Abstract S6-04: Patient-reported outcome (PRO) results, NRG Oncology/NSABP B-35: A clinical trial of anastrozole (A) vs tamoxifen (tam) in postmenopausal patients with DCIS undergoing lumpectomy plus radiotherapy

Background

The clinical results of NSABP B-35, phase III trial comparing 1 mg/day A to 20 mg/day tam, each given for 5 years, were reported at ASCO 2015. B-35 demonstrated a statistically significant benefit in breast cancer free interval for women assigned to A, primarily in women <60 years. A secondary endpoint of B-35 was quality of life (QOL) and symptom (SX) outcomes in the two treatment groups. The primary hypotheses of the PRO study were that there would be no differences in QOL between the two treatments, and that patients receiving A would report higher rates of hot flashes compared to patients receiving tam. Other SX comparisons were secondary endpoints.

Methods

QOL and SX were assessed at baseline (prior to randomization), and every 6 months thereafter for 5 years of treatment and in the following 12 months. QOL was measured with the SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS). SX were measured with selected scales from the BCPT symptom-checklist, and other standardized instruments. Stratification was by age (<60 v ≥60) as in the main trial. Study hypotheses and endpoints were examined by comparing PROs in the two treatment arms using a mixed model for repeated measures analysis with adjustment for the baseline scores, time point and age category, using an intention-to-treat principle and including only patients who completed the baseline and at least one follow-up questionnaire. Patients with protocol events were censored. Only data through 60 months are reported here. The accrual goal for the sub-study was 1,150 consecutive patients.

Results

Between January 6, 2003 and June 15, 2006, a total of 3,104 patients were entered and randomly assigned to NSABP Protocol B-35. Accrual to the PRO study of B-35 closed on December 28, 2004, at which time 1,275 patients were entered, with 1,193 patients included in this analysis. There were no medical or demographic differences between patients assigned to A or tam in the PRO sub-study, and they reflected the characteristics of the parent trial. Adherence to data collection across the 60 months was 87%. There were no significant differences in QOL outcomes by treatment for the PCS (p=0.16) or the MCS (p=0.38). SX subscales: hot flash scale was greater in tam group and this difference varied over time (p=0.001); musculoskeletal pain was significantly greater in A group for time points 6-24 months (all p<.001); vaginal problems were greater in A group (p=0.03). Hot flash and vaginal problems were significantly worse in women <60 years. Additional SX outcomes (depression, fatigue, sexual function) will be reported at presentation.

Conclusion

In this large, double-blind, placebo-controlled trial comparing A to tam in patients with DCIS, there was no significant difference in QOL between the two treatments. However, there were important treatment differences in SX outcomes, which should be considered as part of treatment decision-making discussions, along with the clinical breast cancer outcome results.

Support: CA-180868, 180822, 189867, 196067, 114732; AstraZeneca Pharmaceuticals LP.

Citation Format: Ganz PA, Cecchini RS, Julian TB, Margolese RG, Costantino JP, Vallow LA, Albain KS, Whitworth PW, Cianfrocca ME, Brufsky A, Gross HM, Soori GS, Hopkins JO, Fehrenbacher L, Sturtz K, Wozniak TF, Seay TE, Mamounas EP, Wolmark N. Patient-reported outcome (PRO) results, NRG Oncology/NSABP B-35: A clinical trial of anastrozole (A) vs tamoxifen (tam) in postmenopausal patients with DCIS undergoing lumpectomy plus radiotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S6-04.

Abstract P1-12-06: N0937 (Alliance): Preliminary results of a phase II clinical trial of cisplatin and the novel agent brostallicin in patients with metastatic triple negative breast cancer (mTNBC)

Background: TNBC is characterized by unique molecular profiles, aggressive behavior, poor prognosis and lack of targeted therapies. Brostallicin is a novel synthetic compound from the class of DNA minor groove binding (MGB) anti-cancer agents, making it a logical agent to evaluate in the setting of TNBC. It retains activity in cancer cells resistant to alkylating agents, topoisomerase I inhibitors and is fully active against DNA-mismatch repair deficient tumor cells. Preclinical models using cell lines demonstrate that cells expressing relatively high glutathione/glutathione S-transferase (GSH/GST) levels are more susceptible to brostallicin's antitumor efficacy. Cisplatin administration increases expression of GSH/GST in tumor cells, thus leading to an increased anti-tumor efficacy of brostallicin.

Methods: Phase II cooperative group study in pts with mTNBC (³18 years of age with measurable metastatic disease, ER/PR ≤1%; HER2 negative, who had received 0–4 prior chemotherapy regimens in the metastatic setting; with adequate hematologic, renal and hepatic functions; and no active CNS metastases; prior exposure to cisplatin allowed). Cisplatin on Day 1 followed by brostallicin on Day 2, repeated every 21 days. Aim: efficacy of brostallicin and proof of concept of its mechanism of action in mTNBC. Primary endpoint progression-free survival (PFS) at 3 months with 89% power (0.10 significance level) to detect an absolute difference of 20% (35% vs 55%), based on the median PFS of 60 days in pts with mTNBC from the N0234 trial of erlotinib and gemcitabine as 1st/2nd line. Secondary endpoints include ORR, duration of response (DOR), 6-month PFS, OS and AE profile. Tertiary endpoints include assessment of 1) GSH levels prior to the administration of cisplatin and of brostallicin; and 2) the prevalence of BCRA-1 mutation by IHC in primary or metastatic tumor.

Results: Study closed on 3/28/12 and it accrued 48 pts (median f/u 2.3 mo; 0–15.3); 33 pts are off treatment and 15 pts remain on study; 38 pts evaluable for response, and 43 evaluable for AEs. 50% received therapy as 3rd to 5th line. Median number of cycles 2.5 (off-treatment: 2; on-treatment: 3, range 0–15). There are currently 5 confirmed responses (4 PR and 1 CR); DOR: 2.8–13.3 months. The 6-mo PFS is currently 19.2% (95% CI: 8.9%, 41.3%); the median TTP is 3.0 months (95% CI: 1.7 months, 4.2 months). Current data are premature to determine the primary endpoint (3-mo PFS) but we expect to report such data by November 2012. Current toxicity data: 69.7% G3/4 heme toxicity. Non-heme toxicity G3 (30.2%) and G4 (9.3)% (febrile neutropenia 21%; fatigue G3 14%); and no G5 non-heme AE.

Conclusions: The current preliminary data of this trial show very encouraging activity of this regimen (brostallicin plus cisplatin) in mTNBC. Near 1/3 of pts are still currently receiving therapy, and we expect to provide primary and additional secondary endpoint data at SABCS 2012.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-12-06.

A phase II study of cetuximab and radiation in elderly and/or poor performance status patients with locally advanced non-small-cell lung cancer (N0422)

BACKGROUND

Non-small-cell lung cancer (NSCLC) is a disease of the elderly. Seeking a tolerable but effective regimen, we tested cetuximab + radiation in elderly and/or poor performance status patients with locally advanced NSCLC.

PATIENTS AND METHODS

Older patients [≥ 65 years with an Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2] or younger patients (performance status of 2) received cetuximab 400 mg/m(2) i.v. on day 1 followed by weekly cetuximab 250 mg/m(2) i.v. with concomitant radiation of 6000 cGy in 30 fractions. The primary end point was the percentage who lived 11+ months.

RESULTS

This 57-patient cohort had a median age (range) of 77 years (60-87), and 12 (21%) had a performance status of 2. Forty of 57 (70%) lived 11+ months, thus exceeding the anticipated survival rate of 50%. The median survival was 15.1 months [95% confidence interval (CI) 13.1-19.3 months], and the median time to cancer progression was 7.2 months (95% CI 5.8-8.6 months). No treatment-related deaths occurred, but 31 patients experienced grade 3+ adverse events, most commonly fatigue, anorexia, dyspnea, rash, and dysphagia, each of which occurred in <10% of patients.

CONCLUSION

This combination merits further study in this group of patients.

Phase II trial of subcutaneous interleukin-2, subcutaneous interferon-alpha, intravenous combination chemotherapy, and oral tamoxifen in the treatment of metastatic melanoma: final results of cancer biotherapy research group 94-11

BACKGROUND

The treatment of metastatic melanoma remains unsatisfactory despite encouraging results with biotherapy and combination chemotherapy. Combining these two modalities may improve outcomes for such patients.

METHODS

Eligible patients had metastatic melanoma, were in good medical condition, and had not been treated previously for metastatic disease. A 42-day treatment cycle consisted of: tamoxifen 10 mg p.o. b.i.d. days 1-42, carmustine 150 mg/m2 i.v. on day three, dacarbazine 220 mg/m2 and cisplatin 25 mg/m2 i.v. q.d. days 3-5, and 24-26, interferon-alpha 2b 6.0 MU/m2 s.c. days 8-12 and 29-33, and interleukin-2 11 MU/m2 s.c. days 8, 10, 12 and 29, 31, 33. In the absence of tumor progression, patients could receive up to six cycles of alternating treatment. Toxicity and tumor response was assessed following each treatment cycle; survival was determined from the first date of treatment.

RESULTS

The 28 melanoma patients included 21 men and 7 women, with a median age of 55 years with a range of 26-77. Fifty-four percent were asymptomatic when treatment was initiated. Eighty percent had soft tissue metastases, 32% lung, 28% liver, and 8% bone. There were nine patients with significant tumor responses (three complete, six partial) for a response rate of 32% (18-57% 95% CI) based on intent-to-treat analysis, and 38% (18-57%, 95% CI) for the 24 patients who were evaluable for response. The months of duration of survival for responders were 38.9+, 27.2+, 22.8+, 16.3, 13.2, 9.4, 7.5, 6.5+, and 5.8. At a median follow-up of 31 months, the median duration of event-free survival was 4.6 months; median survival was 9.4 months. The survival rate one year from initiating treatment was 42%; 2-year survival was 14%. The most frequent toxicities were 96% nausea/vomiting, 80% fatigue, 73% thrombocytopenia, 60% neutropenia, and 44% fever. Two patients experienced early death that may have been treatment related; one died of cardiovascular complications and the other of a central nervous system event.

CONCLUSION

This outpatient regimen was associated with significant toxicity including a 7% rate of possible treatment-related death. Tumor regression rates and survival were similar to results reported for chemotherapy alone, or inpatient IL-2-based therapy, but did not suggest an improvement in outcome.

Chemo-biotherapy with 5-fluorouracil, leucovorin, and alpha interferon in metastatic carcinoma of the colon--a Cancer Biotherapy Research Group [CBRG] phase II study

BACKGROUND

Biochemical modulation of 5-Fluorouracil activity with Leucovorin has been well documented in colorectal cancer. Several studies have shown increased efficacy of 5-fluorouracil in combination with alpha interferon. We therefore initiated a phase II trial of dual modulation of 5-fluorouracil with leucovorin and alpha interferon to evaluate outcomes in patients with metastatic carcinoma of the colon.

METHODS

Patients with metastatic colon carcinoma with expected survival > 4 months and performance status of ECOG < or = 2 were treated weekly with Leucovorin 400 mg i.v. followed by 5-FU 600 mg/m2 i.v. bolus. Alpha interferon 3-9 million units was administered subcutaneously every Monday, Wednesday and Friday. Patients were analyzed for toxicity, tumor response and survival.

RESULTS

Sixteen patients with a median age of 66 years were treated. Three patients were not evaluable for response but were evaluable for toxicity. Grades 3 and 4 toxicities were neutropenia, diarrhea, mucositis, nausea and vomiting, fatigue, fever, asthenia and elevated hepatic enzymes. One patient died from complications associated with diverticulitis and neutropenia. Objective response rate was 23% (95% confidence interval 4-46%) and median survival was 11.5 months (95% confidence interval 6.3-19 months). Thirty-eight percent of the patients were alive at one year and 19% at two years.

CONCLUSION

The combination of 5-fluorouracil, leucovorin and alpha interferon as administered in this phase II study did not result in enhanced response rate or survival. However this regimen was associated with considerable toxicity.

Continuous-infusion floxuridine and alpha interferon in metastatic renal cancer: a national biotherapy study group phase II study

Eighteen patients with advanced renal cancer were treated with 0.15 mg/kg/day floxuridine by continuous intravenous infusion for 14 days with 3 million IU/m2/day alpha interferon subcutaneously three times weekly. Treatment cycles were repeated every 28 days. Floxuridine dosages were escalated to a maximum of 0.2 mg/kg/day and alpha interferon dosages were escalated to a maximum of 6 million IU/m2/day depending on patient tolerability. A total of 49 treatment courses were administered with a median of 2.7 courses per patient. Of 14 assessable patients, there were no complete or partial responses. Eight patients (57%) had stabilization of disease. The median survival for patients with stable disease was 20.9 months and for all 18 patients was 7.2 months. Grades 3 and 4 toxicities included diarrhea (44%), nausea/vomiting (28%), mucositis (11%), fever (22%), and fatigue (50%). Dose-limiting toxicities were primarily gastrointestinal symptoms. There were no treatment-related deaths. This combination in the dose schedule used did not result in any significant objective tumor response but was associated with considerable toxicity.

Interferon-alpha and chemohormonal therapy for patients with advanced melanoma: final results of a phase I-II study of the Cancer Biotherapy Research Group and the Mid-Atlantic Oncology Program

BACKGROUND

The treatment of metastatic melanoma remains unsatisfactory despite encouraging results with biotherapy and combination chemotherapy. Combining these two modalities may improve outcomes for such patients.

METHODS

Patients who were eligible for this study had metastatic melanoma and were in good medical condition. The following regimen was used: dacarbazine 220 mg/m2 and cisplatin 25 mg/m2 administered intravenously (i.v.) daily x 3 days every 3 weeks, carmustine 150 mg/m2 i.v. every 6 weeks, tamoxifen 10 mg administered orally twice a day, and interferon-alpha2b 3.0 thousandths of an International Unit (mIU)/m2 administered subcutaneously on Days 1, 3, and 5 of each week a patient was on study. Patients were analyzed for toxicity, tumor response, and survival. Because of severe toxicity, partway through the trial the regimen was modified as follows: dacarbazine and cisplatin were given at the same dose every 4 weeks, and carmustine was reduced to 100 mg/m2 every 8 weeks.

RESULTS

Forty-two patients with a median age of 61 years were enrolled. Twenty had liver metastases and 18 had lung metastases. Forty patients were evaluable for toxicity, 17 at the original dose and 23 at the new dose; of these, 35 were evaluable for response. Hematologic toxicity was severe at the original dose: 10 patients had a nadir < 500/microL, 10 had platelets < 25,000/microL, and 2 discontinued treatment because of toxicity. At the reduced dose, 5 had a nadir absolute neutrophil count < 500, and 10 had platelets < 25,000. Of the 35 patients evaluable for response, there were 10 partial responses (29%) and 2 minimal responses. Median duration of disease control was 4 months. Median survival was 8.9 months. One partial and one minimal responder were removed from the study because they experienced toxicity while still responding.

CONCLUSIONS

The addition of interferon-alpha to this chemohormonal therapy regimen greatly increased toxicity without improving the response rate or survival for patients with metastatic melanoma.

Eosinophilia associated with bupropion

OBJECTIVE

To describe the first incidence of eosinophilia following administration of bupropion.

CASE SUMMARY

The patient was a 72-year-old woman admitted for evaluation of chest pain. During hospitalization, the eosinophil count reached 0.60 fraction of 1.00, with absolute eosinophil count of 6693 x 10(6)/L and a white blood cell count of 18.5 x 10(9)/L. She had been receiving bupropion therapy for 5 days prior to this admission.

DISCUSSION

Potential causes of the eosinophilia, including disease states and medications, were reviewed comprehensively and ruled out. A review of the literature (MEDLINE 1966-1994) did not identify previous cases of eosinophilia associated with bupropion therapy. Causes of eosinophilia include parasitic infections, allergic diseases, and medication use. A proposed mechanism for the occurrence of eosinophilia in this patient is unknown.

CONCLUSIONS

Considering the temporal sequence of events, drugs administered prior to the development of eosinophilia, and the rapid decline of the eosinophil count following discontinuation of the medication, bupropion appears to be the precipitating agent.

Interferon alpha-2a and external beam radiotherapy in the initial management of patients with glioma: a pilot study of the National Biotherapy Study Group

The National Biotherapy Study Group conducted a phase I/II trial of alpha-interferon (IFN) plus radiation therapy (RT) in glioma patients to confirm the feasibility of combining these two modalities. Patients newly diagnosed gliomasreceived external beam RT as 180 cGy in 33 fractions over six to seven weeks, five days a week, and IFN at a dose of 3 MIU SC Monday, Wednesday and Friday of each week. IFN was increased to 5 MIU after two weeks and was given for up to 16 weeks. Patients were monitored for toxicity and failure-free and overall survival. There were 12 men and seven women with an age range of 24-77, and a median age of 64 years. There were 12 glioblastomas and seven advanced astrocytomas. Complete surgical resection was carried out in two patients, nine had a partial resection, and eight had a biopsy only. Two patients in the latter group deteriorated rapidly and received < 2 weeks of RT/IFN. One patient stopped IFN because of a skin rash, another stopped because of concurrent pneumonia, and one patient was noncompliant. RT and IFN were well-tolerated; 14 of the 19 patients completed the eight weeks of IFN/RT. However, only three patients took IFN for the maximum of 16 weeks. The only grade 4 toxicities noted were increases SGOT in three, increases alk phos in two, and severe fatigue in four patients. The median failure-free survival was two months, median survival was 7.5 months, and four patients survived beyond one year. The longest survivor was 29.1 months, and one patient is still alive after 20.7 months. IFN/RT can be safely co-administered in patients with gliomas. A randomized trial would be needed to establish clinical benefit.

Systemic polyclonal B-immunoblastic proliferation with marked peripheral blood and bone marrow plasmacytosis

The clinical and pathologic features of a case of acute systemic polyclonal B-immunoblastic proliferation characterized by pronounced peripheral blood and bone marrow plasmacytosis and infiltration of the hepatic portal areas by immunoblasts, plasma cells, and lymphocytes are reported. Clinical and laboratory findings during the acute phase and long-term follow-up support the diagnosis of a benign process, possibly related to Pseudomonas aeruginosa septicemia. The patient experienced a dramatic clinical recovery on administration of high-dose intravenous corticosteroids. Pathologists should be aware of this entity so as not to confuse it with non-Hodgkin's lymphoma or a form of plasma cell dyscrasia.