placebo-controlled trial of seviprotimut-L polyvalent melanoma vaccine in patients with post-resection melanoma at high risk of recurrence. J Immunother Cancer 2021; 9:jitc-2021-003272. [PMID: 34599031 PMCID: PMC8488725 DOI: 10.1136/jitc-2021-003272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Accepted: 09/06/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Most patients with advanced melanomas relapse after checkpoint blockade therapy. Thus, immunotherapies are needed that can be applied safely early, in the adjuvant setting. Seviprotimut-L is a vaccine containing human melanoma antigens, plus alum. To assess the efficacy of seviprotimut-L, the Melanoma Antigen Vaccine Immunotherapy Study (MAVIS) was initiated as a three-part multicenter, double-blind, placebo-controlled phase III trial. Results from part B1 are reported here. METHODS Patients with AJCC V.7 stage IIB-III cutaneous melanoma after resection were randomized 2:1, with stage stratification (IIB/C, IIIA, IIIB/C), to seviprotimut-L 40 mcg or placebo. Recurrence-free survival (RFS) was the primary endpoint. For an hypothesized HR of 0.625, one-sided alpha of 0.10, and power 80%, target enrollment was 325 patients. RESULTS For randomized patients (n=347), arms were well-balanced, and treatment-emergent adverse events were similar for seviprotimut-L and placebo. For the primary intent-to-treat endpoint of RFS, the estimated HR was 0.881 (95% CI: 0.629 to 1.233), with stratified logrank p=0.46. However, estimated HRs were not uniform over the stage randomized strata, with HRs (95% CIs) for stages IIB/IIC, IIIA, IIIB/IIIC of 0.67 (95% CI: 0.37 to 1.19), 0.72 (95% CI: 0.35 to 1.50), and 1.19 (95% CI: 0.72 to 1.97), respectively. In the stage IIB/IIC stratum, the effect on RFS was greatest for patients <60 years old (HR=0.324 (95% CI: 0.121 to 0.864)) and those with ulcerated primary melanomas (HR=0.493 (95% CI: 0.255 to 0.952)). CONCLUSIONS Seviprotimut-L is very well tolerated. Exploratory efficacy model estimation supports further study in stage IIB/IIC patients, especially younger patients and those with ulcerated melanomas. TRIAL REGISTRATION NUMBER NCT01546571.
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Affiliation(s)
- Craig L Slingluff
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Karl D Lewis
- University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Robert Andtbacka
- Huntsman Cancer Institute Cancer Hospital, Salt Lake City, Utah, USA
| | - John Hyngstrom
- Huntsman Cancer Institute Cancer Hospital, Salt Lake City, Utah, USA
| | - Mohammed Milhem
- The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | | | - Omid Hamid
- Cedars-Sinai Medical Center Angeles Clinic and Research Institute, Santa Monica, California, USA
| | - Leonel Hernandez-Aya
- Department of Medicine, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Joel Claveau
- CHU de Quebec-Universite Laval, Quebec, Québec, Canada
| | - Sekwon Jang
- Department of Medical Oncology, Inova Health System, Falls Church, Virginia, USA
| | | | - Shernan G Holtan
- University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
| | - Montaser F Shaheen
- University of Arizona Medical Center - University Campus, Tucson, Arizona, USA
| | - Brendan Curti
- Earle A Chiles Research Institute, Providence Portland Medical Center, Portland, Oregon, USA
| | | | - Marcus O Butler
- Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Juan Paramo
- Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Jose Lutzky
- Department of Oncology, Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | | | - Sajeve Thomas
- MD Anderson Cancer Center Orlando, Orlando, Florida, USA
| | - Daniel Milton
- Investigative Clinical Research of Indiana, Indianapolis, Indiana, USA
| | - Andrew Pecora
- Department of Oncology, John Theurer Cancer Center, Hackensack, New Jersey, USA
| | - Takami Sato
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eddy Hsueh
- St. Louis University Hospital, St. Louis, Missouri, USA
| | | | - John Keech
- Multicare Institute for Research and Innovation, Tacoma, Washington, USA
| | - Sujith Kalmadi
- Ironwood Cancer and Research Centers, Chandler, Arizona, USA
| | - Pallavi Kumar
- Harry and Jeanette Weinberg Cancer Institute at Franklin Square, Baltimore, Maryland, USA
| | - Robert Weber
- St. Mary's Hospital and Medical Center, San Francisco, California, USA
| | - Edward Levine
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam Berger
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Anna Bar
- Oregon Health & Science University, Portland, Oregon, USA
| | - J Thaddeus Beck
- Department of Medical Oncology, Highlands Oncology Group, Fayetteville, Arkansas, USA
| | | | | | - Brian Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Suthee Rapisuwon
- Department of Oncology, Georgetown University Medical Center, Washington, District of Columbia, USA,Department of Hematology/Oncology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - John Glaspy
- University of California Los Angeles, Los Angeles, California, USA
| | | | - Vinay Gupta
- MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
| | - Deepti Behl
- Sutter Institute for Medical Research, Sacramento, California, USA
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Ferrarotto R, Anderson I, Medgyasszay B, García-Campelo MR, Edenfield W, Feinstein TM, Johnson JM, Kalmadi S, Lammers PE, Sanchez-Hernandez A, Pritchett Y, Morris SR, Malik RK, Csőszi T. Trilaciclib prior to chemotherapy reduces the usage of supportive care interventions for chemotherapy-induced myelosuppression in patients with small cell lung cancer: Pooled analysis of three randomized phase 2 trials. Cancer Med 2021; 10:5748-5756. [PMID: 34405547 PMCID: PMC8419768 DOI: 10.1002/cam4.4089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/01/2021] [Revised: 05/24/2021] [Accepted: 06/04/2021] [Indexed: 12/11/2022] Open
Abstract
Background Supportive care interventions used to manage chemotherapy‐induced myelosuppression (CIM), including granulocyte colony‐stimulating factors (G‐CSFs), erythropoiesis‐stimulating agents (ESAs), and red blood cell (RBC) transfusions, are burdensome to patients and associated with greater costs to health care systems. We evaluated the utilization of supportive care interventions and their relationship with the myeloprotective agent, trilaciclib. Methods Data were pooled from three independent randomized phase 2 clinical trials of trilaciclib or placebo administered prior to chemotherapy in patients with extensive‐stage small cell lung cancer (ES‐SCLC). The impact of supportive care on the duration of severe neutropenia (DSN), occurrence of severe neutropenia (SN), and occurrence of RBC transfusions on/after week 5 was analyzed across cycles 1–4. Concordance and association between grade 3/4 anemia, RBC transfusions on/after week 5, and ESA administration was also evaluated. Results The use of G‐CSFs, ESAs, or RBC transfusions on/after week 5 was significantly lower among patients receiving trilaciclib versus placebo (28.5% vs. 56.3%, p < 0.0001; 3.3% vs. 11.8%, p = 0.0254; and 14.6% vs. 26.1%, p = 0.0252, respectively). Compared with placebo, trilaciclib significantly reduced DSN and SN, irrespective of G‐CSF administration. RBC transfusions and ESAs were most often administered in patients with grade 3/4 anemia; however, patients typically received RBC transfusions over ESA administration. Conclusions By improving CIM and reducing the need for associated supportive care, trilaciclib has the potential to reduce the burden of myelosuppression on patients receiving myelosuppressive chemotherapy for the treatment of ES‐SCLC. Trial registration ClinicalTrials.gov (NCT02499770; NCT03041311; NCT02514447).
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Affiliation(s)
| | - Ian Anderson
- St Joseph Heritage Healthcare, Santa Rosa, CA, USA
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8
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Hurvitz SA, Saura C, Oliveira M, Trudeau ME, Moy B, Delaloge S, Gradishar W, Kim SB, Haley B, Ryvo L, Dai MS, Milovanov V, Alarcón J, Kalmadi S, Cronemberger E, Souza C, Landeiro L, Bose R, Bebchuk J, Kabbinavar F, Bryce R, Keyvanjah K, Brufsky AM. Efficacy of Neratinib Plus Capecitabine in the Subgroup of Patients with Central Nervous System Involvement from the NALA Trial. Oncologist 2021; 26:e1327-e1338. [PMID: 34028126 PMCID: PMC8342591 DOI: 10.1002/onco.13830] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 12/01/2020] [Accepted: 05/03/2021] [Indexed: 11/28/2022] Open
Abstract
Background Neratinib has efficacy in central nervous system (CNS) metastases from HER2‐positive metastatic breast cancer (MBC). We report outcomes among patients with CNS metastases at baseline from the phase III NALA trial of neratinib plus capecitabine (N + C) versus lapatinib plus capecitabine (L + C). Materials and Methods NALA was a randomized, active‐controlled trial in patients who received two or more previous HER2‐directed regimens for HER2‐positive MBC. Patients with asymptomatic/stable brain metastases (treated or untreated) were eligible. Patients were assigned to N + C (neratinib 240 mg per day, capecitabine 750 mg/m2 twice daily) or L + C (lapatinib 1,250 mg per day, capecitabine 1,000 mg/m2 twice daily) orally. Independently adjudicated progression‐free survival (PFS), overall survival (OS), and CNS endpoints were considered. Results Of 621 patients enrolled, 101 (16.3%) had known CNS metastases at baseline (N + C, n = 51; L + C, n = 50); 81 had received prior CNS‐directed radiotherapy and/or surgery. In the CNS subgroup, mean PFS through 24 months was 7.8 months with N + C versus 5.5 months with L + C (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.41–1.05), and mean OS through 48 months was 16.4 versus 15.4 months (HR, 0.90; 95% CI, 0.59–1.38). At 12 months, cumulative incidence of interventions for CNS disease was 25.5% for N + C versus 36.0% for L + C, and cumulative incidence of progressive CNS disease was 26.2% versus 41.6%, respectively. In patients with target CNS lesions at baseline (n = 32), confirmed intracranial objective response rates were 26.3% and 15.4%, respectively. No new safety signals were observed. Conclusion These analyses suggest improved PFS and CNS outcomes with N + C versus L + C in patients with CNS metastases from HER2‐positive MBC. Implications for Practice In a subgroup of patients with central nervous system (CNS) metastases from HER2‐positive breast cancer after two or more previous HER2‐directed regimens, the combination of neratinib plus capecitabine was associated with improved progression‐free survival and CNS outcomes compared with lapatinib plus capecitabine. These findings build on previous phase II and III studies describing efficacy of neratinib in the prevention and treatment of CNS metastases, and support a role for neratinib as a systemic treatment option in the management of patients with HER2‐positive brain metastases following antibody‐based HER2‐directed therapies. This article reports outcomes among HER2‐positive breast cancer patients with central nervous system metastases at baseline from the phase III NALA trial of neratinib plus capecitabine versus lapatinib plus capecitabine.
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Affiliation(s)
- Sara A Hurvitz
- University of California Los Angeles/Jonsson Comprehensive Cancer Center, Los Angeles, California, USA
| | - Cristina Saura
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, SOLTI Breast Cancer Cooperative Group, Barcelona, Spain
| | - Mafalda Oliveira
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, SOLTI Breast Cancer Cooperative Group, Barcelona, Spain
| | | | - Beverly Moy
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | | | - William Gradishar
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Sung-Bae Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Barbara Haley
- University of Texas Southwestern, Dallas, Texas, USA
| | - Larisa Ryvo
- Sourasky Medical Center (Ichilov), Tel Aviv, Israel
| | - Ming-Shen Dai
- Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | - Jesús Alarcón
- Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Sujith Kalmadi
- Ironwood Cancer and Research Centers, Chandler, Arizona, USA
| | | | | | | | - Ron Bose
- Washington University School of Medicine, St Louis, Missouri, USA
| | | | | | - Richard Bryce
- Puma Biotechnology, Inc., Los Angeles, California, USA
| | | | - Adam M Brufsky
- Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
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9
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Moy B, Oliveira M, Saura C, Gradishar W, Kim SB, Brufsky A, Hurvitz SA, Ryvo L, Fagnani D, Kalmadi S, Silverman P, Delaloge S, Alarcon J, Kwong A, Lee KS, Ang PCS, Ow SGW, Chu SC, Bryce R, Keyvanjah K, Bebchuk J, Zhang B, Oestreicher N, Bose R, Chan N. Neratinib + capecitabine sustains health-related quality of life in patients with HER2-positive metastatic breast cancer and ≥ 2 prior HER2-directed regimens. Breast Cancer Res Treat 2021; 188:449-458. [PMID: 33909203 PMCID: PMC8260518 DOI: 10.1007/s10549-021-06217-4] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/27/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To characterize health-related quality of life (HRQoL) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) from the NALA phase 3 study. METHODS In NALA (NCT01808573), patients were randomized 1:1 to neratinib + capecitabine (N + C) or lapatinib + capecitabine (L + C). HRQoL was assessed using seven prespecified scores from the European Organisation for Research and Treatment of Cancer Quality Of Life Questionnaire core module (QLQ-C30) and breast cancer-specific questionnaire (QLQ-BR23) at baseline and every 6 weeks. Descriptive statistics summarized scores over time, mixed models evaluated differences between treatment arms, and Kaplan-Meier methods were used to assess time to deterioration in HRQoL scores of ≥ 10 points. RESULTS Of the 621 patients randomized in NALA, patients were included in the HRQoL analysis if they completed baseline and at least one follow-up questionnaire. The summary, global health status, physical functioning, fatigue, constipation, and systemic therapy side effects scores were stable over time with no persistent differences between treatment groups. There were no differences in time to deterioration (TTD) for the QLQ-C30 summary score between treatment arms; the hazard ratio (HR) for N + C vs. L + C was 0.94 (95% CI 0.63-1.40). Only the diarrhea score worsened significantly more in the N + C arm as compared to the L + C arm, and this remained over time (HR for TTD for N + C vs. L + C was 1.71 [95% CI 1.32-2.23]). CONCLUSION In NALA, patients treated with N + C maintained their global HRQoL over time, despite a worsening of the diarrhea-related scores. These results may help guide optimal treatment selection for HER2-positive MBC.
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Affiliation(s)
- Beverly Moy
- Massachusetts General Hospital Cancer Center, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Mafalda Oliveira
- Vall D'Hebron University Hospital, Vall D'Hebron Institute of Oncology, Barcelona, Spain
| | - Cristina Saura
- Vall D'Hebron University Hospital, Vall D'Hebron Institute of Oncology, Barcelona, Spain
| | - William Gradishar
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Sung-Bae Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Adam Brufsky
- Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Sara A Hurvitz
- University of California Los Angeles/Jonsson Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Larisa Ryvo
- Assuta Ashdod Medical Center, Ashdod, Israel
| | - Daniele Fagnani
- Azienda Socio-Sanitaria Territoriale Di Vimercate, Vimercate, Italy
| | | | - Paula Silverman
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Jesus Alarcon
- Servicio de Oncologia, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Ava Kwong
- Department of Surgery, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Keun Seok Lee
- National Cancer Center, Gyeonggi-do, Republic of Korea
| | | | | | | | | | | | | | - Bo Zhang
- Puma Biotechnology Inc., Los Angeles, CA, USA
| | | | - Ron Bose
- Washington University School of Medicine, St. Louis, MO, USA
| | - Nancy Chan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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10
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Purkalne G, Ferrarotto R, Anderson I, Medgyasszay B, García-Campelo M, Edenfield W, Feinstein T, Johnson J, Kalmadi S, Lammers P, Purkalne G, Hernandez A, Pritchett Y, Malik R, Morris S, Csőszi T. OA03.08 Trilaciclib Reduces the Need for Growth Factors and Red Blood Cell Transfusions to Manage Chemotherapy-Induced Myelosuppression. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2020.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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11
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Lazaryan A, Kalmadi S, Almhanna K, Pelley R, Kim R. Predictors of clinical outcomes of resected ampullary adenocarcinoma: a single-institution experience. Eur J Surg Oncol 2011; 37:791-7. [PMID: 21741199 DOI: 10.1016/j.ejso.2011.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 05/25/2011] [Accepted: 06/14/2011] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In the absence of prospective data, the use of adjuvant therapy in ampullary adenocarcinoma is contingent upon the clinicopathological features which can correlate to 5-year post-operative survival and disease relapse. METHODS We investigated the factors associated with clinical outcomes among 72 patients who underwent pancreatoduodenectomy at the Cleveland Clinic from 1995 to 2007 for histologically confirmed adenocarcinoma of the ampulla of Vater. RESULTS R0 resection was achieved in 96% of patients (median age, 72 years; 58% males, 89% Caucasians). Nineteen patients experienced disease relapse after surgery and 61% were alive within 5 years of follow up. Thirty five percent of patients received some form of adjuvant therapy. Perineural tumor invasion (p < 0.01) and presence of ulcerated tumor on histopathology (p < 0.01) were associated with higher rates of tumor relapse and poor 5-year overall survival in multivariable analysis. Lymph node involvement (p = 0.02) also portended poor overall survival after adjustment for other covariates. Although adjuvant therapy was associated with poor clinical outcomes in univariate analysis, it demonstrated a favorable albeit non-significant trend in multivariable analysis. CONCLUSIONS Factors associated with poor clinical outcomes in this contemporary single-institution study, included perineural invasion, tumor ulceration, and lymph node involvement. No definite conclusion could be made in regards to adjuvant treatment.
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Affiliation(s)
- A Lazaryan
- Cleveland Clinic Taussig Cancer Institute, R35, Cleveland OH 44195, USA
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12
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Abstract
Metastatic androgen-independent prostate cancer presents an intriguing clinical challenge, with a subtle interaction between hormone-responsive and refractory tumor cell elements. The treatment of advanced prostate carcinoma, which had remained stagnant for several decades following the understanding of the link between androgenic stimulation and carcinogenesis, has now started to make steady headway with chemotherapy and targeted approaches. Metastatic prostate cancer is almost always treated with initial androgen deprivation, in various forms. However, despite such treatment androgen-independent prostate cancer cells eventually emerge and progress to threaten life. The therapeutic objectives for treatment of metastatic prostate cancer are to maintain the quality of life and prolong survival. The out-dated nihilistic dogma of deferring chemotherapy until the most advanced stages in advanced prostate cancer is now falling by the wayside with the development of newer effective, tolerable agents.
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Affiliation(s)
- Sujith Kalmadi
- Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Derek Raghavan
- Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
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13
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Almhanna K, Lazaryan A, Kalmadi S, Kim RD, Saxton JP, Lavery I, Foazio V, Kay E, Pelley R. Predictors of recurrence after definitive chemoradiation for anal cancer: The Cleveland Clinic experience. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.15000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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Lazaryan A, Almhanna K, Elson P, Kalmadi S, Vogt D, Walsh M, Henderson M, Pelley R, Kim RD. Factors associated with tumor recurrence and 5-year postoperative survival in ampullary carcinoma: Cleveland Clinic Experience. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.15575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Videtic G, Desai A, Reddy C, Kalmadi S, Mekhail T. Daily Subcutaneous Amifostine Facilitates Radiation Dose Escalation for Poor Risk Unresectable Stage III Lung Cancer. Int J Radiat Oncol Biol Phys 2007. [DOI: 10.1016/j.ijrobp.2007.07.1695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Almhanna K, Kalmadi S, Pelley R, Kim R. Neoadjuvant therapy for hepatocellular carcinoma: is there an optimal approach? Oncology (Williston Park) 2007; 21:1116-22; discussion 1122, 1124, 1127-8. [PMID: 17910314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Hepatocellular carcinoma (HCC) is an aggressive tumor that often occurs in the setting of chronic liver disease and cirrhosis. The incidence of hepatocellular carcinoma is increasing in the United States and worldwide. Orthotopic liver transplantation (OLT) is a viable and potentially curative option for selected patients with HCC. Locoregional therapy has been used to control HCC before transplantation because of the limited number of donor organs, to prevent tumor progression, and to decrease the incidence of dropouts from the transplant waiting list. Traditionally, multiple investigational locoregional modalities such as tumor resection, radiofrequency ablation, transarterial chemoembolization, and systemic chemotherapy have been used as "bridging" therapies. While the investigation of novel neoadjuvant treatments is justified in an effort to prevent tumor progression, the absence of randomized controlled trials leaves uncertainty about the utility of these maneuvers in improving outcome. This review summarizes the current data on the different modalities used worldwide in the neoadjuvant treatment of hepatocellular carcinoma, the rationale for these approaches, efficacy, potential complications, and future prospects.
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Affiliation(s)
- Khaldoun Almhanna
- Gastrointestinal Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio 44195, USA
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17
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Almhanna K, Golshayan A, Sands M, Levitin A, Kim R, Pelley R, Kalmadi S. Response to trans-arterial chemoembolization prior to orthotopic liver transplantation or hepatic resection in patients with hepatocellular carcinoma. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.15114] [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: 11/20/2022] Open
Abstract
15114 Background: Trans-arterial chemoembolization (TACE) is often used as pre-operative therapy for patients with hepatocellular carcinoma (HCC) prior to orthotopic liver transplantation (OLT) or hepatic resection (HR). However, the benefit of response to TACE on overall survival (OS) and progression free survival (PFS) remains unclear. Methods: Complete data was available for 24 patients with HCC who underwent TACE prior to either OLT or HR from 1998–2006. Known prognostic factors including tumor size, histology, number of nodules, Child-Pugh class, Okuda stage, MELD score, CLIP score were recorded. Clinical features before and after TACE were identified and tested by univariate analysis. Results: The mean patient age was age 51 years (range 31–65). Underlying diagnoses included: HBV (17%), HCV (54%), alcohol abuse (63%), cryptogenic (8%), nonalcoholic steotohepatitis (4%). The mean maximum tumor diameter was 6.2 cm (range 1.6–16.1 cm), with 13 tumors (54%) measuring >5 cm. The median number of lesions were 2 (range 1 - 7). The Milan criteria was met in 15 patients (63%). Eighteen subjects underwent OLT, while 6 had HR. Median PFS was 35 months (m) (95% C.I. 17–58 m). One- and three-year OS were 95.8% and 73%, respectively. TACE was performed within a mean time of 2.5 months from diagnosis (range 0.5–9 m). Post-TACE, eleven subjects demonstrated a biologic response, defined as decrease in serum alfa-fetoprotein (AFP) by >50%, or reduction in AFP level to <10 ng/mL. However, biologic response did not predict for improved PFS (p =0.41). Additionally, nine patients had a radiographic response to TACE as measured by RECIST criteria, but this also did not predict for improved PFS (p = 0.79). Only tumor size >5 cm (p = 0.04) and CLIP score (p = 0.01) were found to be independent predictors of improved PFS. Conclusions: Neither radiographic nor biologic responses to TACE appear to serve as selection criteria for OLT or HR. Those patients who fail to demonstrate response to TACE should not necessarily be denied surgical therapy. Larger, prospective trials are needed to better evaluate which patients will benefit most from TACE prior to OLT or HR. No significant financial relationships to disclose.
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Affiliation(s)
- K. Almhanna
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
| | - A. Golshayan
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
| | - M. Sands
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
| | - A. Levitin
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
| | - R. Kim
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
| | - R. Pelley
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
| | - S. Kalmadi
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH; Cleveland Clinic, Cleveland, OH
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Abstract
Lenalidomide is an immunomodulatory drug that was developed by modification of the first-generation immunomodulatory drug thalidomide in a drug discovery program. Lenalidomide more potently regulates cellular immune and cytokine responses, while lacking the side-effect profile of thalidomide. The promising activity seen in multiple myeloma and myelodysplastic syndrome has led to its approval by the U.S. Food and Drug Administration in these conditions. The clinical results that we have seen so far, which demonstrate significant efficacy with a tolerable toxicity profile, provide a strong basis for the use of lenalidomide in other malignancies. Combination therapy with lenalidomide could enhance this agent's antineoplastic role; this is likely the position it will occupy in the armamentarium against cancer.
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Affiliation(s)
- Sujith Kalmadi
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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19
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Kalmadi S, McNeill G, Davis M, Peereboom D, Adelstein D, Mekhail T. Phase II trial of weekly docetaxel and gemcitabine as first-line therapy for patients with advanced non-small cell lung cancer. Med Oncol 2007; 23:507-13. [PMID: 17303909 DOI: 10.1385/mo:23:4:507] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 11/30/1999] [Accepted: 07/18/2006] [Indexed: 11/11/2022]
Abstract
BACKGROUND A platinum doublet has been the standard treatment for patients with advanced non-small cell lung cancer (NSCLC) and good performance status. This treatment results in almost a doubling of 1-yr survival, along with an improvement in quality of life despite treatment-related toxicities. However, platinum-based treatment may be associated with significant toxicity. MATERIALS AND METHODS In this trial, we prospectively evaluated a weekly regimen of docetaxel and gemcitabine for advanced NSCLC. The endpoints of this study included objective response rate, survival, and toxicity. Forty-two patients with previously untreated, advanced NSCLC with PS 0-1 were included. Patients received docetaxel (36 mg/m2) and gemcitabine (600 mg/m2) on d 1, 8, and 15 of a 28-d cycle. Responses were assessed every two cycles. The median age was 63 yr; with 22 males and 20 females; 67% were >or=60 years old; and 38 patients had stage IV disease. RESULTS In the intent-to-treat (ITT) analysis of response, 16 patients had a partial response (38%) and 15 patients had stable disease (36%). The 1-yr survival was 48%; median survival for all patients was 11.3 mo and the median progression-free survival was 5.1 mo. Toxicities (>or= grade 3) included neutropenia (29%), asthenia (26%), diarrhea (14%), thrombocytopenia (10%), pneumonitis (7%), peripheral neuropathy (5%), peripheral edema (5%), nail changes (2%), and myositis (2%). CONCLUSIONS This study demonstrated that this non-platinum doublet (docetaxel + gemcitabine) given on a weekly schedule for advanced NSCLC was well tolerated with efficacy comparable to that reported with platinum-based chemotherapy regimens.
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Affiliation(s)
- Sujith Kalmadi
- Thoracic and Gastrointestinal oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA.
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20
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Almhanna K, Kim R, Kalmadi S. Treatment Approaches for Hepatocellular Carcinoma. Clin Med Oncol 2007. [DOI: 10.1177/117955490700100002] [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: 11/17/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide, and it is responsible for up to one million deaths annually. Although multiple risk factors for HCC have been identified, and despite preventive measures, the incidence of HCC continues to rise to epidemiologic proportions in the United States. In general, tumor resection and orthotopic liver transplantation are the treatment with the best outcome; however, HCC is generally diagnosed late in its course when patients are not eligible for curative treatment options. HCC is a relatively Chemo-refractory tumor secondary to heterogeneity of the tumor and the high rate of multidrug resistant gene expression. There are no standard treatments for HCC, multiple palliative treatment modalities have been used for patients with unresectable disease. None of these modalities have shown any superiority; and the retrospective nature of these available data has confounded any reasonable conclusions. Different institutions use different treatment schema dependent on the center expertise. Sorafenib, a tyrosine kinase inhibitor, has recently demonstrated a survival advantage in metastatic HCC, and if approved by the FDA, might become the standard of care. In this article we will review the rationale behind the currently available treatment options for HCC.
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Affiliation(s)
- Khaldoun Almhanna
- Gastrointestinal Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Richard Kim
- Gastrointestinal Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Sujith Kalmadi
- Gastrointestinal Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
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21
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Kalmadi S, Davis M, Dowlati A, O'Keefe S, Cline-Burkhardt M, Pelley RJ, Borden E, Dreicer R, Bukowski R, Mekhail T. Phase I trial of three-weekly Docetaxel, Carboplatin and oral lenalidomide (Revlimid®) in patients with advanced solid tumors. Invest New Drugs 2006; 25:211-6. [PMID: 17103043 DOI: 10.1007/s10637-006-9025-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 10/12/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lenalidomide is an immunomodulatory derivative of thalidomide with significantly greater in vitro activity and a different toxicity profile. In preclinical trials it has shown synergy with chemotherapy. PATIENTS AND METHODS Primary objective of this study was to determine the maximum tolerated doses of docetaxel and carboplatin when combined with oral lenalidomide in a standard phase I study design. Between September 2004 and May 2005, 14 patients with pathologically proven solid tumors, < or =2 prior chemotherapy regimens, performance status ECOG 0/1, and adequate organ function were enrolled. Dose limiting toxicities (DLT) were defined as > or = grade 3 non-hematological, or grade 4 hematological toxicity. No growth factors were used during cycle 1. RESULTS Three of four patients treated at dose level 1, docetaxel 60 mg/m(2) and carboplatin AUC 6 on Day 1, and lenalidomide 10 mg orally daily on Days 1-14 of a 21 day cycle experienced DLT (grade 3 electrolyte changes in two patients, and grade 4 neutropenia in one patient). Ten patients were treated at dose level -1, docetaxel 60 mg/m(2) and carboplatin AUC 6 on Day 1, and lenalidomide 5 mg orally daily on Days 1-14 of a 21 day cycle with one DLT (Grade 4 neutropenia). There were no treatment-related deaths or irreversible toxicities. Of the 14 response-evaluable patients, five achieved a partial response (5 out of 9 patients with non-small cell lung cancer. CONCLUSIONS Docetaxel 60 mg/m(2) and carboplatin AUC 6 on Day 1, with lenalidomide 5 mg orally daily on Days 1-14 days of a 21 day cycle is the maximum tolerated dose without the use of prophylactic growth factors. This combination is active and further evaluation in a phase II trial is warranted.
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Affiliation(s)
- S Kalmadi
- Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
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McNeill G, Kalmadi S, Davis M, Peereboom D, Adelstein DJ, Bukowski RM, Mekhail T. Phase II trial of weekly docetaxel and gemcitabine as first line therapy for patients with advanced non-small cell lung cancer. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.17076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
17076 Background: A platinum doublet has been the standard treatment for patients with advanced non-small cell lung cancer (NSCLC) and good performance status. This treatment results in almost a doubling of 1-year survival, along with an improvement in quality of life despite treatment related toxicities. However, platinum based treatment is associated with significant toxicity. Methods: In this trial, we prospectively evaluated a weekly regimen of docetaxel and gemcitabine for advanced NSCLC from December 2001 to January 2005. The endpoints of this study included objective response rate, survival and toxicity. Forty-two patients with previously untreated, advanced NSCLC with PS 0–1 were included. Patients received docetaxel (36 mg/m2) and gemcitabine (600 mg/m2) on days 1,8 and 15 of a 28-day cycle. Responses were assessed every two cycles. Results: The median age was 63 years; with 22 males and 20 females; 67% were >60 years old; and 38 patients had stage IV disease. In the intent-to-treat (ITT) analysis of response, 16 patients had a partial response (38%) and 15 patients had stable disease (36%). The 1-year survival was 48%; median survival for all patients was 11.3 months and the median progression-free survival was 5.1 months. Toxicities (> grade 3) included neutropenia (29%), asthenia (26%), thrombocytopenia (14%), diarrhea (14%), pneumonitis (7%), peripheral neuropathy (5%), peripheral edema (5%), nail changes (2%), and myositis (2%). Conclusions: This study demonstrated that this non-platinum doublet (docetaxel + gemcitabine) given on a weekly schedule for advanced NSCLC was well tolerated with efficacy comparable to platinum based chemotherapy regimens. [Table: see text]
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Affiliation(s)
- G. McNeill
- Cleveland Clinic Foundation, Cleveland, OH
| | - S. Kalmadi
- Cleveland Clinic Foundation, Cleveland, OH
| | - M. Davis
- Cleveland Clinic Foundation, Cleveland, OH
| | | | | | | | - T. Mekhail
- Cleveland Clinic Foundation, Cleveland, OH
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Kalmadi S, Tiu R, Lowe C, Jin T, Kalaycio M. Epsilon aminocaproic acid reduces transfusion requirements in patients with thrombocytopenic hemorrhage. Cancer 2006; 107:136-40. [PMID: 16708357 DOI: 10.1002/cncr.21958] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Epsilon aminocaproic acid (EACA) is an antifibrinolytic drug that has been used to control hemorrhage by stabilizing the thrombus. It has been used in thrombocytopenic patients largely on an empiric basis. METHODS Concerns regarding side effects have limited the use of this drug. The authors reviewed their experience with EACA at the Cleveland Clinic Foundation from 1997 to 2003. RESULTS Of 77 patients with thrombocytopenic hemorrhage, 51 (66%) patients achieved a complete response and 13 (17%) patients achieved a partial response, resulting in a decrease in platelet and red blood cell transfusions. Adverse effects were manageable in this set of patients with severe underlying disease. CONCLUSIONS Based on this experience, EACA may be a valuable adjunctive therapy in the treatment of patients with thrombocytopenic hemorrhage.
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Affiliation(s)
- Sujith Kalmadi
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, Ohio 44122, USA.
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Gordon SM, LaRosa SP, Kalmadi S, Arroliga AC, Avery RK, Truesdell-LaRosa L, Longworth DL. Should prophylaxis for Pneumocystis carinii pneumonia in solid organ transplant recipients ever be discontinued? Clin Infect Dis 1999; 28:240-6. [PMID: 10064238 DOI: 10.1086/515126] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Solid organ transplant recipients are at risk for Pneumocystis carinii pneumonia (PCP), but the risk of PCP beyond 1 year is poorly defined. We identified 25 cases of PCP in 1,299 patients undergoing solid organ transplantation between 1987 and 1996 at The Cleveland Clinic Foundation (4.8 cases per 1,000 person transplant-years [PTY]). Ten (36%) of 28 PCP cases (transplantation was performed before 1987 in three cases) occurred > or = 1 year after transplantation, and no patient developed PCP while receiving prophylaxis for PCP. The incidence of PCP during the first year following transplantation was eight times higher than that during subsequent years. The highest rate occurred among lung transplant recipients (22 cases per 1,000 PTY), for whom the incidence did not decline beyond the first year of transplantation. We conclude that the incidence of PCP is highest during the first year after transplantation and differs by type of solid organ transplant. Extending the duration of PCP prophylaxis beyond 1 year may be warranted for lung transplant recipients.
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Affiliation(s)
- S M Gordon
- Department of Infectious Diseases and Pulmonary Medicine, The Cleveland Clinic Foundation, Ohio 44195, USA.
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