Addition of gemcitabine to paclitaxel, epirubicin, and cyclophosphamide adjuvant chemotherapy for women with early-stage breast cancer (tAnGo): final 10-year follow-up of an open-label, randomised, phase 3 trial

BACKGROUND

The tAnGo trial was designed to investigate the potential role of gemcitabine when added to anthracycline and taxane-containing adjuvant chemotherapy for early breast cancer. When this study was developed, gemcitabine had shown significant activity in metastatic breast cancer, and there was evidence of a favourable interaction with paclitaxel.

METHODS

tAnGo was an international, open-label, randomised, phase 3 superiority trial that enrolled women aged 18 years or older with newly diagnosed, early-stage breast cancer who had a definite indication for chemotherapy, any nodal status, any hormone receptor status, Eastern Cooperative Oncology Group performance status of 0-1, and adequate bone marrow, hepatic, and renal function. Women were recruited from 127 clinical centres and hospitals in the UK and Ireland, and randomly assigned (1:1) to one of two treatment regimens: epirubicin, cyclophosphamide, and paclitaxel (four cycles of 90 mg/m2 intravenously administered epirubicin and 600 mg/m2 intravenously administered cyclophosphamide on day 1 every 3 weeks, followed by four cycles of 175 mg/m2 paclitaxel as a 3 h infusion on day 1 every 3 weeks) or epirubicin, cyclophosphamide, and paclitaxel plus gemcitabine (the same chemotherapy regimen as the other group, with the addition of 1250 mg/m2 gemcitabine to the paclitaxel cycles, administered intravenously as a 0·5 h infusion on days 1 and 8 every 3 weeks). Patients were randomly assigned by a central computerised deterministic minimisation procedure, with stratification by country, age, radiotherapy intent, nodal status, and oestrogen receptor and HER-2 status. The primary endpoint was disease-free survival and the trial aimed to detect 5% differences in 5-year disease-free survival between the treatment groups. Recruitment completed in 2004 and this is the final, intention-to-treat analysis. This trial is registered with EudraCT (2004-002927-41), ISRCTN (51146252), and ClinicalTrials.gov (NCT00039546).

FINDINGS

Between Aug 22, 2001, and Nov 26, 2004, 3152 patients were enrolled and randomly assigned to epirubicin, cyclophosphamide, paclitaxel, and gemcitabine (gemcitabine group; n=1576) or to epirubicin, cyclophosphamide, and paclitaxel (control group; n=1576). 11 patients (six in the gemcitabine group and five in the control group) were ineligible because of pre-existing metastases and were therefore excluded from the analysis. At this protocol-specified final analysis (median follow-up 10 years [IQR 10-10]), 1087 disease-free survival events and 914 deaths had occurred. Disease-free survival did not differ significantly between the treatment groups at 10 years (65% [63-68] in the gemcitabine group vs 65% [62-67] in the control group), and median disease-free survival was not reached (adjusted hazard ratio 0·97 [95% CI 0·86-1·10], p=0·64). Toxicity, dose intensity, and a detailed safety substudy showed both regimens to be safe, deliverable, and tolerable. Grade 3 and 4 toxicities were reported at expected levels in both groups. The most common were neutropenia (527 [34%] of 1565 patients in the gemcitabine group vs 412 [26%] of 1567 in the control group), myalgia and arthralgia (207 [13%] vs 186 [12%]), fatigue (207 [13%] vs 152 [10%]), infection (202 [13%] vs 141 [9%]), vomiting (143 [9%] vs 108 [7%]), and nausea (132 [8%] vs 102 [7%]).

INTERPRETATION

The addition of gemcitabine to anthracycline and taxane-based adjuvant chemotherapy at this dose and schedule confers no therapeutic advantage in terms of disease-free survival in early breast cancer, although it can cause increased toxicity. Therefore, gemcitabine has not been added to standard adjuvant chemotherapy in breast cancer for any subgroup.

FUNDING

Cancer Research UK core funding for Clinical Trials Unit at the University of Birmingham, Eli Lilly, Bristol-Myers Squibb, and Pfizer.

Structural evidence for evolution of shark Ig new antigen receptor variable domain antibodies from a cell-surface receptor

The Ig new antigen receptors (IgNARs) are single-domain antibodies found in the serum of sharks. Here, we report 2.2- and 2.8-A structures of the type 2 IgNAR variable domains 12Y-1 and 12Y-2. Structural features include, first, an Ig superfamily topology transitional between cell adhesion molecules, antibodies, and T cell receptors; and, second, a vestigial complementarity-determining region 2 at the "bottom" of the molecule, apparently discontinuous from the antigen-binding paratope and similar to that observed in cell adhesion molecules. Thus, we suggest that IgNARs originated as cell-surface adhesion molecules coopted to the immune repertoire and represent an evolutionary lineage independent of variable heavy chain/variable light chain type antibodies. Additionally, both 12Y-1 and 12Y-2 form unique crystallographic dimers, predominantly mediated by main-chain framework interactions, which represent a possible model for primordial cell-based interactions. Unusually, the 12Y-2 complementarity-determining region 3 also adopts an extended beta-hairpin structure, suggesting a distinct selective advantage in accessing cryptic antigenic epitopes.

Surgery without adjuvant chemotherapy for early epithelial ovarian carcinoma after comprehensive surgical staging

From January 1981 to December 1987, 82 patients with carcinoma of the ovary, Stages 1A, 1B, and 1C (cytology negative) (FIGO 1988), were enrolled in this study following accurate surgical staging. No patient received adjunctive therapy and all were followed from 2 to 6 years with a mean duration of follow-up of 4 years. Sixty-eight patients were eligible for review--thirty-nine Stage 1A, six Stage 1B, and twenty-three Stage 1C (twenty-one with tumor rupture, two with excrescences). The mean age was 48.8 years. Three patients had a recurrence of their disease (one death). Forty patients in this series were Stage 1A or 1B (well or moderately well differentiated, no excrescences, no rupture). Only 1 patient in this group (with clear cell carcinoma) has recurred, suggesting that this patient population can be followed without adjunctive therapy. Adhesions or rupture in this series did not affect outcome. Clear cell tumors may have an ominous prognosis despite apparent local disease.

A randomized, double-blind, placebo-controlled, cross-over trial to assess the side effects of medroxyprogesterone acetate in hormone replacement therapy

Cyclic progestin therapy has been widely advocated as an adjunct to postmenopausal estrogen replacement therapy to reduce the risk of endometrial carcinoma. Acceptance of this approach, however, appears to have preceded detailed evaluation of possible adverse side effects of progestins that could result in patient noncompliance. We evaluated the nonmenstrual physical and psychological side effects of oral medroxyprogesterone acetate given in conjunction with transdermal estrogen in two groups of women with previous hysterectomy and oophorectomy. Twenty-four women with prospectively documented severe premenstrual syndrome (PMS) before surgery and 24 women with no such history of adverse premenstrual changes received transdermal estrogen 100 micrograms on days 1-25 and either oral medroxyprogesterone acetate 10 mg daily or an identical placebo (days 12-25) in a randomized, double-blind, cross-over design. Mood and physical symptoms were monitored prospectively, using daily self-ratings on the Daily Symptoms Checklist. The Beck Depression Inventory and Premenstrual Tension Self-Rating Scale were completed on day 24. At the study's completion, the patients were asked which treatment period they preferred. Paired comparisons did not reveal any significant differences, and preference for treatment was equally divided between medroxyprogesterone acetate and placebo. We conclude that addition of medroxyprogesterone acetate 10 mg/day for 14 days to cyclic transdermal estrogen therapy (days 1-25) produces no consistent adverse physical or psychological effects on women for one cycle of treatment, regardless of their PMS history.

The management of minor degrees of cervical dysplasia associated with the human papilloma virus

This report attempts to define further the natural history of minor degrees of cervical dysplasia associated with human papilloma virus (HPV). Five hundred and twenty-five patients with a diagnosis of mild to moderate cervical dysplasia and HPV effects were followed without treatment for six months to five years. Those patients who progressed to a greater degree of dysplasia were removed from follow-up and treated appropriately. Those patients who regressed to a non-dysplastic state were returned to the original referring physician to be followed with annual cytology. Regression to a non-dysplastic state was 30.5 percent at six months, 50.4 percent at 1 1/2 years, 60.5 percent at 2 1/2 years, 70.9 percent at 3 1/2 years, 77.3 percent at 4 1/2 years, 7.8 percent have progressed to a greater degree of cervical dysplasia, removed from follow-up, and treated, and 22 patients have recurred, all with minor degrees of dysplasia. No invasive cancer has been diagnosed in this group of patients. From these results, we conclude that patients with minor degrees of dysplasia associated with HPV can be followed in a routine screening program with the anticipation that the great majority will, over time, convert to a non-dysplastic state. A small number of patients will progress to a higher degree of dysplasia and will be effectively identified, to be referred for colposcopic assessment and appropriate treatment.

Cervical dysplasia and human papillomavirus

Evidence suggests a link between human papillomavirus infections and cervical dysplasia-carcinoma. This has led to the recommendation that when human papillomavirus infections are identified on the cervix, especially in association with dysplasia, these patients should have colposcopic assessment and treatment. The natural history of cervical human papillomavirus infections, particularly when associated with mild or moderate dysplasia, is not clear. To assess this question, 235 women with mild to moderate cervical dysplasia associated with a human papillomavirus infection were prospectively evaluated at 6-month intervals by the Colposcopy Clinic. This review suggests that mild to moderate cervical dysplasia associated with human papillomavirus infection eventually spontaneously disappears or, at worse, lingers on over many months in a mild to moderate form. These observations do not support the current popular practice of treating all mild to moderate cervical dysplasias associated with human papillomavirus infection or cervical human papillomavirus infection not associated with dysplastic lesions.

Advanced carcinoma of the ovary with central nervous system relapse

Interdisciplinary protocols for management of advanced adenocarcinoma of the ovary have resulted in prolonged patient survival. A subset of patients is emerging in whom central nervous system (CNS) relapse occurs even following negative second-look procedures (SLP). Seven of 342 eligible patients entered in a National Cancer Institute of Canada Trial for Ovarian Cancer, from February 1, 1980 to March 31, 1984, had CNS relapse. All patients received adriamycin and cisplatin. SLP was performed in 5 patients, 3 of whom were complete responders (CR). Two additional patients failed to complete their chemotherapy and had progressive pelvic disease. The median age of these 7 patients was 57 years, their overall survival time was 28 months, compared with an average age of 58 years and survival of 21.6 months, for the entire group. Two patients had prolonged survival after their CNS relapse; 1 patient lived 26 months, and the other, who underwent craniotomy for primary management of the metastasis survived 18 months. Confirmation of metastatic disease was obtained in 4 of the 7 patients. The results of this study suggest that management of CNS involvement in adenocarcinoma of the ovary should be determined by overall performance status even in the presence of generalized disease.

Toxicity of abdominopelvic radiation in advanced ovarian carcinoma patients after cisplatin/cyclophosphamide therapy and second-look laparotomy

Twenty-seven advanced ovarian carcinoma patients who had received six courses of cyclophosphamide/cisplatin and had either microscopic disease (15 patients) or no pathologically detectable disease (12 patients) after second-look laparotomy were treated with abdominopelvic radiation (2250 cGy to the abdomen and pelvis and a 2250-cGy pelvic boost). Acute myelosuppression or gastrointestinal toxicity prevented completion of treatment in only three patients. However, bowel obstruction occurred in 13 (48%), ten of whom required surgery. Five of these ten had recurrent tumor, but the other five did not. Subsequently two of the latter five did develop a recurrence, one in the lung and one in the liver. A third patient died as an indirect result of radiation damage to the bowel. Median follow-up duration is 17 months from completion of radiation. So far, 13 (48%) have developed progressive disease: four (33%) of the 12 who had a negative second-look laparotomy and nine (60%) of the 15 who had microscopic disease before radiation. While acute toxicity is tolerable, the incidence of serious chronic bowel toxicity is high. Efforts should be made to alter this therapy in order to decrease the frequency of long-term morbidity.

Presurgical prognostic factors in carcinoma of the cervix, stages IB and IIA

Possible prognostic factors in early stage cervical cancer include patient age, tumor size, cell type, differentiation, and channel invasion. In this study each of these factors was evaluated based only on the findings available before surgery, and the observations are compared with patient survival and incidence of node metastases. One hundred consecutive patients with stage IB or IIA cervical cancer treated by primary radical surgery and followed at least 2 years are reported. Disease-free survival was 90% at 2 years and 85% at 5 years; 19% had node metastases. Of the factors studied, only age greater than 50 years was associated with poor prognosis (p less than 0.02 versus age less than 50 years). Only large tumor size was associated with increased node metastases (p less than 0.001 versus medium and small size). Tumor cell type, differentiation, and channel involvement had no bearing on survival or node metastases. Because older age and large tumors appear to be factors of poor prognosis for surgery, and yet it is not clear that these patients fare better with radiotherapy, we suggest a prospective trial of radiotherapy versus surgery for this group.

A predictive index of cure versus no cure in advanced ovarian carcinoma patients--replacement of second-look laparotomy as a diagnostic test

Three hundred forty-two Stage III and IV epithelial ovarian carcinoma patients received cytoreductive surgery followed by Adriamycin and cisplatin, 50 mg/m2 each, q 4 weeks for 9 courses. One hundred ninety-seven were clinically NED at completion of treatment and 173 of these 197 had a second-look laparotomy. One hundred twenty had persistent disease. Fifty-three were second-look negative and had no further treatment. Thirty of these latter patients relapsed--all (with one exception) within 2 years. Those not relapsing after negative second-look are considered "cured" (median follow-up 42 months, range 24-68 months) and all others "failures." Stage was a significant predictor of treatment failure--there were no Stage IV "cures." In Stage III patients, age and largest residual tumor diameter post initial surgery were significant predictors of failure. Performance status was marginally significant. In our series, any patient with Stage IV disease or Stage III disease with at least two of the following three poor prognostic factors had a chance of cure of 2.2% (2 "cures" out of 90 patients): age greater than 60 years, macroscopic residual initially, or initial performance status of 2 or 3. Under normal circumstances a second-look procedure to identify persistent disease in this group of patients does not appear justified.

Cervical carcinoma in women aged 34 and younger

This presentation addresses three questions concerning invasive cervical carcinoma in women 34 years of age and younger. Is there an increase in the incidence of the disease? Is it more or less susceptible to prevention by cervical screening? Is the clinical behavior different for this age group? Three separate studies are reported: (1) Incidence data in the younger age group have been reviewed at the national, provincial, and local levels. (2) Cytologic screening histories of 125 patients who subsequently developed cervical carcinoma were reviewed. (3) The clinical histories of 121 women 34 years of age and younger, with invasive cervical carcinoma, were reviewed and compared with those of 242 control women 35 years of age and older. Results indicate an increase in incidence in the younger age groups in the three prairie provinces only. Cytologic histories are similar except for an increase in false negative reports in the younger age group. Clinical behavior of the disease is similar for both age groups.

Treatment of cervical intraepithelial neoplasia with electrocautery: a report of 776 cases

From 1973 to 1984, 776 patients with cervical intraepithelial neoplasia were treated with outpatient electrocautery (hot cautery) without anesthesia. Of these, 726 (94%) were available for follow-up in 3 to 6 months. An initial cure rate with one treatment of 89% to 90% was achieved. Cure rates were similar for all degrees of dysplasia, including carcinoma in situ. There were no complications. All patients with failure of the initial treatment who returned for further outpatient management were eventually cured with use of electrocautery. Long-term follow-up rates ranged from 75% at 1 year to 46% at 5 years. There were few late recurrences, most of which were treated again (successfully) with electrocautery. Electrocautery produces cure rates similar to those for other forms of conservative management and may be the most cost-effective method of management of cervical intraepithelial neoplasia.

Treatment of cervical intraepithelial neoplasia with electrocautery: report of 426 cases

Four hundred twenty-six patients with colposcopically directed, biopsy-proved, mild, moderate, or marked dysplasia or carcinoma in situ of the cervix were treated with outpatient electrocauterization, from 1973 to mid- 1982. Of these, 413 were available for follow-up between 3 and 6 months. The initial cure rate was 85.95%, and the cure rate when a second treatment for initial failures was included was 96.6%. These patients have been followed for 1 to 5 years, and the annual follow-up rate has ranged from 65% to 80%. Recurrences were few, but did occur as late as 3 years after treatment.

The cytologic history of 245 patients developing invasive cervical carcinoma

A review was made of the cytologic history of 245 patients who developed invasive carcinoma of the cervix, and three groups of patients were identified. Group 1 included 149 patients (60.8%) who had never had a cervical cytologic examination, group 2 included 26 patients (10.6%) whose cytologic history in terms of frequency of examination and or timing was considered to be unsatisfactory, and group 3 included 70 patients (28.6%) whose cytologic history was considered to be satisfactory. Only 53 (35.6%) of the patients in group 1 had Stage I disease. Stage I disease was present in 16 patients (61.5%) of group 2 and in 55 patients (78.6%) of group 3. There was no significant difference between the three groups with respect to site of residence or access to the health care system. Of the patients in group 3, 20 (28.6%) had normal cytologic findings and 50 (71.4%) had abnormal cytologic findings. Of the 50 patients with abnormal cytologic findings, 31 (62.0%) did not have further examination for 6 months or longer after identification of the abnormal smear. The majority of these patients had minor degrees of cytologic abnormalities. A review of 299 original cervical smears revealed that 52 (17.4%) had been significantly undercalled, but only 21 (7.0%) had been undercalled as normal. In this study, 28 patients (11.4%) developed adenocarcinoma. In these patients, staging was unrelated to screening.

Cervical dysplasia

Invasive squamous carcinoma of the cervix is preceded by a series of premalignant changes described as mild, moderate, or severe dysplasia, and carcinoma in situ. These premalignant states are identified by cervical cytology, diagnosed by colposcopy and if effectively treated, can prevent invasive squamous carcinoma of the cervix. Because of the apparent biological variation of the premalignant states, even the most aggressive cervical screening program cannot be expected to eliminate all invasive squamous cancer of the cervix. Optimal results of a cervical screening program will be achieved when all women under 35 years of age and sexually active have an annual cytological smear; the cytology is screened by a laboratory with high quality control; the patient's positive cytology is accurately assessed by an experienced colposcopist, and the premalignant lesion is effectively treated.