Abstract P4-11-04: A Structured Genetic Risk Evaluation and Testing Program in the Community Oncology Practice Increases Identification of Individuals at Risk for BRCA Mutations

Background: Genetic risk assessment is an important component of the care of the community oncology breast cancer patient. However, identification of at-risk patients is largely an ad-hoc process and practices lack a systematic approach to genetic risk evaluation. The US Oncology Network Genetic Risk Evaluation and Testing (USON GREAT) Program provides a structured approach to implementation of genetic risk evaluation, testing, and triage for appropriate intervention.

Methods: In 2009, our multi-disciplinary community oncology practice implemented the USON GREAT Program. The practice's program has a single dedicated nurse practitioner and physician lead, trained in part through a core educational curriculum and utilizing US Oncology Network-wide genetics resources (web-based MD, midlevel, and genetic counselor conferencing; discussion Portal; published guidelines and office procedures). NCCN guidelines were used to guide testing recommendations. Sequential risk evaluations were documented prospectively. We retrospectively analyzed how evaluation patterns changed over a 4 year time period. We also sought to capture descriptive characteristics of the evaluated population.

Results: Overall, between 2008 and 2011, our practice evaluated 1018 patients at potential risk for a BRCA mutation (mut), based on personal history of breast cancer under age 50; ovarian, fallopian or peritoneal cancer; known family history of malignancy; or known BRCA mutation in the family.

A randomized, multicenter phase III trial comparing doxorubicin + cyclophosphamide followed by paclitaxel or doxorubicin + paclitaxel followed by weekly paclitaxel as adjuvant therapy for high-risk breast cancer

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Background: This study compared the disease-free survival (DFS) obtained with 2 regimens of adjuvant therapy for patients (pts) with high-risk breast cancer Methods: Women PS 0–1 with local, operable, confirmed stage I-III adenocarcinoma were eligible. Pts may have had primary surgery, with no residual tumor. Therapy was as follows:Arm 1 (AC→T) - doxorubicin 60 mg/m2 plus cyclophosphamide 600 mg/m2 repeated every 3 weeks for 4 cycles → paclitaxel 175 mg/m2 repeated every 3 weeks for 4 cycles; Arm 2 (AT→T) - doxorubicin 50 mg/m2 plus paclitaxel 200 mg/m2 repeated every 3 weeks for 4 cycles → paclitaxel 80 mg/m2 weekly ×12. Results: 1,830 pts were enrolled and treated; n=915 Arm 1 (AC→T) and n=915 Arm 2 (AT→T). Pts were: PS=0 (70%/Arm), ER+/PR+ (54% and 50%, Arms 1 and 2 respectively), ER-/PR- (35% and 34%) with 0 positive nodes (N+) (28% and 27%), 1–3 (N+) (44% and 46%), 4–9 (N+) (21% and 18%) and 10+ (N+) (7% and 8.5%). Most were postmenopausal (57%/Arm); median age was 52 years/Arm. To date 1,655 pts (90%) are alive. 5-year DFS was 80% vs 81% for Arms 1 and 2 Overall 5-year survival was 86% vs 89%, in Arms 1 and 2. Cause of death was recurrence for 76 pts in Arm 1 and 56 pts in Arm 2. The main reasons for pts being taken off study treatment were toxicity (85 pts Arm 1 vs 128 pts Arm 2), recurrence (79 pts Arm 1 vs 52 pts Arm 2), and consent withdrawal (18 pts Arm 1 vs 30 pts Arm 2). The most frequent toxicities were neutropenia, leukopenia, neuropathy, febrile neutropenia, nausea, vomiting, arthralgia, and myalgia. GI toxicities were more frequent in Arm 1. Alopecia occurred in both Arms (77%). Conclusions: At 5-years, the AT→T produced significantly better OS (p=0.054) and improved DFS (p=0.19). Clinically important toxicities were more frequent with AC→T. Given this, AT→T in the adjuvant treatment of breast cancer is well tolerated and warranted in place of AC→T in these pts. Research support provided by Bristol-Myers Squibb (Princeton, NJ).

No significant financial relationships to disclose.

A Phase II study of gemcitabine plus zoledronic acid in subjects with Stage IV pancreatic cancer

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Background: Gemcitabine, the standard chemotherapy for advanced pancreatic cancer (APC), produces low response rates and short time to progression. Preclinical studies suggest that zoledronic acid inhibits pancreatic cell lines by interfering with the p21ras/raf-1/MEK1/ERKL signaling pathway. We conducted this trial to evaluate the efficacy and toxicity of gemcitabine and zoledronic acid in subjects with APC. Methods: Eligible subjects had histological or cytological diagnosis of metastatic pancreatic adenocarcinoma (Stage IV) not amenable to resection with curative intent. Gemcitabine 1000 mg/m2 IV was given on Days 1, 8, 15, and 22 in Cycle 1 and Days 1, 8, and 15 in subsequent cycles. Zoledronic acid 4 mg IV was given on Day 1 every 4 weeks. Toxicity was assessed at each visit. Results: Between December 2004 and July 2005, 35 subjects were enrolled. Baseline characteristics: 20 males (57%), median age 66.7 years (range, 40–83.5), and KPS of 70/80/90/100 = 8%/29%/34%/29%, respectively. Four patients had locally advanced disease (3 stage IIB and 1 stage III), 86% of subjects had Stage IV disease at diagnosis; 91% of subjects had adenocarcinoma. Prior therapy included surgery (n=15, 43%), chemotherapy (n=3, 9%), and radiotherapy (n=2, 6%). To date, there has been 1 PR and 9 SD; the clinical benefit rate (PR+SD≥6 months) was 14%. Grade 3 and 4 treatment-related toxicities included: neutropenia (22%); thrombocytopenia and fatigue, (12.5% each); and anemia, nausea/vomiting, dehydration, and diarrhea (6% each). Seven treatment-related SAEs have been reported; 28 subjects are off study. Patients discontinued treatment due to: progressive disease (PD) (n=15), toxicity (n=4, 1 each DVT, infection, back pain, and generalized weakness), withdrew consent (n=3), MD decision (n=2), patient request (n=2), and death (n=2), To date, 21 subjects have died; deaths were attributed to PD (n=16), CVA (n=1), and unknown (n=4). Conclusions: Pancreatic cancer, typically advanced at diagnosis, remains a major treatment challenge. Zoledronic acid in combination with gemcitabine was well-tolerated in this study. Future genomic testing is proposed for responders. Updated toxicity, response, and survival data will be presented. Supported by Novartis Pharmaceuticals Corp., East Hanover, NJ.

No significant financial relationships to disclose.

Reducing red cell transfusion by audit, education and a new guideline in a large teaching hospital

Safety concerns combined with the greatly increased costs and difficulties of maintaining the blood supply are major considerations for transfusion services. Previous local surveys demonstrated that hospital blood use at our hospital could be improved. Excessive cross-matching, unnecessary transfusion and high return rates of unused blood were commonplace. Transfusion practice was audited over a 3-month period. An education package with guidelines for transfusion was delivered to all clinician groups within the hospital, over the following 9 months. The audit was repeated exactly 1 year later at the same time period. During the second audit, inpatient hospital numbers increased by 1.02% (from n = 7262 to n = 7336) but no differences in length of stay, cardiovascular morbidity or mortality were demonstrated. Twenty percent (n = 254, 2002; n = 316, 2001) fewer patients received blood, and the number of red cell packs used reduced by 19% (from n = 1093 to n = 880). Total number of patients transfused reduced from 4.4% to 3.5% which, as an absolute difference, is a reduction of 0.9% (CI 0.3-1.5, P = 0.006). The audit, guideline and education package had a major impact on red cell use within the hospital with no adverse effects. Blood use can be improved by the implementation of a suitable education package and guideline. If it is possible to replicate the results of this education programme nationwide, the effect on blood use, with subsequent savings and enhanced patient safety could be significant.

The relationship between glaucoma and myopia: the Blue Mountains Eye Study

OBJECTIVE

To quantify the relationship between myopia and open-angle glaucoma, ocular hypertension (OH), and intraocular pressure (IOP) in a representative older population.

DESIGN

Cross-sectional population-based study of 3654 Australians 49 to 97 years of age.

METHODS

Subjects with any myopia (> or =-1.0 diopter [D]) were identified by a standardized subjective refraction and categorized into low myopia (> or =-1.0 D to <-3.0 D) or moderate-to-high myopia (> or =-3.0 D). Glaucoma was diagnosed from characteristic visual field loss, combined with optic disc cupping and rim thinning, without reference to IOP. Ocular hypertension was diagnosed when applanation IOP was greater than 21 mmHg in either eye in the absence of glaucomatous visual field and optic disc changes.

MAIN OUTCOME MEASURE

General estimating equation models were used to assess associations between eyes with myopia and either glaucoma or OH.

RESULTS

Glaucoma was present in 4.2% of eyes with low myopia and 4.4% of eyes with moderate-to-high myopia compared to 1.5% of eyes without myopia. The relationship between glaucoma and myopia was maintained after adjusting for known glaucoma risk factors, odds ratio (OR) of 2.3, and 95% confidence intervals (CI) of 1.3 to 4.1 for low myopia. It was stronger for eyes with moderate-to-high myopia (OR, 3.3; CI, 1.7-6.4). Only a borderline relationship was found with OH, OR of 1.8 (CI, 1.2-2.9) for low myopia, and OR of 0.9 (CI, 0.4-2.0) for moderate-to-high myopia. Mean IOP was approximately 0.5 mmHg higher in myopic eyes compared to nonmyopic eyes.

CONCLUSIONS

This study has confirmed a strong relationship between myopia and glaucoma. Myopic subjects had a twofold to threefold increased risk of glaucoma compared with that of nonmyopic subjects. The risk was independent of other glaucoma risk factors and IOP.

A multicenter, phase II trial of weekly irinotecan (CPT-11) in patients with previously treated colorectal carcinoma

BACKGROUND

This multicenter, Phase II trial was performed to evaluate the antitumor activity and toxicity of irinotecan (CPT-11) in patients with metastatic colorectal carcinoma that had recurred or progressed after 5-fluorouracil (5-FU)-based chemotherapy.

METHODS

CPT-11 was given as a 90-minute intravenous infusion in repeated 6-week (42-day) courses comprising weekly treatment for 4 consecutive weeks followed by a 2-week rest. Tumor measurements were obtained after every second course of therapy. Toxicity was assessed weekly using the National Cancer Institute Common Toxicity Criteria.

RESULTS

A total of 166 patients were entered into the trial. The first 64 patients received a starting dose of 125 mg/m2. An additional 102 patients were enrolled at a starting dose of 100 mg/m2 to determine whether a reduction in the starting dose would result in lower toxicity without sacrificing efficacy. Objective responses to CPT-11 were observed in 18 patients (1 complete response and 17 partial responses) (response rate [RR] = 10.8%; 95% confidence interval [CI], 6.1-15.6%). An additional 67 patients (40.4%) had stable disease as their best response. At the 125 mg/m2 starting dose, the RR was 14.1% (9 of 64 patients; 95% CI, 5.5-22.6%). Among patients given a starting dose of 100 mg/m2, the RR was 8.8% (9 of 102 patients; 95% CI, 3.3-14.3%). The overall median survival was 9.9 months (range, 0.3-36.8 months). The most frequently observed Grade 3/4 toxicities were gastrointestinal events (i.e., diarrhea [27.1%], nausea [15.1%], emesis [9.6%], abdominal cramping [22.2%], and neutropenia [19.9%]). There were no significant differences in the frequencies of Grade 3/4 toxicities between the 125 mg/m2 and 100 mg/m2 starting dose levels except for Grade 3/4 emesis (21.9% vs. 2%; P < 0.001). Patients age > or = 65 years were twice as likely (38.6% vs. 18.8%; P < 0.008) to develop Grade 3/4 diarrhea compared with younger patients when all courses of therapy were evaluated. However, older age did not significantly predict for a higher incidence of first-course diarrhea (25.0% vs. 14.7%; P = 0.106).

CONCLUSIONS

CPT-11 can induce tumor regression in patients with metastatic colorectal carcinoma that has progressed during or shortly after 5-FU-based chemotherapy. Gastrointestinal events and neutropenia were the most common serious toxicities. Given the trend toward a higher response rate without substantially greater toxicity, 125 mg/m2 has been selected as the preferred starting dose for further studies. Careful attention to appropriate CPT-11 dose modification and early intervention with loperamide may be especially important in elderly patients.

The Heimann-Bielscholwsky phenomenon: dissociated vertical nystagmus

BACKGROUND

The Heimann-Bielschowsky phenomenon (HBP) is a unilateral vertical nystagmus with coarse, slow pendular movements that typically occurs in an eye with profound visual loss. There are no sinister neurological implications.

METHODS

Symptoms and signs on presentation and the subsequent course are described in detail in 10 patients. Eye movements were recorded for one patient.

RESULTS

Three patients had corrected vision of 6/24 or better. Strabismus was seen in eight patients. Symptoms of diplopia and oscillopsia were infrequent.

CONCLUSIONS

We believe that the HBP may be a reasonably common condition, although very under diagnosed. This condition may be similar to Central Fusion Disruption. Patients with HBP appear to have lost the potential for fusion.

Comparison of single-dose oral granisetron versus intravenous ondansetron in the prevention of nausea and vomiting induced by moderately emetogenic chemotherapy: a multicenter, double-blind, randomized parallel study

PURPOSE

The antiemetic effectiveness and safety of single-dose oral granisetron were compared with intravenous (I.V.) ondansetron in chemotherapy-naive patients who received moderately emetogenic chemotherapy.

PATIENTS AND METHODS

In this double-blind, parallel-group study, patients naive to emetogenic chemotherapy (N = 1,085) who were scheduled to receive cyclophosphamide- (500 to 1,200 mg/m2) or carboplatin (> or = 300 mg/m2) based chemotherapy, were randomized to receive either oral granisetron (n = 542) or I.V. ondansetron (n = 543). Efficacy assessments included the proportion of patients in each treatment group with total control over the 24 and 48 hours following chemotherapy initiation, as well as incidence and severity of nausea and emesis and use of antiemetic rescue medication. Prophylactic corticosteroids were allowed. Safety assessment was based on patients' reports of adverse experiences.

RESULTS

Approximately 80% of patients received prophylactic corticosteroids. Single-dose oral granisetron (2 mg) and I.V. ondansetron (32 mg) resulted in equivalent levels of total emetic control during the first 48 hours after chemotherapy. The proportion of nausea- and emesis-free patients at 24 and 48 hours were also approximately equivalent. The most commonly reported adverse experiences were headache, asthenia, and constipation. More patients who received ondonsetron than granisetron reported dizziness (9.6% v 5.4%, respectively; P = .011) and abnormal vision (4.2% v 0.6%, respectively; P < .001).

CONCLUSION

A single oral dose of granisetron (2 mg) resulted in equivalent levels of antiemetic protection as I.V. ondansetron (32 mg). Both agents were well tolerated, although more dizziness and abnormal vision were reported with ondansetron. Because the two antiemetic regimens exhibited equivalent efficacies, additional factors such as convenience and cost of therapy should be considered.

The gap effect and express saccades in the auditory modality

Latencies of eye movements to peripheral targets are reduced when there is a short delay (typically 200 ms) between the offset of a central visual fixation point and the target onset. This has been termed the gap effect. In addition, some subjects, usually with practice, exhibit a separate population of very short latency saccades, called express saccades. Both these phenomena have been attributed to disengagement of visual attention when the fixation point is extinguished. A competing theory of the gap effect attributes it to disengagement of oculomotor fixation during the temporal gap. It is known that auditory targets are effective in eliciting saccadic eye movements, and also that covert attention operates in the auditory modality. If the gap effect and express saccades are due to disengagement of spatial attention, both should persist in the auditory modality. However, fixation of gaze is largely under visual control. If the gap effect results from disengagement of fixation, then at least a reduced effect should be seen in the auditory modality. Human subjects performed the gap task and a control task in the dark, using auditory fixation points and saccadic targets, on five successive days. Despite this practice, express saccades were not observed. There was a reliable gap effect, but the reduction in saccadic latency was only 17 ms, compared with 32 ms for the same subjects in the visual modality. This suggests that about half the gap effect is due to disengagement of visual fixation. The remainder was not due to non-specific warning effects and could be attributed to offset of the auditory fixation stimulus.

Central ocular motor disorders

Our understanding of the complexities of the central mechanisms that control human eye movements continues to expand rapidly under the twin impetus of more widespread use of high-resolution eye movement recording techniques and improved anatomical localization of lesions using magnetic resonance imaging. In parallel, there has been continued expansion of sophisticated neurophysiological studies in monkeys examining basic ocular motor control mechanisms. Another important area that is now rapidly expanding is the application to human diseases of more complex and cognitively demanding saccadic eye movement stimulus paradigms such as antisaccades, memory-guided saccades, and express saccades. Finally, a much clearer understanding and exposition of the complexities of central vestibular function appears to be gathering pace.

Bisantrene, an active drug in patients with advanced breast cancer

We have previously reported that bisantrene has significant activity against a variety of tumors in the human tumor soft agar cloning assay. An update of that experience reveals that 26% of evaluable human breast cancer specimens were sensitive to bisantrene, which had activity equivalent or superior to that of doxorubicin. Because of the preclinical activity of bisantrene and its activity in the cloning assay, bisantrene was studied in a phase II clinical trial of 30 patients with advanced breast cancer refractory to standard agents. Six patients (20%) had objective complete or partial regressions, including one patient with complete regression of lymphangitic lung metastases lasting greater than 18 months, confirming the antitumor activity of this compound. Two of the six responding patients had failed doxorubicin treatment, implying a lack of complete cross-resistance. Bisantrene toxicity was acceptable in most patients, with reversible myelosuppression being the most frequent side effect. Phase III trials of this promising new agent are warranted.

Direct cloning of human breast cancer in soft agar culture

A human tumor cloning system has been utilized to grow human breast carcinoma. A total of 225 specimens have been placed in culture. One hundred thirty-two were from primary chest cancer specimens and 93 were from metastatic lesions. Of these, 71% of the primary breast carcinomas and 75% of metastases formed greater than or equal to 5 colonies per 500,000 cells plated. Forty-five percent of the primary breast carcinomas and 52% of the metastases formed enough colonies (greater than or equal to 30 colonies per 500,000 cells plated) to perform meaningful in vitro drug testing. Estrogen receptor status did not influence the percentage of tumors which formed colonies in vitro. Histologic and nude mouse studies provided confirmatory evidence the colonies were composed of breast cancer cells. In 176 in vitro chemotherapeutic drug tests, the anticancer agents commonly used clinically for treatment of breast cancer, i.e., Adriamycin, 5-fluorouracil, etc., showed some in vitro activity. This activity was not as dramatic as is seen in the clinic with these conventional agents. Future work should concentrate on improving the number of colonies which form from breast cancer specimens and on prospective use of the system for screening for new agents for the treatment of human breast cancer.

Potential and problems with growth of breast cancer in a human tumor cloning system

A human tumor cloning system has been utilized to culture 431 patients' breast cancer specimens. Overall, 288 or 67% of the specimens formed colonies in soft agar. Of the primary lesions 188/260 (72%) formed colonies and 100/171 (58%) of the metastatic lesions formed colonies. The median number of colonies per 500,000 nucleated cells plated was 47 for the primary lesions and 30 for the metastatic lesions. Growth from a variety of metastatic sites ranged from 22% for intradermal lesions to 77% for solid visceral metastases. Methods to increase the number of colonies from a specimen are reported including increasing the number of nucleated cells plated and making a variety of changes in the growth media. None of these methods has had a major impact on colony growth. The antitumor activity of standard anticancer agents such as adriamycin and medroxyprogesterone in the assay is presented. In addition, in vitro results with two new anthracene derivatives demonstrate good antitumor activity for the derivatives. The cloning assay represents a new model for both the basic and clinical studies of human breast cancer.

Association between human tumor colony-forming assay results and response of an individual patient's tumor to chemotherapy

An in vitro tumor colony-forming assay was utilized to measure the sensitivity of 800 individual patients' tumors to a variety of antineoplastic agents. Thirty-six separate histologic types of cancer were represented. Only 199 of the 800 patients' tumors (25 percent) both formed colonies in vitro and had enough cells in the biopsy or fluid specimen to perform drug sensitivity assays. In 123 instances the drug tested in vitro against the tumor was also used clinically to treat the patient. The clinician caring for the patient did not know the results of the in vitro test. When analyzed in a retrospective manner, the probability of a positive prediction from the assay, given the patient responded clinically, was 0.88. The probability for a negative prediction of the assay given the patient did not respond, was 0.94. Associations of in vitro and in vivo results in the 123 correlations were highly significant (p less than 0.001). We conclude that, as now constituted, the human tumor colony-forming assay can provide useful sensitivity information for only about 25 percent of the general oncology patients. Secondly, a prospective clinical trial of the assay is needed to insure that the assay is indeed predictive of which drug will produce a patient response and that it is not merely an indicator that a particular patient's tumor is highly responsive in vivo.