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Kingma JS, Peeters NWL, Knibbe CAJ, Agterof MJ, Derksen WJM, Burgers DMT, van den Broek MPH. Clinical Guidance for Dosing and Monitoring Oral Antihormonal Drugs in Patients with Breast Cancer After Roux-en-Y Gastric Bypass. Ther Drug Monit 2024; 46:404-409. [PMID: 38018850 DOI: 10.1097/ftd.0000000000001159] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/08/2023] [Indexed: 11/30/2023]
Abstract
ABSTRACT Obesity is associated with an increased risk of cancers, such as breast cancer. Roux-en-Y gastric bypass (RYGB) is a common surgical intervention used to induce weight loss, reduce comorbidities, and improve overall survival. Due to alterations in the gastrointestinal tract, RYGB is associated with changes in oral drug disposition, which can affect treatment outcomes. Oral antihormonal agents were monitored in 9 patients who previously underwent RYGB. The results of therapeutic drug monitoring and estradiol concentrations were analyzed, and a review of the relevant literature was performed. As only 1 of the 6 patients prescribed tamoxifen achieved a therapeutic endoxifen concentration with the standard dose of 20 mg/d, a higher starting dose of 40 mg/d was recommended to increase the probability of attaining a therapeutic plasma concentration. All patients with decreased CYP2D6 metabolic activity could not achieve therapeutic plasma concentrations; therefore, CYP2D6 genotyping was recommended before the initiation of tamoxifen therapy to identify patients who should be switched to aromatase inhibitors. Anastrozole and letrozole exposure in patients who underwent RYGB patients appeared sufficient, with no dose adjustment required. However, until more data become available, monitoring aromatase inhibitor efficacy is recommended. Monitoring the drug concentrations is a viable option; however, only indicative data on therapeutic drug monitoring are available. Therefore, estradiol concentrations should be measured.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
| | - Niels W L Peeters
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
- Division of Systems Pharmacology & Pharmacy, Leiden Academic Center for Drug Research, Leiden University, Leiden, the Netherlands
| | - Mariette J Agterof
- Department of Internal Medicine, St. Antonius Hospital, Utrecht, the Netherlands
| | - Wouter J M Derksen
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; and
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
| | - Marcel P H van den Broek
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
- Department of Pharmaceutics, Faculty of Science, Utrecht University, Utrecht, the Netherlands
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van der Voort A, Louis FM, van Ramshorst MS, Kessels R, Mandjes IA, Kemper I, Agterof MJ, van der Steeg WA, Heijns JB, van Bekkum ML, Siemerink EJ, Kuijer PM, Scholten A, Wesseling J, Vrancken Peeters MJTFD, Mann RM, Sonke GS. MRI-guided optimisation of neoadjuvant chemotherapy duration in stage II-III HER2-positive breast cancer (TRAIN-3): a multicentre, single-arm, phase 2 study. Lancet Oncol 2024; 25:603-613. [PMID: 38588682 DOI: 10.1016/s1470-2045(24)00104-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Patients with stage II-III HER2-positive breast cancer have good outcomes with the combination of neoadjuvant chemotherapy and HER2-targeted agents. Although increasing the number of chemotherapy cycles improves pathological complete response rates, early complete responses are common. We investigated whether the duration of chemotherapy could be tailored on the basis of radiological response. METHODS TRAIN-3 is a single-arm, phase 2 study in 43 hospitals in the Netherlands. Patients with stage II-III HER2-positive breast cancer aged 18 years or older and a WHO performance status of 0 or 1 were enrolled. Patients received neoadjuvant chemotherapy consisting of paclitaxel (80 mg/m2 of body surface area on day 1 and 8 of each 21 day cycle), trastuzumab (loading dose on day 1 of cycle 1 of 8 mg/kg bodyweight, and then 6 mg/kg on day 1 on all subsequent cycles), and carboplatin (area under the concentration time curve 6 mg/mL per min on day 1 of each 3 week cycle) and pertuzumab (loading dose on day 1 of cycle 1 of 840 mg, and then 420 mg on day 1 of each subsequent cycle), all given intravenously. The response was monitored by breast MRI every three cycles and lymph node biopsy. Patients underwent surgery when a complete radiological response was observed or after a maximum of nine cycles of treatment. The primary endpoint was event-free survival at 3 years; however, follow-up for the primary endpoint is ongoing. Here, we present the radiological and pathological response rates (secondary endpoints) of all patients who underwent surgery and the toxicity data for all patients who received at least one cycle of treatment. Analyses were done in hormone receptor-positive and hormone receptor-negative patients separately. This trial is registered with ClinicalTrials.gov, number NCT03820063, recruitment is closed, and the follow-up for the primary endpoint is ongoing. FINDINGS Between April 1, 2019, and May 12, 2021, 235 patients with hormone receptor-negative cancer and 232 with hormone receptor-positive cancer were enrolled. Median follow-up was 26·4 months (IQR 22·9-32·9) for patients who were hormone receptor-negative and 31·6 months (25·6-35·7) for patients who were hormone receptor-positive. Overall, the median age was 51 years (IQR 43-59). In 233 patients with hormone receptor-negative tumours, radiological complete response was seen in 84 (36%; 95% CI 30-43) patients after one to three cycles, 140 (60%; 53-66) patients after one to six cycles, and 169 (73%; 66-78) patients after one to nine cycles. In 232 patients with hormone receptor-positive tumours, radiological complete response was seen in 68 (29%; 24-36) patients after one to three cycles, 118 (51%; 44-57) patients after one to six cycles, and 138 (59%; 53-66) patients after one to nine cycles. Among patients with a radiological complete response after one to nine cycles, a pathological complete response was seen in 147 (87%; 95% CI 81-92) of 169 patients with hormone receptor-negative tumours and was seen in 73 (53%; 44-61) of 138 patients with hormone receptor-positive tumours. The most common grade 3-4 adverse events were neutropenia (175 [37%] of 467), anaemia (75 [16%]), and diarrhoea (57 [12%]). No treatment-related deaths were reported. INTERPRETATION In our study, a third of patients with stage II-III hormone receptor-negative and HER2-positive breast cancer had a complete pathological response after only three cycles of neoadjuvant systemic therapy. A complete response on breast MRI could help identify early complete responders in patients who had hormone receptor negative tumours. An imaging-based strategy might limit the duration of chemotherapy in these patients, reduce side-effects, and maintain quality of life if confirmed by the analysis of the 3-year event-free survival primary endpoint. Better monitoring tools are needed for patients with hormone receptor-positive and HER2-positive breast cancer. FUNDING Roche Netherlands.
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Affiliation(s)
- Anna van der Voort
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Fleur M Louis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mette S van Ramshorst
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Rob Kessels
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ingrid A Mandjes
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Inge Kemper
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mariette J Agterof
- Department of Medical Oncology, St Antonius Hospital, Nieuwegein, Netherlands
| | | | - Joan B Heijns
- Department of Medical Oncology, Amphia, Breda, Netherlands
| | | | - Ester J Siemerink
- Department of Medical Oncology, Ziekenhuisgroep Twente, Hengelo, Netherlands
| | | | - Astrid Scholten
- Department of Radiation, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology and Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Pathology, University Medical Centre, Leiden, Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Surgery, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Ritse M Mann
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Medical Imaging, Radboud University Medical Center, Amsterdam, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Medical Oncology, Amsterdam University Medical Centre, Amsterdam, Netherlands.
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3
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Janssen LM, Janse MHA, Penning de Vries BBL, van der Velden BHM, Wolters-van der Ben EJM, van den Bosch SM, Sartori A, Jovelet C, Agterof MJ, Ten Bokkel Huinink D, Bouman-Wammes EW, van Diest PJ, van der Wall E, Elias SG, Gilhuijs KGA. Predicting response to neoadjuvant chemotherapy with liquid biopsies and multiparametric MRI in patients with breast cancer. NPJ Breast Cancer 2024; 10:10. [PMID: 38245552 PMCID: PMC10799888 DOI: 10.1038/s41523-024-00611-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 12/07/2023] [Indexed: 01/22/2024] Open
Abstract
Accurate prediction of response to neoadjuvant chemotherapy (NAC) can help tailor treatment to individual patients' needs. Little is known about the combination of liquid biopsies and computer extracted features from multiparametric magnetic resonance imaging (MRI) for the prediction of NAC response in breast cancer. Here, we report on a prospective study with the aim to explore the predictive potential of this combination in adjunct to standard clinical and pathological information before, during and after NAC. The study was performed in four Dutch hospitals. Patients without metastases treated with NAC underwent 3 T multiparametric MRI scans before, during and after NAC. Liquid biopsies were obtained before every chemotherapy cycle and before surgery. Prediction models were developed using penalized linear regression to forecast residual cancer burden after NAC and evaluated for pathologic complete response (pCR) using leave-one-out-cross-validation (LOOCV). Sixty-one patients were included. Twenty-three patients (38%) achieved pCR. Most prediction models yielded the highest estimated LOOCV area under the curve (AUC) at the post-treatment timepoint. A clinical-only model including tumor grade, nodal status and receptor subtype yielded an estimated LOOCV AUC for pCR of 0.76, which increased to 0.82 by incorporating post-treatment radiological MRI assessment (i.e., the "clinical-radiological" model). The estimated LOOCV AUC was 0.84 after incorporation of computer-extracted MRI features, and 0.85 when liquid biopsy information was added instead of the radiological MRI assessment. Adding liquid biopsy information to the clinical-radiological resulted in an estimated LOOCV AUC of 0.86. In conclusion, inclusion of liquid biopsy-derived markers in clinical-radiological prediction models may have potential to improve prediction of pCR after NAC in breast cancer.
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Affiliation(s)
- L M Janssen
- Image Sciences Institute, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - M H A Janse
- Image Sciences Institute, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - B B L Penning de Vries
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - B H M van der Velden
- Image Sciences Institute, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | - A Sartori
- Agena Bioscience GmbH, Hamburg, Germany
| | - C Jovelet
- Stilla Technologies, Villejuif, France
| | - M J Agterof
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - D Ten Bokkel Huinink
- Department of Medical Oncology, Alexander Monro Hospital, Bilthoven, The Netherlands
| | - E W Bouman-Wammes
- Department of Medical Oncology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - E van der Wall
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - S G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - K G A Gilhuijs
- Image Sciences Institute, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
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4
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Hackert MQN, van Uden-Kraan CF, Agterof MJ, van der Velden AWG, Vriens BEPJ, Janssen JJB, Geenen M, van der Padt-Pruijsten A, van de Garde EMW. Real-world palbociclib effectiveness in patients with metastatic breast cancer: Focus on neutropenia-related treatment modification strategies and clinical outcomes. Cancer Treat Res Commun 2023; 35:100691. [PMID: 36913809 DOI: 10.1016/j.ctarc.2023.100691] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION In addition to clinical trials, real-world data is needed to verify the effectiveness of the CDK 4/6 inhibitor palbociclib. The primary aim was to examine real-world variation in treatment modification strategies for neutropenia and its relation to progression-free survival (PFS). The secondary aim was to assess if there is a gap between real-world and clinical trial outcomes. MATERIALS AND METHODS In this multicenter, retrospective observational cohort study 229 patients were analyzed who started palbociclib and fulvestrant as second- or later-line therapy for HR-positive, HER2-negative metastatic breast cancer in the Santeon hospital group in the Netherlands between September 2016 and December 2019. Data were manually retrieved from patients' electronic medical records. PFS was examined using the Kaplan-Meier method to compare neutropenia-related treatment modification strategies within the first three months after neutropenia grade 3 - 4 occurred, as well as patients' eligibility to have participated in the PALOMA-3 clinical trial or not. RESULTS Even though treatment modification strategies differed from those in PALOMA-3 (dose interruptions: 26 vs 54%, cycle delays: 54 vs 36%, and dose reductions: 39 vs 34%), these did not influence PFS. Patients who were PALOMA-3 ineligible experienced a shorter median PFS than those who were eligible (10.2 vs. 14.1 months; HR 1.52; 95% CI 1.12 - 2.07). An overall longer median PFS was found compared to PALOMA-3 (11.6 vs. 9.5 months; HR 0.70; 95% CI 0.54 - 0.90). CONCLUSION This study suggests no impact of neutropenia-related treatment modifications on PFS and confirms inferior outcomes outside clinical trial eligibility.
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Affiliation(s)
| | | | - Mariette J Agterof
- Department of Internal Medicine, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
| | | | - Birgit E P J Vriens
- Department of Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Johan J B Janssen
- Department of Medical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Maud Geenen
- Department of Medical Oncology, OLVG, Amsterdam, The Netherlands
| | | | - Ewoudt M W van de Garde
- Department of Clinical Pharmacy, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
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5
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Sallevelt BTGM, Teunis T, Agterof MJ, van den Broek MPH. Extravasation of an antibody-drug conjugate: A case report of epidermal necrosis after trastuzumab-emtansine extravasation. J Clin Pharm Ther 2020; 45:832-835. [PMID: 32412114 PMCID: PMC7383643 DOI: 10.1111/jcpt.13148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/17/2020] [Revised: 02/15/2020] [Accepted: 04/03/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Trastuzumab-emtansine is an antibody-drug conjugate developed to decrease off-target toxicity. According to the product label, reactions secondary to extravasation are mild or moderate. CASE SUMMARY We report on a 51-year-old woman who developed epidermal necrosis after extravasation of trastuzumab-emtansine, which required surgical intervention. Six weeks later, the lesions were healed with residual hyperpigmentation. WHAT IS NEW AND CONCLUSION We describe the course of a case of severe toxicity following trastuzumab-emtansine extravasation. We provide treatment recommendations and recommend amending the information on the product label on extravasation.
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Affiliation(s)
- Bastiaan T G M Sallevelt
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Teun Teunis
- Department of Plastic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Mariette J Agterof
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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6
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Gregorowitsch ML, Ghedri A, Young-Afat DA, Bijlsma R, Baas IO, van Schaik-van de Mheen C, Agterof MJ, Göker E, Ten Bokkel Huinink D, van den Bongard HJGD, Verkooijen HM. The effect of chemotherapy on subjective cognitive function in younger early-stage breast cancer survivors treated with chemotherapy compared to older patients. Breast Cancer Res Treat 2019; 175:429-441. [PMID: 30746636 PMCID: PMC6533221 DOI: 10.1007/s10549-019-05149-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 11/16/2018] [Accepted: 01/22/2019] [Indexed: 01/22/2023]
Abstract
Purpose To evaluate the impact of chemotherapy on subjective cognitive functioning according to age in a large cohort of breast cancer patients. Methods Within the UMBRELLA cohort, 715 patients with early-stage primary invasive breast cancer (T1-3N0-1M0) were selected. Subjective cognitive function was assessed by means of the EORTC QLQ-C30 up to 24 months and compared between patients treated with and without chemotherapy, for three different age strata (355 patients < 55 years, 240 patients aged 55–65 years, and 120 patients > 65 years). Differences between chemotherapy and non-chemotherapy patients by age at different time points were assessed by linear mixed-effect models correcting for age, tumor stage, educational level, endocrine therapy, anxiety, and depression. Results In total, 979 patients from the UMBRELLA cohort were included, of which 715 (73%) responded to baseline and at least one follow-up questionnaire. Questionnaire response rates ranged between 92 and 70%. The proportion of patients treated with chemotherapy decreased with age: 64% (n = 277) in patients < 55 years, 45% (n = 107) in patients 55–65 years, and 23% (n = 27) in patients > 65 years. Chemotherapy was associated with reduced subjective cognitive functioning. The impact of chemotherapy on subjective cognitive function was most pronounced in patients < 55 years, followed by those between 55 and 65 years. In the youngest age groups, patients treated with chemotherapy had significantly lower cognitive functioning up to 24 months. In women over 65 years, subjective cognitive functioning was comparable between patients treated with and without chemotherapy. Conclusion This study confirms that chemotherapy is associated with impaired subjective self-reported cognitive functioning in breast cancer patients, and the effect persists at least up to 2 years after diagnosis. The impact of chemotherapy on self-reported cognitive functioning in the first 24 months is most pronounced in younger patients, especially those under 55 years of age. Electronic supplementary material The online version of this article (10.1007/s10549-019-05149-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M L Gregorowitsch
- Department of Radiation Oncology, University Medical Center (UMC) Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - A Ghedri
- University of Utrecht, Utrecht, The Netherlands
| | - D A Young-Afat
- Department of Radiation Oncology, University Medical Center (UMC) Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - R Bijlsma
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I O Baas
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - M J Agterof
- Department of Medical Oncology, St. Antonius, Nieuwegein, The Netherlands
| | - E Göker
- Department of Medical Oncology, Alexander Monro Clinics, Bilthoven, The Netherlands
| | | | - H J G D van den Bongard
- Department of Radiation Oncology, University Medical Center (UMC) Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H M Verkooijen
- University of Utrecht, Utrecht, The Netherlands.,Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
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7
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Bui TBV, Burgers DM, Agterof MJ, van de Garde EM. Real-World Effectiveness of Palbociclib Versus Clinical Trial Results in Patients With Advanced/Metastatic Breast Cancer That Progressed on Previous Endocrine Therapy. Breast Cancer (Auckl) 2019; 13:1178223418823238. [PMID: 30675102 PMCID: PMC6330732 DOI: 10.1177/1178223418823238] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/09/2018] [Indexed: 11/23/2022]
Abstract
Objective: The aim of this study was to assess the real-world effectiveness and
tolerability of palbociclib combined with endocrine therapy for the
treatment of hormone receptor positive (HR-positive), human epidermal growth
factor receptor 2 negative (HER2-negative), advanced/metastatic breast
cancer that progressed on previous endocrine therapy, and to compare these
results with the outcomes of the PALOMA-3 clinical trial. Methods: This study was a retrospective observational cohort study including all
patients who started with palbociclib in the St. Antonius Hospital between
September 1, 2016 and April 1, 2018 for the treatment of HR-positive,
HER2-negative advanced/metastatic breast cancer that progressed on previous
endocrine therapy. Individual patient data were collected from electronic
medical records. Primary study outcomes were progression-free survival (PFS)
and the number of permanent treatment discontinuations before disease
progression due to adverse events (AEs). Secondary outcomes were the
frequency of all (serious) AEs and the frequency of and reasons for dose
reductions, -interruptions and cycle delays. Results: A total of 46 patients were studied with a median follow-up of 13.0 months.
Overall, the median PFS in real-world clinical practice was 10.0 months (95%
confidence interval (CI) 4.9-15.1), compared with 9.5 months in PALOMA-3
(95% CI 9.2-11.0). Two patients discontinued treatment because of AEs.
Neutropenia was the most frequent grade 3-4 AE, but with no febrile
neutropenia events. Most AEs were managed with palbociclib dose
modifications. Regarding these modifications, more cycle delays, less dose
reductions, and less dose interruptions occurred in clinical practice
compared with PALOMA-3 (59 vs 36%, 22 vs 34%, and 9 vs 54%, respectively).
Patients who did not meet the PALOMA-3 study eligibility criteria (n = 16)
showed a lower median PFS of 5.5 months (95% CI 4.7-6.4). Conclusions: The effectiveness and tolerability of palbociclib in real-world clinical
practice corresponded well with the results obtained in the PALOMA-3
clinical trial. Despite the differences in dose modifications, this study
suggests that there is no efficacy-effectiveness gap in this patient
population.
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Affiliation(s)
- Tam Binh V Bui
- Department of Clinical Pharmacy, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
| | - Desirée Mt Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
| | - Mariette J Agterof
- Department of Internal Medicine, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands
| | - Ewoudt Mw van de Garde
- Department of Clinical Pharmacy, St. Antonius Hospital, Utrecht/Nieuwegein, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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8
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Schraa SJ, Frerichs KA, Agterof MJ, Hunting JCB, Los M, de Jong PC. Relative dose intensity as a proxy measure of quality and prognosis in adjuvant chemotherapy for breast cancer in daily clinical practice. Eur J Cancer 2017; 79:152-157. [PMID: 28494406 DOI: 10.1016/j.ejca.2017.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/03/2017] [Indexed: 11/19/2022]
Abstract
AIM Adjuvant chemotherapy treatment of women with breast cancer is frequently complicated by toxic side-effects, resulting in dose reduction and delay. In Dutch guidelines, a relative dose intensity (RDI) of at least 85% is recommended for optimal treatment. The aim was to investigate predictors of low RDI and its effect on prognosis. METHODS All patients treated in the St. Antonius Hospital with adjuvant chemotherapy for breast cancer between 2008 and 2013 were included (N = 605). RDI was calculated for each single chemotherapeutic agent and for chemotherapy regimens in total. Incidence and causes of RDI <85% were studied, as well as the effect of RDI on prognosis. RESULTS About 10% of 605 patients had RDIs <85%. Predictive factors included age, episodes of febrile neutropenia and grade III or IV hypersensitivity reaction to taxanes. Other adverse events, such as peripheral neuropathy, did not affect RDI. The incidence of febrile neutropenia in the 5-fluorouracil, epirubicin, cyclofosfamide, docetaxel (FEC-D) protocol was 24% and therefore was above the threshold set by the European Organisation for Research and Treatment of Cancer for primary granulocyte colony-stimulating factor (G-CSF) prophylaxis. No relationship between RDI and (disease-free) survival was found with a median follow-up of 38 months. Apart from the stage of disease, obesity is a predictor of poor outcome. CONCLUSIONS RDI <85% is predicted by patients' age, febrile neutropenia and hypersensitivity reactions to taxanes. The incidence of febrile neutropenia in FEC-D treatment indicates primary prophylaxis with G-CSF following docetaxel treatment. No relationship was found between RDI and (disease-free) survival, but longer follow-up is needed.
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Affiliation(s)
- S J Schraa
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - K A Frerichs
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Agterof
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J C B Hunting
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M Los
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - P C de Jong
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands.
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9
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Zondag W, Agterof MJ, Schutgens REG, Dekkers OM, Biesma DH, Huisman MV. Repeated NT-proBNP testing and risk for adverse outcome after acute pulmonary embolism. Thromb Haemost 2011; 106:1226-7. [PMID: 22012299 DOI: 10.1160/th11-07-0462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 09/02/2011] [Indexed: 11/05/2022]
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Agterof MJ, Schutgens REG, Moumli N, Eijkemans MJC, van der Griend R, Tromp EAM, Biesma DH. A prognostic model for short term adverse events in normotensive patients with pulmonary embolism. Am J Hematol 2011; 86:646-9. [PMID: 21630313 DOI: 10.1002/ajh.22066] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [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: 01/10/2011] [Revised: 04/13/2011] [Accepted: 04/19/2011] [Indexed: 11/08/2022]
Abstract
Risk stratification of patients with PE has gained interest in terms of the identification of patients in whom treatment on an outpatient base can be considered. Previous studies are of limited value due to their focus on adverse clinical events within several months after diagnosis of PE. We developed a prognostic model, based on easily accessible, clinical, and laboratory parameters, to predict adverse events during the first 10 days after the diagnosis of acute PE. We have analyzed the data of 210 outpatients with confirmed PE. Collected data included medical history, pulse rate, blood pressure, NT-proBNP, and D-dimer concentrations. The primary outcome was the occurrence of adverse clinical events in a 10 day follow-up period. Our final prognostic model to predict short-term adverse events consists of NT-proBNP levels, D-dimer concentrations, pulse rate, and the occurrence of active malignancy; the total score ranges from 0 to 37 points. Patients with a low score (no active malignancy, pulse rate <90 bpm, NT-proBNP <500 pg/ml, and D-dimer <3,000 μg/l FEU) have a 10-day adverse event risk <1.5%. This risk increases to over 30% in patients with a maximum score, based on high pulse rate, D-dimer concentrations, and NT-proBNP levels. Our prognostic model, once prospectively validated in an independent sample of patients, can be used in the early risk stratification of PE to estimate the risk of adverse events and to differentiate between candidates for in- or out- hospital treatment.
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Affiliation(s)
- Mariette J Agterof
- Department of Internal Medicine, Julius Center for Health Sciences and Primary Care University Medical Centre Utrecht, The Netherlands.
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Agterof MJ, Schutgens REG, Verzijlbergen JF, van Buul MMC, Tromp EAM, Eijkemans MJC, van der Griend R, Biesma DH. No firm association between N-terminal pro-brain natriuretic peptide and percentage of pulmonary vascular obstruction in patients with acute pulmonary embolism. Thromb Res 2011; 127:547-50. [PMID: 21421260 DOI: 10.1016/j.thromres.2011.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 02/10/2011] [Accepted: 02/20/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High concentrations of N-terminal-pro-brain natriuretic peptide (NT-proBNP) are found in patients with right ventricular overload. Right ventricular overload may be the result of large perfusion defects in patients with pulmonary embolism (PE). NT-proBNP levels are associated with poorer outcome in patients with acute PE. Likewise, the percentage of pulmonary vascular obstruction (PVO) has shown to be a prognostic parameter for outcome in PE-patients. We postulated that NT-proBNP is associated with the amount of perfusion defects, expressed as the PVO, on perfusion scintigraphy. METHODS We included 85 consecutive patients in whom the diagnosis PE was confirmed by ventilation-perfusion scintigraphy. PVO was calculated in all patients. NT-proBNP concentrations were measured at presentation. We plotted the logarithm of NT-proBNP versus the PVO. The strength of the estimated association between NT-proBNP and the PVO was expressed by R2. RESULTS Eighteen percent of the variation in PVO could be explained by NT-proBNP. A positive association becomes apparent for NT-proBNP values above 200 pg/mL, with an increase in PVO of 6.3% (95% Confidence Interval 2.0 to 10.6), with every doubling of NT-proBNP. CONCLUSION There is an association between NT-proBNP concentrations and PVO, although this relation is quite weak. Some patients with low NT-proBNP values can have a high PVO, which might be relevant for outcome. Therefore, we advise caution in risk stratification and not to focus on NT-proBNP, without involving the clinical condition.
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Affiliation(s)
- M J Agterof
- Department of Internal Medicine, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
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Agterof MJ, Schutgens REG, Snijder RJ, Epping G, Peltenburg HG, Posthuma EFM, Hardeman JA, van der Griend R, Koster T, Prins MH, Biesma DH. Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level. J Thromb Haemost 2010; 8:1235-41. [PMID: 20230418 DOI: 10.1111/j.1538-7836.2010.03831.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Low NT-proBNP levels are associated with an uncomplicated course in patients with pulmonary embolism (PE). The aim of this multicenter management study was to investigate the safety of home treatment of patients with PE with low (< 500 pg mL(-1)) NT-proBNP. METHODS AND RESULTS Hemodynamically stable outpatients with acute PE and NT-proBNP level < 500 pg mL(-1) were included. Patients were discharged immediately from the emergency room or within a maximum of 24 h after admission. The primary study objective was the absence of mortality during the first 10 days of treatment. Secondary objectives were the incidence of re-admission due to PE or its treatment and the patient's satisfaction during the first 10 days of treatment as well as the incidence of serious adverse events during the 3-month follow-up period. Of 351 patients, 152 (43%) fulfilled the inclusion criteria and were treated as outpatients. No deaths, major bleedings or recurrent venous thromboembolism occurred in the first 10 days of treatment or in the follow-up period of 3 months in these patients. Seven patients required readmission in the first 10 days: three because of complaints that could be related to PE and four due to an illness unrelated to PE. The HADS-A anxiety score did not change significantly between day 0 and day 10. The PSQ-18 showed a high score for satisfaction with home treatment. CONCLUSION Out of hospital treatment is safe in hemodynamically stable patients with PE with low (< 500 pg mL(-1)) NT-proBNP levels. Approximately 45% of patients with PE can be treated in an outpatient setting. Patients do not consider out of hospital treatment as inconvenient and have no increase in anxiety scores. CLINICAL TRIAL REGISTRATION INFORMATION http://clinicaltrials.gov/ct2/show/NCT00455819.
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Affiliation(s)
- M J Agterof
- Departments of Internal Medicine and Hematology/Van Creveldkliniek, University Medical Center, Utrecht, the Netherlands
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Agterof MJ, van Bladel ER, Schutgens REG, Snijder RJ, Tromp EAM, Prins MH, Biesma DH. Risk stratification of patients with pulmonary embolism based on pulse rate and D-dimer concentration. Thromb Haemost 2010; 102:683-7. [PMID: 19806253 DOI: 10.1160/th09-04-0229] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To enable outpatient treatment of a selected group of patients with pulmonary embolism (PE), insight in the determinants of adverse clinical outcome is warranted. We have identified risk factors for serious adverse events (SAE) within the first 10 days of acute PE. We have retrospectively analysed data of 440 consecutive patients with acute PE. Collected data included age, gender, medical history, blood pressure, pulse rate and D-dimer concentration. The variables associated with SAE in the first 10 days in univariate analysis (p<0.15) have been included in a multivariate logistic regression model (backward conditional, p out >0.10). In 440 patients with acute PE, 20 SAEs occurred in a 10-day follow-up period. Pulse rate > or = 100 beats per minute (bpm) (OR, 6.85; 95%CI 1.43-32.81) and D-dimer concentration > or = 3,000 microg/ml (OR, 5.51; 95%CI 0.68-44.64) were significantly related to the SAEs. All SAEs were predicted by a pulse rate > or = 100 bpm and/or a D-dimer concentration > or = 3,000 microg/ml. Older age, gender, history of venous thromboembolism (VTE), heart failure, chronic obstructive pulmonary disease, cancer or a systolic blood pressure < 90 mm Hg had no significant influence on short term SAEs. Pulse rate and D-dimer concentration can be used to identify patients with acute PE, who are at risk for adverse clinical outcome during the first 10 days of hospitalisation. Outpatient treatment of PE-patients with a pulse rate > or = 100 bpm and/or a D-dimer concentration > or = 3,000 microg/ml has to be discouraged.
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Affiliation(s)
- Mariette J Agterof
- Department of Internal Medicine, University Medical Centre Utrecht, P.O. Box 85500, 3508 AB Utrecht, the Netherlands.
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Agterof MJ, ter Borg EJ. Erythematous pigmentation of the arm for more than ten years. Neth J Med 2008; 66:176-179. [PMID: 18424868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- M J Agterof
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands.
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Agterof MJ, van der Bruggen T, Tersmette M, ter Borg EJ, van den Bosch JMM, Biesma DH. Nocardiosis: a case series and a mini review of clinical and microbiological features. Neth J Med 2007; 65:199-202. [PMID: 17587645] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Infections caused by Nocardia species are uncommon and have a wide variety of clinical manifestations in immunocompetent and immunocompromised patients. The diagnosis of nocardiosis can easily be missed because there are no characteristic symptoms. We present one case of a Nocardia infection in detail and give a brief description of eight other cases, including a relatively unique type of Nocardia veterana, diagnosed in our hospital during a five-year period. The diversity of clinical manifestations, microbiological identification and general principles of treatment of nocardiosis are reviewed.
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Affiliation(s)
- M J Agterof
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands.
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Schutgens REG, Haas FJLM, Agterof MJ, Vos M, Biesma DH. The role of fibrin monomers in optimizing the diagnostic work-up of deep vein thrombosis. Thromb Haemost 2007; 97:807-13. [PMID: 17479192] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Despite the use of a clinical score and D-dimers to exclude deep vein thrombosis (DVT), the majority of patients still need repeated ultrasound (US). The aim of the study was to investigate whether fibrin monomers (FMs), as markers of thrombin generation, have additional value in the diagnosis of DVT. This is a posthoc analysis of 464 outpatients, participants in a management study using D-dimers (Tina-Quant and a clinical score in the exclusion of DVT. Two new FM assays (Auto LIA-FM and IATRO SF, Japan) were performed. Overall sensitivity, negative predictive value (NPV) and specificity of the D-dimer test were 98%, 98% and 42%. The optimal cut-off point for the Auto LIA-FM test was <or=3 microg/ml with values of 88%, 88% and 59%, respectively. The IATRO SF test had an optimal cut-off point of <or=2 microg/ml with values of 92%, 81 and 22%, respectively. The NPV of a non-high clinical score and a normal D-dimer (n=97) was 100%. In patients with a high clinical score (n=160), the NPV of the D-dimer was 88%. In these patients, a single US combined with a normal D-dimer or FM test had an equal NPV as serial US (100 versus 98%, respectively) and lead to a reduction in the need for US by 36-53%, respectively. In patients with abnormal D-dimer concentrations (n=343), a normal US combined with a normal Auto LIA-FM test had a NPV of 97%, which was also true for serial US. This could lead to a reduction in the need for US by 45%. The present studied FMs are inferior to the Tina-Quant D-dimer test when used as primary screening tool to exclude DVT. Adding these FMs to patients with a normal Tina-Quant D-dimer has no benefit. In patients with a high pretest clinical probability score, a single US in combination with a normal D-dimer or FM test might be as safe as serial US. In patients with abnormal D-dimer concentrations and a normal US, a normal FM test might be able to replace the second US.
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Affiliation(s)
- Roger E G Schutgens
- Department of Haematology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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