Outcomes of Older Women With Hormone Receptor–Positive, Human Epidermal Growth Factor Receptor–Negative Metastatic Breast Cancer Treated With a CDK4/6 Inhibitor and an Aromatase Inhibitor: An FDA Pooled Analysis

PURPOSE

Many older women will be treated with a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor and an aromatase inhibitor (AI), given US Food and Drug Administration approval of three agents in this class. The current pooled analysis examines the efficacy and safety of this combination in older women.

PATIENTS AND METHODS

We pooled data from three randomized controlled studies (N = 1,827) of different CDK4/6 inhibitors in combination with an AI for initial treatment of postmenopausal women with hormone receptor–positive, human epidermal growth factor receptor 2–negative metastatic breast cancer. The effect of age on progression-free survival was evaluated using Kaplan-Meier estimates and a Cox proportional hazards regression model.

RESULTS

For patients age 75 years or older (n = 198) who were treated with a CDK4/6 inhibitor and an AI, hazard ratio was 0.49 (95% CI, 0.31 to 0.76) with an estimated median progression-free survival of 31.1 months (95% CI, 20.2 months to not reached) versus 13.7 months (95% CI, 10.9 months to 24.9 months) for those treated with an AI. Incidence of grade 3 to 4 adverse events was 88.8% in patients age 75 years and older and 73.4% in patients younger than age 75 years. Patients age 75 years or older reported a decline in quality-of-life measures using the EQ-5D regardless of treatment with AI alone or with the addition of a CDK4/6 inhibitor.

CONCLUSION

There was similar efficacy with a CDK4/6 inhibitor in combination with an AI compared with AI alone for first-line treatment of hormone receptor–positive, human epidermal growth factor receptor 2–negative metastatic breast cancer in older women compared with younger patients. Patients older than age 75 years experienced higher rates of toxicity, dose modifications, and a decrease from baseline in quality-of-life measures.

Patient reported outcomes in anti-PD-1/PD-L1 inhibitor immunotherapy registration trials: FDA analysis of data submitted and future directions

BACKGROUND

Patient-reported outcome measures can be used to capture the patient's experience with disease and treatment. Immunotherapy agents including the anti-programmed death receptor-1/programmed death-ligand-1 inhibitor therapies have unique symptomatic side effects and patient-reported outcome data can help to characterize the benefits and burdens associated with therapy.

METHODS

We reviewed registration trials in the Food and Drug Administration database for five anti-programmed death receptor-1/programmed death-ligand-1 inhibitor therapies to characterize trial design and patient-reported outcome assessment strategy (cutoff 31 December 2017). We evaluated the patient-reported outcome measurement coverage of eight key symptoms related to adverse events reported in immunotherapy agent product labels (fatigue, diarrhea, cough, shortness of breath, musculoskeletal pain, rash, pruritus, and fever).

RESULTS

There were a total of 28 trials across seven disease types and one tumor agnostic indication reviewed, of which 17 were randomized and 25 were open label. Of the 28 trials, 21 contained patient-reported outcome measures and all 21 used >1 instrument. The most common instruments were the EuroQol five dimension (N = 19), and the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (N = 17). Disease-specific patient-reported outcome tools were included in nine trials (six lung, one head and neck, one melanoma and one renal cell). No trial used a patient-reported outcome strategy assessing all eight selected adverse events.

CONCLUSION

Collection of patient-reported outcome data in anti-programmed death receptor-1/programmed death-ligand-1 inhibitor trials were variable and did not consistently assess important symptomatic adverse events. Use of a patient-reported outcome instrument with well-defined functional scales supplemented by item libraries to incorporate relevant symptomatic adverse events may allow for improved understanding of the patient experience while receiving therapy. These data, along with other clinical data such as hospitalizations and supportive care medication use can help inform the benefit-risk assessment for regulatory purposes.

FDA Approval Summary: Pertuzumab for Adjuvant Treatment of HER2-Positive Early Breast Cancer

On December 20, 2017, the FDA granted regular approval to pertuzumab in combination with trastuzumab and chemotherapy for the adjuvant treatment of patients with HER2-positive early breast cancer (EBC) at high risk of recurrence. Approval was based on data from the APHINITY trial, which randomized patients to receive pertuzumab or placebo in combination with trastuzumab and chemotherapy. After 45.4-month median follow-up, the proportion of invasive disease-free survival (IDFS) events in the intent-to-treat population was 7.1% (n = 171) in the pertuzumab arm and 8.7% (n = 210) for placebo [hazard ratio (HR), 0.82; 95% confidence interval (CI), 0.67-1.00; P = 0.047]. The proportion of IDFS events in patients with hormone receptor-negative disease was 8.2% (n = 71) and 10.6% (n = 91) in the pertuzumab and placebo arms, respectively (HR, 0.76; 95% CI, 0.56-1.04). The proportion of IDFS events for patients with node-positive disease was 9.2% (n = 139) and 12.1% (n = 181) in the pertuzumab and placebo arms, respectively (HR, 0.77; 95% CI, 0.62-0.96). Adverse reactions in ≥30% of patients receiving pertuzumab were diarrhea, nausea, alopecia, fatigue, peripheral neuropathy, and vomiting. From a regulatory standpoint, the benefits of the addition of pertuzumab to adjuvant treatment outweighed the risks for patients with EBC at high risk of recurrence.

FDA Approval Summary: Niraparib for the Maintenance Treatment of Patients with Recurrent Ovarian Cancer in Response to Platinum-Based Chemotherapy

The FDA approved niraparib, a poly(ADP-ribose) polymerase (PARP) inhibitor, on March 27, 2017, for maintenance treatment of patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in response to platinum-based chemotherapy. Approval was based on data from the NOVA trial comparing niraparib with placebo in two independent cohorts, based on germline BRCA mutation status (gBRCAm vs. non-gBRCAm). Progression-free survival (PFS) in each cohort was the primary endpoint. In the gBRCAm cohort, estimated median PFS on niraparib was 21 months versus 5.5 months on placebo [HR, 0.26; 95% confidence interval (CI), 0.17-0.41; P < 0.0001]. In the non-gBRCAm cohort, estimated median PFS for niraparib and placebo was 9.3 and 3.9 months, respectively (HR, 0.45; 95% CI, 0.34-0.61; P < 0.0001). Common adverse reactions (>20% and higher incidence in the niraparib arm) with niraparib included thrombocytopenia, anemia, neutropenia, nausea, constipation, vomiting, mucositis, fatigue, decreased appetite, headache, insomnia, nasopharyngitis, dyspnea, rash, and hypertension. There were five cases of myelodysplastic syndrome and acute myeloid leukemia (1.4%) in patients treated with niraparib compared with two cases (1.1%) on placebo. Niraparib is the first PARP inhibitor approved as maintenance therapy for patients with ovarian, fallopian tube, or primary peritoneal cancer, with improvement in PFS, regardless of gBRCAm status. Clin Cancer Res; 24(17); 4066-71. ©2018 AACRSee related commentary by Konstantinopoulos and Matulonis, p. 4062.

Neoadjuvant use of ipilimumab in locally advanced melanoma

Recent advances in immune modulating therapies show great promise for patients with advanced melanoma, however optimal strategies for achieving long-term disease control in locally advanced melanoma are unclear. We present two cases of neoadjuvant ipilimumab, one case in combination with isolated limb infusion (ILI) followed by surgical resection and one followed by surgery alone. Both patients have had durable responses. These cases highlight the ongoing need for prospective trials in the neoadjuvant setting.

Abstract P3-07-22: Predictors of neoadjuvant chemotherapy use in women with breast cancer: A review of 169,329 patients from the American College of Surgeons' National Cancer Database

Background: Randomized controlled trials have demonstrated that neoadjuvant chemotherapy (NAC) offers equivalent long-term outcomes when compared to adjuvant chemotherapy while improving rates of breast conservation therapy (BCT). We sought to evaluate the national use of NAC and the patient, tumor, and provider characteristics associated with its use among women with stage I-III breast cancer. We hypothesize that younger women with larger tumors and HER-2+ or triple negative disease are more likely to receive NAC than their older counterparts with ER+ disease, and that use of NAC varies by region and practice setting.

Methods: Using the American College of Surgeons National Cancer Database, which captures data on approximately 70% of new cancer diagnoses in the U.S., we identified women with diagnosed with stage I-III invasive cancer between 2008-2013. Women treated with both surgery and chemotherapy were included in the study. Demographic and clinical factors including race, ethnicity, income, insurance type, region of treatment facility, treatment facility type, tumor size, hormone receptor status, HER-2 status and Charlson Comorbidity score were analyzed to determine predictors associated with receipt of NAC. Utilization of preoperative chemotherapy and rates of breast conserving therapy (BCT) were evaluated as outcomes.

Results: 169,329 women with stage I-III breast cancer underwent treatment with chemotherapy and surgery during the study period. Of these, 81.0% were White, 14.4% were Black, 4.6% were classified as Other Race. 28.7% were 18-49, 46.8% were 50-64 and 24.5% were &gt;65 years. 64.4% had private insurance while 35.6% had public insurance (Medicaid, Medicare and VA), and 71.4% were treated at Community-Based Clinics while 28.6% were treated at Academic Medical Centers.

Patients with larger tumors (p&lt;0.0001) and triple negative disease were significantly more likely to be treated with NAC than those with ER+ or HER2+ disease (p&lt;0.0001). Among women who received NAC, the median age was 54 as compared to 57 in those receiving adjuvant chemotherapy (p&lt;0.0001). Treatment facility type impacted rates of NAC use, with academic centers being more likely than community-based practices to give chemotherapy preoperatively (12.1% vs. 9.8%, p&lt;0.0001) and urban vs. rural settings (10.4% vs 8.2%, p&lt;0.0001). Rates of NAC utilization differed regionally with the highest rate being 14.0% and the lowest rate 7.9% (p&lt;0.0001).

The overall % of BCT following NAC was 36.1% compared to 59.0% for those receiving adjuvant chemotherapy. The proportion of BCT following NAC differed significantly by subtype, 54.6% for ER+, 54.5% for Her2 +, and 59.7% for triple negative breast cancer (TNBC) (p &lt;0.0001).

Conclusions: In the treatment of stage I-III breast cancer across the US, variations in the utilization of neoadjuvant chemotherapy exist across the country suggesting clinical uncertainty about its use. Further research about the use of NAC therapy and the relationship to clinical outcomes can identify patient subsets who might obtain greatest clinical benefit from preoperative systemic therapy.

Citation Format: Lynn J Howie, Rachel Greenup, Kevin Houck, Julie A Sosa, E Shelley Hwang, Jeffrey M Peppercorn. Predictors of neoadjuvant chemotherapy use in women with breast cancer: A review of 169,329 patients from the American College of Surgeons' National Cancer Database [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-22.

There is a mismatch between the medicare benefit package and the preferences of patients with cancer and their caregivers

PURPOSE

To identify insured services that are most important to Medicare beneficiaries with cancer and their family caregivers when coverage is limited.

METHODS

A total of 440 participants (patients, n = 246; caregivers, n = 194) were enrolled onto the CHAT (Choosing Health Plans All Together) study from August 2010 to March 2013. The exercise elicited preferences about what benefits Medicare should cover for patients with cancer in their last 6 months of life. Facilitated sessions lasted 2.5 hours, included 8 to 10 participants, and focused on choices about Medicare health benefits within the context of a resource-constrained environment.

RESULTS

Six of 15 benefit categories were selected by > 80% of participants: cancer care, prescription drugs, primary care, home care, palliative care, and nursing home coverage. Only 12% of participants chose the maximum level of cancer benefits, a level of care commonly financed in the Medicare program. Between 40% and 50% of participants chose benefits not currently covered by Medicare: unrestricted cash, concurrent palliative care, and home-based long-term care. Nearly one in five participants picked some level of each of these three benefit categories and allocated on average 30% of their resources toward them.

CONCLUSION

The mismatch between covered benefits and participant preferences shows that addressing quality of life and the financial burden of care is a priority for a substantial subset of patients with cancer in the Medicare program. Patient and caregiver preferences can be elicited, and the choices they express could suggest potential for Medicare benefit package reform and flexibility.

The ethics of clinical trials for cancer therapy

Cancer clinical trials are intended to evaluate novel interventions and to improve outcomes. Such research depends on the participation of patients seeking the best options for care. The design, conduct, and analysis of trials must therefore be grounded in an ethical framework that respects and protects the interests of clinical trial participants.

To stent or not to stent: an evidence-based approach to palliative procedures at the end of life

Patients near the end of life often undergo invasive procedures, such as biliary stenting for obstructive jaundice, with the intent of relieving symptoms. We describe a case in which the medical team and a patient and family are considering a second palliative biliary stent despite the patient's limited life expectancy. We review available evidence to inform the decision, focusing on the specific question of whether the benefits of palliative biliary stents in patients with advanced cancer outweigh the risks. We then apply the evidence to the issue of how the primary and/or palliative care team and the interventionist communicate with patients and their families about the risks and benefits of palliative procedures. Review of the evidence found several prospective case series without control groups that measured patient-centered outcomes. Studies had high attrition rates, results for improvements in symptoms and quality of life were mixed, and rates of complications and short-term mortality were high. In conclusion, the limited evidence does not support that the benefits of palliative biliary stents in this population outweigh the risks. We propose that primary care teams consider and discuss the larger picture of the goals of care with patients and families when considering offering these procedures, as well as benefits and potential harms, and consider involving palliative care services early, before consultation with an interventionist.

Trends and differential use of assistive technology devices: United States, 1994

OBJECTIVE

This report presents data on annual estimates of the prevalence of use of selected assistive technology devices for vision, hearing, mobility, and orthopedic impairments, including missing limbs. Also presented are statistics on trends in the prevalence of use of selected mobility assistive technology devices for the years 1980, 1990, and 1994.

METHODS

The data used for this report are from the 1994 National Health Interview Survey on Disability (NHIS-D), Phase I, which was co-sponsored by a consortium of U.S. Federal agencies and private foundations. All estimates are based on data from the NHIS-D, Phase I, which represent the civilian, noninstitutional population of the United States.

RESULTS

An estimated 7.4 million persons in the U.S. household population used assistive technology devices for mobility impairments, 4.6 million for orthopedic impairments (including missing limbs), 4.5 million for hearing impairments (not including impairments fully compensated by hearing aids), and 0.5 million for vision impairments. Use of any mobility device for all ages had the highest prevalence rate at 28.5 per 1,000 persons. There was a positive correlation between an increase in age and the increase in the prevalence rate of device usage; for example, of persons in the age group 65 years and over, the rate of mobility, hearing, and vision device usage was more than 4 times the rate for the total population.

CONCLUSION

Assistive technology use has increased because of population size, age composition changes, and a change in the rate of use. Medical and technological advances along with public policy initiatives have also contributed to increased usage.

Ophthalmic examination among adults with diagnosed diabetes mellitus

OBJECTIVE

To assess whether adults with diagnosed diabetes in the United States are receiving recommended eye examinations for detection of diabetic retinopathy and what factors are associated with receiving them.

DESIGN, SETTING, AND PARTICIPANTS

The design was a cross-sectional survey of the civilian, noninstitutionalized US population 18 years of age or older, based on the 1989 National Health Interview Survey. A multistage probability sampling strategy was used to identify a representative sample of 84,572 persons. A questionnaire on diabetes was administered to all subjects with diagnosed diabetes (n = 2405).

MAIN OUTCOME MEASURE

A dilated eye examination in the past year.

MAIN RESULTS

Of all adults with diagnosed diabetes in the United States, only 49% had a dilated eye examination in the past year. This included 57% of people with insulin-dependent diabetes mellitus (IDDM), 55% with insulin-treated non-insulin-dependent diabetes mellitus (NIDDM), and 44% with NIDDM not treated with insulin. Even among diabetics at high risk of vision loss because of retinopathy or long duration of diabetes, the proportion with a dilated eye examination was only 61% and 57%, respectively. By logistic regression, the probability of a dilated eye examination among persons with NIDDM increased with older age, higher socioeconomic status, and having attended a diabetes education class. The probability of a dilated eye examination was not independently related to race, duration of diabetes, frequency of physician visits for diabetes, or health insurance.

CONCLUSIONS

About half of adults with diabetes in the United States are not receiving timely and recommended eye care to detect and treat retinopathy. Widespread interventions, including patient and professional education, are needed to ensure that diabetic patients who are not receiving appropriate eye care have an annual dilated eye examination to detect retinopathy and prevent vision loss.

Self-monitoring of blood glucose by adults with diabetes in the United States population

OBJECTIVE

To evaluate self-monitoring of blood glucose, which is considered an important practice for patients with diabetes. However, little is known about the frequency or determinants of this technique.

RESEARCH DESIGN AND METHODS

A detailed questionnaire on diabetes was administered to a representative sample of 2405 diabetic subjects > or = 18 yr of age in the U.S. population in the 1989 National Health Interview Survey.

RESULTS

Among subjects with IDDM, 40% monitored their blood glucose at least 1 time/day. Among subjects with NIDDM treated with insulin, 26% monitored at least 1 time/day and among NIDDM subjects not treated with insulin, the percentage was 5%. When stratified by age, little difference was observed between IDDM subjects and insulin-treated NIDDM subjects in the percentage testing at least 1 time/day. By multivariate analysis, age and insulin use were the major determinants of whether diabetic subjects tested their blood glucose. Race and education were also independently related to self-monitoring of blood glucose. Blacks were 60% less likely to test their blood glucose at least 1 time/day compared with non-Hispanic whites and Mexican Americans. Those with college education were 80% more likely to test their blood glucose compared with those with lower education levels. Having had a patient education class in diabetes management and frequent physician visits for diabetes care were positively related to self-testing. Self-monitoring was not related to higher income or having health insurance.

CONCLUSIONS

A large proportion of patients with diabetes do not test their blood glucose. Financial barriers associated with income and health insurance do not appear to impede the practice of self-monitoring. Because of the importance of blood glucose control in the prevention of diabetes complications and the role of self-monitoring in achieving blood glucose control, it may be prudent for physicians and their patients to make greater use of this technique. Special attention should be directed to the subgroups of patients (blacks, patients not treated with insulin, those with less education, and those with no education in diabetes) in which the frequency of self-monitoring is particularly low.