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Weiss A, Li T, Desai NV, Tung NM, Poorvu PD, Partridge AH, Nakhlis F, Dominici L, Sinclair N, Spring LM, Faggen M, Constantine M, Krop IE, DeMeo M, Wrabel E, Alberti J, Chikarmane S, Tayob N, King TA, Tolaney SM, Winer EP, Mittendorf EA, Waks AG. Impact of Neoadjuvant Paclitaxel/Trastuzumab/Pertuzumab on Breast Tumor Downsizing for Patients with HER2+ Breast Cancer: Single-Arm Prospective Clinical Trial. J Am Coll Surg 2023:00019464-990000000-00667. [PMID: 37194964 DOI: 10.1097/xcs.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND The impact of abbreviated neoadjuvant regimens for HER2+ breast cancer on rates of breast conservation therapy (BCT) is unclear. We aimed to determine BCT rates in a single-arm prospective trial of neoadjuvant paclitaxel/trastuzumab/pertuzumab (THP) in patients with stage II-III HER2+ breast cancer. STUDY DESIGN BCT eligibility was prospectively recorded before and after THP. Pre- and post-treatment mammogram and breast ultrasound were required; breast MRI was encouraged. Patients with a large tumor to breast size ratio were eligible for downsizing. Multifocal/multicentric tumors, extensive calcifications, and contraindications to radiation were considered BCT contraindications. RESULTS Overall, 92 patients who received neoadjuvant THP on trial were included. At presentation, 39 (42.4%) were considered eligible for BCT and 53 (57.6%) were not. BCT-eligible patients were older (median 54 years versus 47 years, respectively, p=0.006) and had smaller tumors by palpation (median 2.5 cm versus 3 cm, respectively, p=0.004). Of 53 BCT-ineligible patients, 28 were candidates for tumor downsizing, whereas 25 had contraindications to BCT. Overall, 51(55.4%) patients underwent BCT. Of the 28 patients who were candidates for downsizing, 22 (78.6%) became BCT-eligible after THP and 18/22 (81.8%) underwent BCT. In total, 44/92 (47.8%) patients experienced breast pathologic complete response (pCR, ypT0), including 11/25 (44.0%) patients with BCT contraindications at presentation. CONCLUSIONS De-escalated neoadjuvant systemic therapy led to high BCT rates in this cohort. The impact of de-escalated systemic therapy on local therapy and outcomes in early stage HER2+ breast cancer warrants further investigation.
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Affiliation(s)
| | | | - Neelam V Desai
- Harvard Medical School, Boston MA
- Division of Medical Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Nadine M Tung
- Harvard Medical School, Boston MA
- Division of Medical Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Philip D Poorvu
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ann H Partridge
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Faina Nakhlis
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston MA
| | - Laura Dominici
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston MA
| | - Natalie Sinclair
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Laura M Spring
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston MA
| | - Meredith Faggen
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Michael Constantine
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ian E Krop
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Michelle DeMeo
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
| | - Eileen Wrabel
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
| | - Jillian Alberti
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
| | - Sona Chikarmane
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Radiology, Brigham and Women's Hospital, Boston MA
| | - Nabihah Tayob
- Harvard Medical School, Boston MA
- Department of Data Science, Dana-Farber Cancer Institute, Boston MA
| | | | - Sara M Tolaney
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Eric P Winer
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Elizabeth A Mittendorf
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston MA
| | - Adrienne G Waks
- Harvard Medical School, Boston MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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2
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Tarantino P, Tayob N, Dang CT, Yardley D, Isakoff SJ, Valero V, Faggen M, Mulvey T, Bose R, Weckstein D, Wolff AC, Reeder-Hayes K, Rugo H, Ramaswamy B, Zuckerman D, Hart L, Gadi VK, Constantine M, Cheng K, Garrett AM, Marcom PK, Albain KS, DeFusco P, Tung N, Ardman B, Nanda R, Jankowitz RC, Rimawi M, Abramson V, Pohlmann PR, Van Poznak C, Forero-Torres A, Liu MC, Ruddy K, Zheng Y, Barroso-Sousa R, Waks A, DeMeo MK, DiLullo MK, Curigliano G, Burstein H, Partridge A, Winer E, Viale G, Hui W, Mittendorf EA, Schneider BP, Prat A, Krop I, Tolaney S. Abstract PD18-01: Adjuvant Trastuzumab Emtansine Versus Paclitaxel plus Trastuzumab for Stage I HER2+ Breast Cancer: 5-year results and correlative analyses from ATEMPT (TBCRC033). Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-pd18-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: The ATEMPT trial primary analysis found that one year of adjuvant trastuzumab emtansine (T-DM1) achieved a 3-year iDFS of 97.8% for patients with stage I HER2+ breast cancer, but was not associated with fewer clinically relevant toxicities (CRTs) compared with paclitaxel and trastuzumab (TH). In this end-of-study analysis, we report 5-year survival outcomes and correlative analyses from the trial. Methods: Patients with stage I centrally confirmed HER2+ breast cancer were randomly assigned 3:1 to adjuvant T-DM1 for one year or TH and received T-DM1 3.6 mg/kg IV every 3 weeks for 17 cycles or paclitaxel 80 mg/m2 IV with weekly trastuzumab IV followed by trastuzumab for 9 months. The co-primary objectives were to compare the incidence of CRTs between the 2 arms and to evaluate iDFS in patients receiving T-DM1. To investigate proteomic correlates of recurrence, spatial proteomic analyses were performed on samples from 13 patients experiencing iDFS events (cases) and 24 matched controls using the NanoString GeoMx Digital Spatial Profiler. The impact of HER2 heterogeneity on outcomes was investigated among 17 cases and 51 matched controls by fluorescence in-situ hybridization (FISH). HER2 genetic heterogeneity was assessed by scrutinizing the whole tumor area and defined as the occurrence of HER2 gene amplification in >5% but < 50% invasive tumor cells. The risk of recurrence was evaluated centrally with the HER2DX genomic assay from 225 primary tumor samples. Germline whole genome sequencing (WGS) was conducted among 55 patients experiencing T-DM1-induced thrombocytopenia and/or bleeding and 55 matched controls to identify genomic correlates for this side effect. Results: A total of 497 patients who initiated protocol therapy were included in this analysis (383 T-DM1 and 114 TH). After a median follow up 5.8 years, among patients receiving T-DM1 there were a total of 11 iDFS events, with 3 distant recurrences. The 5-year iDFS for T-DM1 was 97.0% (95% CI, 95.3-98.8%), the 5-year recurrence-free interval (RFI) was 98.6% (95% CI: 97.4-99.8%) and the 5-year overall survival (OS) for T-DM1 was 97.8 % (95% CI, 96.3-99.3%). Although the study was not powered to evaluate the efficacy of TH, among the 114 patients receiving TH, a total of 9 iDFS events were observed, including 2 distant events; the 5-year iDFS with TH was 91.3% (95% CI: 86.0-96.9%), 5-year RFI was 93.3% (95% CI: 88.6-98.2%) and 5-year OS was 97.9% (95% CI: 95.2-100%). A total of 56 samples were evaluable for heterogeneity analyses, among which 14% (n=8) harbored HER2 genetic heterogeneity. Spatial proteomic analyses found that NF1 (adjusted p=0.72 × 10-6) and CTLA-4 (adjusted p=0.15 × 10-3) were significantly upregulated in primary samples from cases, while cleaved caspase 9, CD25, GITR, ICOS, p53 and PD-L2 were significantly upregulated in controls (all with adjusted p< 0.05). Germline WGS found that the top gene associations with thrombocytopenia and thrombocytopenia or bleeding were ALMS1 (p=0,19 × 10-3) and APBA3 (p=0,23 × 10-3), respectively, although none reaching the threshold for genome wide significance. rs62143195 and rs114169776 were the top single nucleotide polymorphisms associated with thrombocytopenia and thrombocytopenia or bleeding, respectively. Data on the impact of HER2 heterogeneity and of HER2DX score on survival outcomes will be presented. Conclusion: With longer follow-up, adjuvant T-DM1 confirmed outstanding long-term outcomes among patients with stage I HER2+ breast cancer, demonstrating a 5-year RFI of 98.6%. Spatial proteomic analyses identified a potential association between NF1 and CTLA-4 expression with recurrence. Details on the impact of HER2 heterogeneity and HER2DX assay on prognosis will be presented.
Citation Format: Paolo Tarantino, Nabihah Tayob, Chau T Dang, Denise Yardley, Steven J. Isakoff, Vicente Valero, Meredith Faggen, Therese Mulvey, Ron Bose, Douglas Weckstein, Antonio C. Wolff, Katherine Reeder-Hayes, Hope Rugo, Bhuvaneswari Ramaswamy, Dan Zuckerman, Lowell Hart, Vijayakrishna K. Gadi, Michael Constantine, Kit Cheng, Audrey Merrill Garrett, Paul K. Marcom, Kathy S. Albain, Patricia DeFusco, Nadine Tung, Blair Ardman, Rita Nanda, Rachel C. Jankowitz, Mothaffar Rimawi, Vandana Abramson, Paula R. Pohlmann, Catherine Van Poznak, Andres Forero-Torres, Minetta C. Liu, Kathryn Ruddy, Yue Zheng, Romualdo Barroso-Sousa, Adrienne Waks, Michelle K. DeMeo, Molly K. DiLullo, Giuseppe Curigliano, Harold Burstein, Ann Partridge, Eric Winer, Giuseppe Viale, Winnie Hui, Elizabeth A. Mittendorf, Bryan P. Schneider, Aleix Prat, Ian Krop, Sara Tolaney. Adjuvant Trastuzumab Emtansine Versus Paclitaxel plus Trastuzumab for Stage I HER2+ Breast Cancer: 5-year results and correlative analyses from ATEMPT (TBCRC033) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD18-01.
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Affiliation(s)
- Paolo Tarantino
- 1Breast Oncology Program, Dana-Farber Cancer Institute; Harvard Medical School, Boston, Massachusetts
| | | | | | - Denise Yardley
- 4Sarah Cannon Research Institute, Tennessee Oncology, Nashville, TN, USA
| | | | - Vicente Valero
- 6Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Therese Mulvey
- 8Massachusetts General Hospital North Shore Cancer Center
| | - Ron Bose
- 9Washington University in St Louis School of Medicine
| | | | | | | | - Hope Rugo
- 13University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | - Kathy S. Albain
- 22Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center
| | | | - Nadine Tung
- 24Beth Israel Deaconess Medical Center, Boston
| | | | - Rita Nanda
- 26University of Chicago, Chicago, Illinois
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Giuseppe Viale
- 44European Institute of Oncology IRCCS, and University of Milan, Milan, Italy
| | | | | | | | | | - Ian Krop
- 49Yale School of Medicine, New Haven, Connecticut
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3
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Barroso-Sousa R, Vaz-Luis I, Di Meglio A, Hu J, Li T, Rees R, Sinclair N, Milisits L, Leone JP, Constantine M, Faggen M, Briccetti F, Block C, Partridge A, Burstein H, Waks AG, Tayob N, Trippa L, Tolaney SM, Hassett MJ, Winer EP, Lin NU. Prospective Study Testing a Simplified Paclitaxel Premedication Regimen in Patients with Early Breast Cancer. Oncologist 2021; 26:927-933. [PMID: 34472667 PMCID: PMC8571744 DOI: 10.1002/onco.13960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background In early trials, hypersensitivity reactions (HSRs) to paclitaxel were common, thus prompting the administration of antihistamines and corticosteroids before every paclitaxel dose. We tested the safety of omitting corticosteroids after cycle 2 during the paclitaxel portion of the dose‐dense (DD) doxorubicin‐cyclophosphamide (AC)–paclitaxel regimen. Patients, Materials, and Methods In this prospective, single‐arm study, patients who completed four cycles of DD‐AC for stage I–III breast cancer received paclitaxel 175 mg/m2 every 2 weeks for four cycles. Patients received a standard premedication protocol containing dexamethasone, diphenhydramine, and a histamine H2 blocker prior to the first two paclitaxel cycles. Dexamethasone was omitted in cycles three and four if there were no HSRs in previous cycles. We estimated the rate of grade 3–4 HSRs. Results Among 127 patients enrolled, 125 received more than one dose of protocol therapy and are included in the analysis. Fourteen (11.2%; 90% confidence interval, 6.9%–20.0%) patients had any‐grade HSRs, for a total of 22 (4.5%; 3.1%–6.4%) HSRs over 486 paclitaxel cycles. Any‐grade HSRs occurred in 1.6% (0.3%–5.0%), 6.5% (3.3%–11.3%), 7.4% (3.9%–12.5%), and 2.6% (0.7%–6.6%) of patients after paclitaxel cycles 1, 2, 3, and 4, respectively. Dexamethasone use was decreased by 92.8% in cycles 3 and 4. Only one patient experienced grade 3 HSR in cycles 3 or 4, for a rate of grade 3/4 HSR 0.4% (0.02%–2.0%) (1/237 paclitaxel infusions). That patient had grade 2 HSR during cycle 2, and the subsequent grade 3 event occurred despite usual dexamethasone premedication. A sensitivity analysis restricted to patients not known to have received dexamethasone in cycles 3 and 4 found that any‐grade HSRs occurred in 2.7% (3/111; 0.7%–6.8%) and 0.9% (1/109; 0.05%–4.3%) of patients in cycle 3 and 4, respectively. Conclusion Corticosteroid premedication can be safely omitted in cycles 3 and 4 of dose‐dense paclitaxel if HSRs are not observed during cycles 1 and 2. Implications for Practice Because of the potential for hypersensitivity reactions (HSRs) to paclitaxel, corticosteroids are routinely prescribed prior to each dose, on an indefinite basis. This prospective study, including 125 patients treated with 486 paclitaxel cycles, demonstrates that corticosteroids can be safely omitted in future cycles if HSRs did not occur during cycles 1 and 2 of paclitaxel and that this strategy reduces the use of corticosteroids in cycles 3 and 4 by 92.8% relative to current standard of care. To avoid hypersensitivity reactions, corticosteroids are routinely prescribed before each dose of paclitaxel. This article reports the results of a study that focused on whether corticosteroids could be safely omitted in later cycles of treatment if reactions did not occur during earlier cycles.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Oncology Center, Hospital Sírio-Libanês, Brasília, Brazil
| | - Ines Vaz-Luis
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Institut Gustave Roussy, Unit INSERM 981, Prédicteurs moléculaires et nouvelles cibles en oncologie, Villejuif, France
| | - Antonio Di Meglio
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Institut Gustave Roussy, Unit INSERM 981, Prédicteurs moléculaires et nouvelles cibles en oncologie, Villejuif, France
| | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tianyu Li
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rebecca Rees
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | | | - Meredith Faggen
- Dana-Farber Cancer Institute at South Shore Hospital, South Weymouth, Massachusetts, USA
| | - Frederick Briccetti
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, New Hampshire, USA
| | - Caroline Block
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Ann Partridge
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | - Nabihah Tayob
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard School of Public Health, Boston, Massachusetts, USA
| | - Sara M Tolaney
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Eric P Winer
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy U Lin
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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4
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Ruddy KJ, Zheng Y, Tayob N, Hu J, Dang CT, Yardley DA, Isakoff SJ, Valero VV, Faggen MG, Mulvey TM, Bose R, Sella T, Weckstein DJ, Wolff AC, Reeder-Hayes KE, Rugo HS, Ramaswamy B, Zuckerman DS, Hart LL, Gadi VK, Constantine M, Cheng KL, Briccetti FM, Schneider BP, Merrill Garrett A, Kelly Marcom P, Albain KS, DeFusco PA, Tung NM, Ardman BM, Nanda R, Jankowitz RC, Rimawi M, Abramson V, Pohlmann PR, Van Poznak C, Forero-Torres A, Liu MC, Rosenberg S, DeMeo MK, Burstein HJ, Winer EP, Krop IE, Partridge AH, Tolaney SM. Chemotherapy-related amenorrhea (CRA) after adjuvant ado-trastuzumab emtansine (T-DM1) compared to paclitaxel in combination with trastuzumab (TH) (TBCRC033: ATEMPT Trial). Breast Cancer Res Treat 2021; 189:103-110. [PMID: 34120223 DOI: 10.1007/s10549-021-06267-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 04/19/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Chemotherapy-related amenorrhea (CRA) is a surrogate for ovarian toxicity and associated risk of infertility and premature menopause. Here, we compare CRA rate with paclitaxel (T)-trastuzumab (H) to that with ado-trastuzumab emtansine (T-DM1). METHODS Patients with T1N0 HER2 + early-stage breast cancer (eBC) enrolled on the ATEMPT trial and were randomized 3:1 to T-DM1 3.6 mg/kg IV every (q) 3 weeks (w) × 17 vs. T 80 mg/m2 with H IV qw × 12 (4 mg/kg load → 2 mg/kg), followed by H (6 mg/kg IV q3w × 13). Enrollees who self-reported as premenopausal were asked to complete menstrual surveys at baseline and every 6-12 months for 60 months. 18-month CRA (no periods reported during prior 6 months on 18-month survey) was the primary endpoint of this analysis. RESULTS Of 512 ATEMPT enrollees, 123 who began protocol therapy and answered baseline and at least one follow-up menstrual survey were premenopausal at enrollment. 76 had menstrual data available at 18 months without having received a gonadotropin-releasing hormone agonist or undergone hysterectomy and/or oophorectomy. Median age was 45 (range 23-53) among 18 who had received TH and 46 (range 34-54) among 58 who had received T-DM1. The 18-month rate of CRA was 50% after TH and 24% after T-DM1 (p = 0.045). CONCLUSION Amenorrhea at 18 months was less likely in recipients of adjuvant T-DM1 than TH. Future studies are needed to understand how T-DM1 impacts risk of infertility and permanent menopause, and to assess amenorrhea rates when T-DM1 is administered after standard HER2-directed chemotherapy regimens.
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Affiliation(s)
- Kathryn J Ruddy
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Yue Zheng
- Dana-Farber Cancer Institute, Boston, USA
| | | | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, USA
| | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | | | | | - Ron Bose
- Siteman Cancer Center, St. Louis, USA
| | - Tal Sella
- Dana-Farber Cancer Institute, Boston, USA
| | | | | | | | - Hope S Rugo
- Diller Family Comprehensive Cancer Center, University of California San Francisco Helen, San Francisco, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rachel C Jankowitz
- Penn Medicine Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mothaffar Rimawi
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Paula R Pohlmann
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | | | | | - Minetta C Liu
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | | | | | - Ian E Krop
- Dana-Farber Cancer Institute, Boston, USA
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5
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Tolaney SM, Tayob N, Dang C, Yardley DA, Isakoff SJ, Valero V, Faggen M, Mulvey T, Bose R, Hu J, Weckstein D, Wolff AC, Reeder-Hayes K, Rugo HS, Ramaswamy B, Zuckerman D, Hart L, Gadi VK, Constantine M, Cheng K, Briccetti F, Schneider B, Garrett AM, Marcom K, Albain K, DeFusco P, Tung N, Ardman B, Nanda R, Jankowitz RC, Rimawi M, Abramson V, Pohlmann PR, Van Poznak C, Forero-Torres A, Liu M, Ruddy K, Zheng Y, Rosenberg SM, Gelber RD, Trippa L, Barry W, DeMeo M, Burstein H, Partridge A, Winer EP, Krop I. Adjuvant Trastuzumab Emtansine Versus Paclitaxel in Combination With Trastuzumab for Stage I HER2-Positive Breast Cancer (ATEMPT): A Randomized Clinical Trial. J Clin Oncol 2021; 39:2375-2385. [PMID: 34077270 DOI: 10.1200/jco.20.03398] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The ATEMPT trial was designed to determine if treatment with trastuzumab emtansine (T-DM1) caused less toxicity than paclitaxel plus trastuzumab (TH) and yielded clinically acceptable invasive disease-free survival (iDFS) among patients with stage I human epidermal growth factor receptor 2-positive (HER2+) breast cancer (BC). METHODS Patients with stage I centrally confirmed HER2+ BC were randomly assigned 3:1 to T-DM1 or TH and received T-DM1 3.6 mg/kg IV every 3 weeks for 17 cycles or T 80 mg/m2 IV with H once every week × 12 weeks (4 mg/kg load →2 mg/kg), followed by H × 39 weeks (6 mg/kg once every 3 weeks). The co-primary objectives were to compare the incidence of clinically relevant toxicities (CRTs) in patients treated with T-DM1 versus TH and to evaluate iDFS in patients receiving T-DM1. RESULTS The analysis population includes all 497 patients who initiated protocol therapy (383 T-DM1 and 114 TH). CRTs were experienced by 46% of patients on T-DM1 and 47% of patients on TH (P = .83). The 3-year iDFS for T-DM1 was 97.8% (95% CI, 96.3 to 99.3), which rejected the null hypothesis (P < .0001). Serially collected patient-reported outcomes indicated that patients treated with T-DM1 had less neuropathy and alopecia and better work productivity compared with patients on TH. CONCLUSION Among patients with stage I HER2+ BC, one year of adjuvant T-DM1 was associated with excellent 3-year iDFS, but was not associated with fewer CRT compared with TH.
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Affiliation(s)
- Sara M Tolaney
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | | | - Chau Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Denise A Yardley
- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN
| | | | - Vicente Valero
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Ron Bose
- Washington University, St Louis, MO
| | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | - Dan Zuckerman
- St Luke's Mountain States Tumor Institute, Boise, ID
| | - Lowell Hart
- Wake Forest Baptist Health, Winston-Salem, NC
| | - Vijayakrishna K Gadi
- University of Washington, Seattle, WA. Currently at University of Illinois at Chicago, Chicago, IL
| | | | - Kit Cheng
- North Shore-LIJ Cancer Institute, Lake Success, NY
| | | | | | | | | | | | | | - Nadine Tung
- Harvard Medical School, Boston, MA.,Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | - Mothaffar Rimawi
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | | | - Paula R Pohlmann
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | | | | | | | | | - Yue Zheng
- Dana-Farber Cancer Institute, Boston, MA
| | | | - Richard D Gelber
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | | | | | - Harold Burstein
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Ann Partridge
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Eric P Winer
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Ian Krop
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
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Brown JC, Rosenthal MH, Ma C, Zhang S, Nimeiri HS, McCleary NJ, Abrams TA, Yurgelun MB, Cleary JM, Rubinson DA, Schrag D, Bullock AJ, Allen J, Zuckerman D, Chan E, Chan JA, Wolpin B, Constantine M, Weckstein DJ, Faggen MA, Thomas CA, Kournioti C, Yuan C, Zheng H, Hollis BW, Fuchs CS, Ng K, Meyerhardt JA. Effect of High-Dose vs Standard-Dose Vitamin D 3 Supplementation on Body Composition among Patients with Advanced or Metastatic Colorectal Cancer: A Randomized Trial. Cancers (Basel) 2020; 12:cancers12113451. [PMID: 33233566 PMCID: PMC7699725 DOI: 10.3390/cancers12113451] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
Simple Summary Skeletal muscle and adipose tissue express the vitamin D receptor and may be a mechanism through which vitamin D supplementation slows cancer progression and reduces cancer death. It is unknown if high-dose vitamin D3 impacts skeletal muscle and adipose tissue, as compared with standard-dose vitamin D3, in patients with advanced or metastatic colorectal cancer. In this exploratory analysis of a phase II randomized trial, high-dose vitamin D3 did not lead to changes of body weight, body mass index, muscle area, muscle attenuation, visceral adipose tissue area, or subcutaneous adipose tissue area, as compared with standard-dose vitamin D3. High-dose vitamin D3 did not change body composition in patients receiving chemotherapy for advanced or metastatic colorectal cancer. Abstract Skeletal muscle and adipose tissue express the vitamin D receptor and may be a mechanism through which vitamin D supplementation slows cancer progression and reduces cancer death. In this exploratory analysis of a double-blind, multicenter, randomized phase II clinical trial, 105 patients with advanced or metastatic colorectal cancer who were receiving chemotherapy were randomized to either high-dose vitamin D3 (4000 IU) or standard-dose (400 IU) vitamin D3. Body composition was measured with abdominal computed tomography at enrollment (baseline) and after cycle 8 of chemotherapy (16 weeks). As compared with standard-dose vitamin D3, high-dose vitamin D3 did not significantly change body weight [−0.7 kg; (95% CI: −3.5, 2.0)], body mass index [−0.2 kg/m2; (95% CI: −1.2, 0.7)], muscle area [−1.7 cm2; (95% CI: −9.6, 6.3)], muscle attenuation [−0.4 HU; (95% CI: −4.2, 3.2)], visceral adipose tissue area [−7.5 cm2; (95% CI: −24.5, 9.6)], or subcutaneous adipose tissue area [−8.3 cm2; (95% CI: −35.5, 18.9)] over the first 8 cycles of chemotherapy. Among patients with advanced or metastatic colorectal cancer, the addition of high-dose vitamin D3, vs standard-dose vitamin D3, to standard chemotherapy did not result in any changes in body composition.
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Affiliation(s)
- Justin C. Brown
- Pennington Biomedical Research Center, Baton Rouge, LA 70808, USA
- LSU Health Sciences Center, New Orleans School of Medicine, New Orleans, LA 70012, USA
- Stanley S. Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA 70012, USA
- Correspondence: ; Tel.: +1-225-763-2715
| | - Michael H. Rosenthal
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Chao Ma
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Sui Zhang
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Halla S. Nimeiri
- Division of Hematology Oncology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA;
| | - Nadine J. McCleary
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Thomas A. Abrams
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Matthew B. Yurgelun
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - James M. Cleary
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Douglas A. Rubinson
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Deborah Schrag
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | | | - Jill Allen
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.); (H.Z.)
| | - Dan Zuckerman
- St Luke’s Mountain States Tumor Institute, Boise, ID 83712, USA;
| | - Emily Chan
- Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Jennifer A. Chan
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Brian Wolpin
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | | | | | | | | | | | - Chen Yuan
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Hui Zheng
- Massachusetts General Hospital, Boston, MA 02114, USA; (J.A.); (H.Z.)
| | - Bruce W. Hollis
- Department of Pediatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA;
| | | | - Kimmie Ng
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
| | - Jeffrey A. Meyerhardt
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA; (M.H.R.); (C.M.); (S.Z.); (N.J.M.); (T.A.A.); (M.B.Y.); (J.M.C.); (D.A.R.); (D.S.); (J.A.C.); (B.W.); (C.Y.); (K.N.); (J.A.M.)
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7
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Vaz-Luis I, Barroso-Sousa R, Di Meglio A, Hu J, Rees R, Sinclair N, Milisits L, Leone JP, Constantine M, Faggen M, Briccetti F, Block C, O'Neil K, Partridge A, Burstein H, Waks AG, Trippa L, Tolaney SM, Hassett M, Winer EP, Lin NU. Avoiding Peg-Filgrastim Prophylaxis During the Paclitaxel Portion of the Dose-Dense Doxorubicin-Cyclophosphamide and Paclitaxel Regimen: A Prospective Study. J Clin Oncol 2020; 38:2390-2397. [PMID: 32330102 PMCID: PMC7367545 DOI: 10.1200/jco.19.02484] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE The use of growth factors adds considerable expense and some toxicity to adjuvant breast cancer chemotherapy. We tested the feasibility and safety of omitting routine peg-filgrastim use during the paclitaxel portion of the dose-dense doxorubicin-cyclophosphamide-paclitaxel regimen. PATIENTS AND METHODS This was a prospective, single-arm study in which patients 18 to 65 years of age who completed 4 cycles of dose-dense doxorubicin-cyclophosphamide for stage I-III breast cancer received paclitaxel 175 mg/m2 every 2 weeks. Peg-filgrastim was administered after paclitaxel only if patients had had febrile neutropenia in a prior cycle or at investigator discretion if patients had infections or treatment delays of > 1 week. Once a patient received peg-filgrastim, it was administered in all future cycles. The primary end point was the rate of paclitaxel completion within 7 weeks from cycle 1 day 1 to cycle 4 day 1. If ≥ 100 out of 125 patients completed 4 cycles of paclitaxel without dose delay, the regimen would be considered feasible. RESULTS The enrollment goal of 125 patients was met. Median age was 46 years (range, 21-65 years), and 112 patients (90% [95% CI, 83% to 94%]) completed dose-dense paclitaxel within 7 weeks. Omission of peg-filgrastim was not causally related to noncompletion of paclitaxel in any patients. The most common reasons for dose reduction or delays were nonhematologic. One patient experienced febrile neutropenia but was able to complete paclitaxel on time. Eight patients (6.4%) received peg-filgrastim during the trial. Overall, peg-filgrastim was administered in only 4.3% of paclitaxel cycles. CONCLUSION Omission of routine peg-filgrastim during dose-dense paclitaxel according to a prespecified algorithm seems to be safe and feasible and was associated with a 95.7% reduction in the use of peg-filgrastim relative to the current standard of care.
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Affiliation(s)
- Ines Vaz-Luis
- Dana-Farber Cancer Institute, Boston, MA.,Institut Gustave Roussy, Villejuif, France
| | | | - Antonio Di Meglio
- Dana-Farber Cancer Institute, Boston, MA.,Institut Gustave Roussy, Villejuif, France
| | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | - Meredith Faggen
- Dana-Farber Cancer Institute at South Shore Hospital, South Weymouth, MA
| | - Frederick Briccetti
- Dana-Farber Cancer Institute, Boston, MA.,Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, NH
| | - Caroline Block
- Dana-Farber Cancer Institute, Boston, MA.,Dana-Farber Cancer Institute at St Elizabeth's Medical Center, Boston, MA
| | | | | | | | | | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Boston, MA.,Harvard School of Public Health, Boston, MA
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8
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Partridge A, Zheng Y, Rosenberg S, Gelber R, Gelber S, Barry W, Dang C, Yardley D, Isakoff S, Valero V, Faggen M, Mulvey T, Bose R, Weckstein D, Wolff A, Reeder-Hayes K, Rugo H, Ramaswamy B, Zuckerman D, Hart L, Gadi V, Constantine M, Cheng K, Briccetti F, Schneider B, Garrett M, Marcom PK, Albain K, Defusco P, Tung N, Ardman B, Nanda R, Jankowitz R, DeMeo M, Burstein H, Winer EP, Krop I, Tolaney S. Abstract PD10-02: Patient reported outcomes from the adjuvant trastuzumab emtansine (T-DM1) vs. paclitaxel + trastuzumab (TH) (ATEMPT) trial (TBCRC 033). Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-pd10-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: The ATEMPT trial sought to determine if adjuvant T-DM1 (every 3 wks for 1 yr) for Stage I HER2 positive breast cancer is better tolerated than TH (paclitaxel weekly x 12 wks with 1 yr of trastuzumab). Here we compare patient-reported outcomes (PROs) including quality of life (QOL), specific symptoms, and work productivity between the two treatments over time. Patients and Methods: English-speaking patients were randomized (3:1) to T-DM1 or TH, and completed PRO assessments at baseline (day 1), 3 wks, 12 wks, and 6, 12, and 18 mos after initiation of treatment. Surveys included the FACT-B, Patient-Neurotoxicity Questionnaire (PNQ), Rotterdam Symptom Checklist (RSCL), Alopecia Patient Assessment, and Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI:SHP). Results: 469/497 (94%) patients (363 on T-DM1, 106 on TH) completed surveys at any timepoint, ranging from 100% at baseline to 79% at 18 mos. Median age was 56 yrs (range 23-85). There were different patterns of deterioration and recovery seen over time in each group for QOL and other relevant symptoms. Compared with the T-DM1 group, the TH group had significantly lower mean total FACT-B scores, indicating poorer QOL from baseline to 12 weeks (p<0.001 for each timepoint); mean scores were similar between the groups at 6 and 12 mos, and significantly worse again in the TH group at 18 mos. The greatest mean change from baseline, and lowest FACT-B scores overall were reported in the TH group at 12 weeks. Moderate to severe sensory neuropathy was 8% at 12 weeks for patients receiving T-DM1 and reached its highest level of 15% by 18 mos. In comparison, moderate to severe sensory neuropathy was 35% at 12 weeks and 26% at 18 mos for patients on TH (p<0.001 at 12 weeks and p=0.018 at 18 mos). Hair loss at week 12 was 13% on T-DM1 compared to 77% on TH (p<0.001). Mean physical symptom distress was greater for TH at baseline, 3 and 12 weeks, and greater for T-DM1 at 1 year, with greatest symptom distress reported by the TH group at 12 weeks. Psychological distress was greatest for both groups at enrollment, though significantly greater with TH than T-DM1 at baseline, 12 weeks and 18 mos (groups were similar at 6 and 12 mos). There was limited impact on activity level impairment in both groups. Rates of employment were lowest for the TH group at 12 weeks (49% TH vs. 61% T-DM1, p=0.074) with significant differences seen at 3 and 12 weeks for percent work time missed due to health treatment, percent impairment while working, percent overall work impairment, and percent activity impairment, all favoring T-DM1. Conclusion: PROs differ between patients with Stage I HER2 positive breast cancer treated with T-DM1 vs. TH. T-DM1 treated patients had better QOL, less neuropathy and hair loss, and better work productivity, particularly during the first 12 weeks of treatment, and importantly, differences persist with longer-term follow-up.
Citation Format: Ann Partridge, Yue Zheng, Shoshana Rosenberg, Richard Gelber, Shari Gelber, William Barry, Chau Dang, Denise Yardley, Steven Isakoff, Vicente Valero, Meredith Faggen, Therese Mulvey, Ron Bose, Douglas Weckstein, Antonio Wolff, Katherine Reeder-Hayes, Hope Rugo, Bhuvaneswari Ramaswamy, Dan Zuckerman, Lowell Hart, Vijayakrishna Gadi, Michael Constantine, Kit Cheng, Frederick Briccetti, Bryan Schneider, Merrill Garrett, P. Kelly Marcom, Kathy Albain, Patricia Defusco, Nadine Tung, Blair Ardman, Rita Nanda, Rachel Jankowitz, Michelle DeMeo, Harold Burstein, Eric P. Winer, Ian Krop, Sara Tolaney. Patient reported outcomes from the adjuvant trastuzumab emtansine (T-DM1) vs. paclitaxel + trastuzumab (TH) (ATEMPT) trial (TBCRC 033) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD10-02.
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Affiliation(s)
| | - Yue Zheng
- 1Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | - Chau Dang
- 2Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Ron Bose
- 6Washington University School of Medicine, St. Louis, MO
| | | | | | | | - Hope Rugo
- 9Helen Diller Comprehensive Cancer Center, University of California, San Francisco, CA
| | | | - Dan Zuckerman
- 11St. Luke's Mountain States Tumor Institute, Boise, ID
| | - Lowell Hart
- 12Florida Cancer Specialists and Wake Forest School of Medicine, Ft. Meyers, FL
| | | | | | - Kit Cheng
- 13Northwell Health, Lake Success, NY
| | | | - Bryan Schneider
- 14Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
| | | | | | - Kathy Albain
- 17Loyola University Stritch School of Medicine, Chicago, IL
| | | | - Nadine Tung
- 19Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | | | - Ian Krop
- 1Dana-Farber Cancer Institute, Boston, MA
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9
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Ghobrial IM, Liu C, Zavidij O, Azab AK, Baz R, Laubach JP, Mishima Y, Armand P, Munshi NC, Basile F, Constantine M, Vredenburgh J, Boruchov A, Crilley P, Henrick PM, Hornburg KTV, Leblebjian H, Chuma S, Reyes K, Noonan K, Warren D, Schlossman R, Paba‐Prada C, Anderson KC, Weller E, Trippa L, Shain K, Richardson PG. Phase I/II trial of the CXCR4 inhibitor plerixafor in combination with bortezomib as a chemosensitization strategy in relapsed/refractory multiple myeloma. Am J Hematol 2019; 94:1244-1253. [PMID: 31456261 DOI: 10.1002/ajh.25627] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 11/11/2022]
Abstract
We tested the hypothesis that using CXCR4 inhibition to target the interaction between the tumor cells and the microenvironment leads to sensitization of the tumor cells to apoptosis. Eligibility criteria included multiple myeloma (MM) patients with 1-5 prior lines of therapy. The purposes of the phase I study were to evaluate the safety and maximal-tolerated dose (MTD) of the combination. The treatment-related adverse events and response rate of the combination were assessed in the phase II study. A total of 58 patients were enrolled in the study. The median age of the patients was 63 years (range, 43-85), and 78% of them received prior bortezomib. In the phase I study, the MTD was plerixafor 0.32 mg/kg, and bortezomib 1.3 mg/m2 . The overall response rate for the phase II study was 48.5%, and the clinical benefit rate 60.6%. The median disease-free survival was 12.6 months. The CyTOF analysis demonstrated significant mobilization of plasma cells, CD34+ stem cells, and immune T cells in response to plerixafor. This is an unprecedented study that examines therapeutic targeting of the bone marrow microenvironment and its interaction with the tumor clone to overcome resistance to therapy. Our results indicate that this novel combination is safe and that the objective response rate is high even in patients with relapsed/refractory MM. ClinicalTrials.gov, NCT00903968.
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Affiliation(s)
- Irene M. Ghobrial
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Chia‐Jen Liu
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Oksana Zavidij
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Abdel K. Azab
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
- Department of Radiation OncologyCancer Biology Division, Washington University School of Medicine St. Louis, Missouri
| | - Rachid Baz
- Department of Malignant HaematologyH. Lee Moffitt Cancer Center and Research Institute Tampa, Florida
| | - Jacob P. Laubach
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Yuji Mishima
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Philippe Armand
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Nikhil C. Munshi
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Frank Basile
- Department of Medical OncologyDavenport‐Mugar Cancer Center, Cape Cod Hospital Hyannis Massachusetts
| | - Michael Constantine
- Department of Medical OncologyDana‐Farber/Brigham and Women's Cancer Center, Milford Regional Medical Center Milford Massachusetts
| | - James Vredenburgh
- Department of Medical OncologySaint Francis Hospital and Medical Center Hartford Connecticut
| | - Adam Boruchov
- Department of Medical OncologySaint Francis Hospital and Medical Center Hartford Connecticut
| | - Pamela Crilley
- Department of Medical OncologyCancer Treatment Centers of America, Eastern Regional Medical Center Philadelphia Pennsylvania
| | - Patrick M. Henrick
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Kalvis T. V. Hornburg
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Houry Leblebjian
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Stacey Chuma
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Kaitlen Reyes
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Kimberly Noonan
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Diane Warren
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Robert Schlossman
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Claudia Paba‐Prada
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Kenneth C. Anderson
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Edie Weller
- Department of Biostatistics and Computational BiologyDana‐Farber Cancer Institute Boston Massachusetts
| | - Lorenzo Trippa
- Department of Biostatistics and Computational BiologyDana‐Farber Cancer Institute Boston Massachusetts
| | - Kenneth Shain
- Department of Malignant HaematologyH. Lee Moffitt Cancer Center and Research Institute Tampa, Florida
| | - Paul G. Richardson
- Medical Oncology, Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
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10
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Barroso-Sousa R, Luis IMVD, Di Meglio A, Hu J, Rees R, Sinclair NF, Milisits L, Leone JP, Constantine M, Faggen MG, Briccetti F, Block CC, Partridge AH, Burstein HJ, Waks AG, Trippa L, Tolaney SM, Hassett MJ, Winer EP, Lin NU. Avoiding peg-filgrastim (Peg-F) prophylaxis during the paclitaxel (T) portion of the dose-dense (DD) doxorubicin-cyclophosphamide (AC)-T regimen: A prospective study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
517 Background: Use of growth factors (GF) adds considerable expense and some toxicity to adjuvant breast cancer chemotherapy. We tested the feasibility and safety of omitting routine GF use during the T portion of DD AC-T. Methods: This is a prospective, single-arm study in which patients (pts) who completed 4 cycles of DD-AC proceeded to DD-T 175 mg/m2 every two weeks (wks) without routine GF (NCT02698891). Key inclusion: age≤ 65, ECOG PS≤1, absolute neutrophil count (ANC) ≥1500/mm3, and no febrile neutropenia (FN) during DD-AC. Criteria to treat for T included ANC ≥1000/mm3. Peg-F was given only if pts had FN in a prior cycle, or at investigator discretion if infection or treatment delay > 1 wk. Once Peg-F was given, pts received it in all future cycles. The primary endpoint was the rate of T completion ≤ 7 wks from cycle 1 day 1 (C1D1) to C4D1. Secondary endpoints included total use of Peg-F, rates of hematologic toxicity and FN, reasons for dose modification or hold. If ≥85% of pts completed T on time, the regimen would be considered feasible. If the true on-time completion rate is 75%, the chance the regimen would be declared infeasible is 91%, and if it is 85% the chance that the regimen is falsely declared infeasible is 10% (power = 0.899). ≥100/125 pts had to complete T on time for the regimen to be deemed successful. Results: Among 127 pts enrolled, 125 received ≥1 dose of protocol therapy and are included in the analysis. Median age at registration was 46 (range 21-65). Median C1D1 ANC was 7500/mm3 (range 1500-20500). 112 (90%) (95% CI 83-94%) pts completed DD-T ≤ 7 wks, and 3 (2%) completed within > 7 wks (2 due to neutropenia); 10 (8%) did not complete all cycles of T. Omission of Peg-F was not causally related to non-completion of T in any pts. The most common reasons for dose reduction or delays were non-hematologic. One pt had FN but was able to complete T on time. Eight (6.4%) pts received Peg-F during the trial. Conclusions: Omission of routine GF use during DD-T according to a pre-specified algorithm appears safe, feasible, and was associated with a 95.7% reduction in use of Peg-F, relative to the current standard of care. Additional analyses including cost implications are ongoing. Clinical trial information: NCT02698891.
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Affiliation(s)
| | | | | | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | - Frederick Briccetti
- Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, NH
| | | | | | | | | | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
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Ng K, Nimeiri HS, McCleary NJ, Abrams TA, Yurgelun MB, Cleary JM, Rubinson DA, Schrag D, Miksad R, Bullock AJ, Allen J, Zuckerman D, Chan E, Chan JA, Wolpin BM, Constantine M, Weckstein DJ, Faggen MA, Thomas CA, Kournioti C, Yuan C, Ganser C, Wilkinson B, Mackintosh C, Zheng H, Hollis BW, Meyerhardt JA, Fuchs CS. Effect of High-Dose vs Standard-Dose Vitamin D3 Supplementation on Progression-Free Survival Among Patients With Advanced or Metastatic Colorectal Cancer: The SUNSHINE Randomized Clinical Trial. JAMA 2019; 321:1370-1379. [PMID: 30964527 PMCID: PMC6459117 DOI: 10.1001/jama.2019.2402] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In observational studies, higher plasma 25-hydroxyvitamin D (25[OH]D) levels have been associated with improved survival in metastatic colorectal cancer (CRC). OBJECTIVE To determine if high-dose vitamin D3 added to standard chemotherapy improves outcomes in patients with metastatic CRC. DESIGN, SETTING, AND PARTICIPANTS Double-blind phase 2 randomized clinical trial of 139 patients with advanced or metastatic CRC conducted at 11 US academic and community cancer centers from March 2012 through November 2016 (database lock: September 2018). INTERVENTIONS mFOLFOX6 plus bevacizumab chemotherapy every 2 weeks and either high-dose vitamin D3 (n = 69) or standard-dose vitamin D3 (n = 70) daily until disease progression, intolerable toxicity, or withdrawal of consent. MAIN OUTCOMES AND MEASURES The primary end point was progression-free survival (PFS) assessed by the log-rank test and a supportive Cox proportional hazards model. Testing was 1-sided. Secondary end points included tumor objective response rate (ORR), overall survival (OS), and change in plasma 25(OH)D level. RESULTS Among 139 patients (mean age, 56 years; 60 [43%] women) who completed or discontinued chemotherapy and vitamin D3 (median follow-up, 22.9 months), the median PFS for high-dose vitamin D3 was 13.0 months (95% CI, 10.1 to 14.7; 49 PFS events) vs 11.0 months (95% CI, 9.5 to 14.0; 62 PFS events) for standard-dose vitamin D3 (log-rank P = .07); multivariable hazard ratio for PFS or death was 0.64 (1-sided 95% CI, 0 to 0.90; P = .02). There were no significant differences between high-dose and standard-dose vitamin D3 for tumor ORR (58% vs 63%, respectively; difference, -5% [95% CI, -20% to 100%], P = .27) or OS (median, 24.3 months vs 24.3 months; log-rank P = .43). The median 25(OH)D level at baseline for high-dose vitamin D3 was 16.1 ng/mL vs 18.7 ng/mL for standard-dose vitamin D3 (difference, -2.6 ng/mL [95% CI, -6.6 to 1.4], P = .30); at first restaging, 32.0 ng/mL vs 18.7 ng/mL (difference, 12.8 ng/mL [95% CI, 9.0 to 16.6], P < .001); at second restaging, 35.2 ng/mL vs 18.5 ng/mL (difference, 16.7 ng/mL [95% CI, 10.9 to 22.5], P < .001); and at treatment discontinuation, 34.8 ng/mL vs 18.7 ng/mL (difference, 16.2 ng/mL [95% CI, 9.9 to 22.4], P < .001). The most common grade 3 and higher adverse events for chemotherapy plus high-dose vs standard-dose vitamin D3 were neutropenia (n = 24 [35%] vs n = 21 [31%], respectively) and hypertension (n = 9 [13%] vs n = 11 [16%]). CONCLUSIONS AND RELEVANCE Among patients with metastatic CRC, addition of high-dose vitamin D3, vs standard-dose vitamin D3, to standard chemotherapy resulted in a difference in median PFS that was not statistically significant, but with a significantly improved supportive hazard ratio. These findings warrant further evaluation in a larger multicenter randomized clinical trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01516216.
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Affiliation(s)
- Kimmie Ng
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Halla S. Nimeiri
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | | | | | | | | | | | | | - Rebecca Miksad
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | - Dan Zuckerman
- St Luke’s Mountain States Tumor Institute, Boise, Idaho
| | - Emily Chan
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | | | | | | | - Chen Yuan
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | | | | | - Hui Zheng
- Massachusetts General Hospital, Boston
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12
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Ng K, Nimeiri HS, McCleary NJ, Abrams TA, Yurgelun MB, Cleary JM, Rubinson DA, Schrag D, Allen JN, Zuckerman DS, Miksad RA, Chan E, Constantine M, Weckstein D, Faggen MG, Thomas CA, Kournioti CS, Mackintosh C, Zheng H, Fuchs CS. SUNSHINE: Randomized double-blind phase II trial of vitamin D supplementation in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.3506] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3506 Background: In prospective observational studies of mCRC patients, higher plasma levels of 25-hydroxyvitamin D have been associated with improved progression-free (PFS) and overall survival (OS), but the role of vitamin D supplementation in the treatment of mCRC is unknown. Methods: SUNSHINE was a multi-center double-blind phase II randomized controlled trial in previously untreated mCRC patients. Patients were eligible if they had histologically confirmed mCRC, no prior therapy for metastatic disease, ECOG PS 0-1, and were not taking vitamin D >2,000 IU/day x 1 year. All subjects received standard treatment with mFOLFOX6 + bevacizumab with 1:1 randomization to concurrent: HiVitD (vitamin D3 po 8,000 IU/d x 2 wks as loading dose followed by 4,000 IU/d) or LowVitD (standard vitamin D3 400 IU/d) until disease progression, intolerable toxicity, or withdrawal of consent. The primary endpoint was PFS, with the sample size designed to provide 80% power to detect a HR of 0.66 for PFS at a 1-sided alpha=0.2. Results: From April 2012 to November 2016, 139 patients were randomized. Median age was 54 yrs (range 24-82), 57% were male, 77% were white, and 7% had received prior adjuvant chemo. Baseline characteristics were balanced between arms except ECOG PS = 0 was 42% vs. 60% in HiVitD vs. LowVitD. Median follow-up was 16.1 mos (range 0-45.9) and median compliance with VitD capsules was 98%. Patients randomized to HiVitD experienced longer PFS than those receiving LowVitD (median PFS, 12.4 vs. 10.7 mos, respectively; log rank P=0.03). After multivariate adjustment for prognostic variables, HR was 0.66 (95% CI, 0.45-0.99, 2-sided P=0.04). Comparing HiVitD vs LowVitD, RR was 58% vs. 63% ( P=0.54) and disease control rate was 100% vs. 94% ( P=0.05). The most common grade 3-4 toxicities were as expected for FOLFOX-bevacizumab, and none were related to vitamin D. Currently, 14 patients are still actively receiving treatment, and OS data are not yet mature. Conclusion: SUNSHINE met its prespecified primary endpoint, with patients randomized to HiVitD experiencing longer PFS compared to those randomized to LowVitD. A larger confirmatory phase III randomized trial appears warranted. Clinical trial information: NCT01516216.
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Affiliation(s)
- Kimmie Ng
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | - Emily Chan
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | | | | | - Hui Zheng
- Massachusetts General Hospital, Boston, MA
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Kostka J, Zerillo JA, Kruse A, Sinclair NF, Patrick M, McGovern L, Fuller F, O'Neil K, Hixon N, Weeks K, Johnson BE, Krop IE, Savoie J, Daftary F, Constantine M, Kaddis MS, Rossi HA, Tahir N, Norden AD. Clinical trial enrollment expansion to the community. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.7_suppl.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
112 Background: Oncology patients at community cancer practices generally do not access clinical trials to the same degree as patients at academic medical centers. Collaborations between research and clinical teams across academic hospitals and their affiliated community sites may help to improve this disparity. Methods: To improve clinical trial enrollment, a multidisciplinary team of research and clinical staff from the Dana-Farber Cancer Institute main campus and a community-based satellite site implemented a program to enhance identification of breast cancer patients eligible for clinical trials. The team constructed a process map, cause and effect diagram and collected diagnostic data, which was displayed with a Pareto chart. Process control charts were used to track data over time. Interventions included: (1) a web-based tool to pre-screen patients for community and main campus trials, (2) a training session for clinicians on trial communication skills, (3) designated clinician visits for follow-up trial discussions, and (4) research nurse telephone calls after the initial consultation. Results: Before the program (7/14-10/14), research staff screened 83% of new breast cancer patients for clinical trials, which increased to 97% after the program (11/14-9/15) (p < 0.001). There was not a significant change in trials presented to eligible patients or enrollment in trials. Conclusions: The proportion of patients identified for clinical trials increased and there was numeric improvement in the proportion of eligible patients presented trials. There was an increase in clinical trial enrollment that did not reach statistical significance, possibly due to the low sample size. These results suggest that the interventions would benefit from further modification and use. The project demonstrates the challenges and opportunities inherent in growing successful clinical trial programs in community-based satellite sites. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | - Frances Fuller
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Milford Regional Medical Center, Milford, MA
| | | | | | | | | | | | - Jen Savoie
- Dana-Farber Cancer Institute, Boston, MA
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14
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Dalby CK, Thiele J, Walsh JH, Fuller F, Constantine M, Burke R, Faggen M, Gilchrist H, Norden AD, Kostka J, Jacobson JO. Challenges of implementing the ASCO/ONS oral chemotherapy standards in a community practice network. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.30_suppl.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
93 Background: In March 2013, The American Society of Clinical Oncologists and the Oncology Nursing Society published standards for the safe administration of oral chemotherapy. Gap analysis at Dana-Farber Cancer Institute (DFCI) Satellites revealed opportunities in planning, education, and monitoring of patients prescribed oral chemotherapy. As a quality improvement initiative, the DFCI Satellites designed and implemented a multidisciplinary approach to oral chemotherapy administration. Methods: The Model for Improvement was employed. A process map highlighted gaps in oral chemotherapy. Several improvement opportunities were identified. 1) Pharmacists developed oral chemotherapy treatment algorithms in the EMR. 2) Providers adapted the parenteral chemotherapy treatment plan (CTP) for use with oral chemotherapy. 3) A nursing education program was created, and implemented following completion of the CTP and consent. 4) Continuous monitoring for toxicity and adherence was initiated by providers via clinic visits and telephone screening. Results: Monthly compliance reports measured CTP completion, consent, initial education, and monitoring for adherence. Aggregated rates indicate practice variability. Some sites perform well, while others continue to show room for improvement. Conclusions: Developing a process for oral chemotherapy is challenging. Systems are not set up for oral drug safety. Although we had success with introduction of the intervention, results have not yet demonstrated sufficient reliability. System limitations and human factor challenges have impeded progress. Given the risk potential of oral chemotherapy, adopting a robust process to deliver oral chemotherapy is essential for safe patient care. Oral chemotherapy administration is a work in progress that must be refined to achieve high reliability. [Table: see text]
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Affiliation(s)
| | | | | | - Frances Fuller
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Michael Constantine
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Milford Regional Medical Center, Milford, MA
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15
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McFadden B, Constantine M, Rogers R, Dunivan G, Hammil S, Sussman A, Romero A, Abed H, Kenton K, Sung V. Surgical Consent Factors That Influence Risk Recall for Midurethral Sling Surgery. J Minim Invasive Gynecol 2014. [DOI: 10.1016/j.jmig.2013.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gross A, Mann S, Weingart S, Kalfin M, Norden AD, Buswell LA, Constantine M, Fuller F, Briccetti F, Thiele J, Freter R, Kostka J, Sherwood GK, O'Connor J, Bunnell CA. Disseminating team training across an academic cancer center and community-based satellites. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
188 Background: Dana-Farber Cancer Institute is the first cancer center to implement Team Training (TT). This program illustrates critical lessons about disseminating a quality improvement initiative across an academic center and its regional community-based satellites. Methods: We adapted TT principles to the needs of our satellite centers. This required recognizing different work flows and communication patterns, identifying hazards in routine communications, integrating satellite-main campus communication, and facilitating situational awareness when practicing at multiple sites. Key components included: support from executive leadership and Board of Trustees; previous success at the main campus; use of data and actual near-miss scenarios; development of workflows for critical communications; and workflows for shared care of patients at different sites. Results: Staff surveys demonstrated safer, more efficient, and more respectful practice environments. Higher scores were seen across most categories in comparison to main campus. We observed an increase in the number of chemotherapy orders without issues (81.7% to 91.9%) and a decrease in the number of missing (7.0% to 3.4%) or noncommunicated order changes (3.1% to 1.0%) when the patient arrived for treatment pre TT vs. post TT. Patient perception of teamwork, measured by Press-Ganey, showed a statistically significant increase at both the main and satellite campuses. Conclusions: TT improved communication, task coordination, perceptions of efficiency, quality, safety, and patient perception of care coordination, at both the academic main campus and our community-based satellite practices. [Table: see text]
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Affiliation(s)
- Anne Gross
- Dana-Farber Cancer Institute, Boston, MA
| | - Susan Mann
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | - Michael Constantine
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Frances Fuller
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Frederick Briccetti
- Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, NH
| | | | - Rolf Freter
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center in Clinical Affiliation with South Shore Hospital, South Weymouth, MA
| | | | | | - Janet O'Connor
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Faulkner Hospital, Boston, MA
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17
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Norden AD, Buswell LA, Amorati M, Arthur L, Bernard A, Constantine M, Dalby C, Farrar W, Fuller F, Kerivan D, Lacourse K, McNulty BD, Racicot A, Spinks M, Jacobson JO, Ponte PR, Shulman LN. Wait time reduction for patients awaiting chemotherapy infusion using a formal process improvement approach and sequential. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.34_suppl.92] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
92 Background: At a community hospital satellite of an academic cancer center, baseline data indicated that 49% of patients waited longer than 30 minutes from arrival in the treatment chair until treatment was started, resulting in dissatisfaction and decreased chair turnover. Methods: A team was assembled, including physicians, nurses, pharmacists, and administrative staff. The team constructed a detailed process flow map and performed a cause-and-effect analysis. Wait time data were collected using the electronic scheduling system and time sheets. Additionally, nurses used a structured data collection sheet to categorize the reasons for prolonged wait times. A p-type statistical process control chart was constructed to track the proportion of infusion visits per day with wait times longer than 30 minutes. The team brainstormed process improvements and selected ones to implement by employing a priority/pay-off matrix. Results: Baseline data were assessed for 403 visits over a 3 week period. Of 232 visits with wait times longer than 30 minutes, 98 (42%) involved excessive waiting for the physician to see the patient or write orders. One of 4 physicians was responsible for 56 (57%) of these. This physician’s patients were seen exclusively in the infusion room, while the other physicians saw patients in the exam room before sending them to the infusion area. Three PDSA cycles were conducted: (1) All physicians started seeing patients in the exam room before sending them to infusion chairs, (2) Specific treatments were selected that could be routinely administered without the physician seeing the patient, and (3) A reminder system prompted physicians to enter treatment orders within 24 hours of each patient’s visit. After 6 months, 29% of patients waited longer than 30 minutes, down from 49% at baseline. Conclusions: These interventions implemented using PDSA cycles successfully reduced wait times. Measurement and presentation of data were critical in persuading physicians to practice in a more homogeneous fashion.
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Affiliation(s)
| | | | - Meg Amorati
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Lois Arthur
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Antoinette Bernard
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Michael Constantine
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | | | - Wendy Farrar
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Frances Fuller
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Dawn Kerivan
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Kristin Lacourse
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Brendan D. McNulty
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
| | - Adonica Racicot
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center at Milford Regional Medical Center, Milford, MA
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18
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Joyce R, Fenton MA, Rode P, Constantine M, Gaynes L, Kolvenbag G, DeWolf W, Balk S, Taplin ME, Bubley GJ. High dose bicalutamide for androgen independent prostate cancer: effect of prior hormonal therapy. J Urol 1998; 159:149-53. [PMID: 9400459 DOI: 10.1016/s0022-5347(01)64039-4] [Citation(s) in RCA: 160] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE A pilot study of the antiandrogen bicalutamide at 150 mg. a day for androgen independent prostate cancer was performed. This study was based on the possibility that androgen independent cases might display responses to additional hormonal agents. MATERIALS AND METHODS The study included 31 androgen independent cases with an increasing prostate specific antigen (PSA) and progressive disease. PSA measurements were used as the primary method of assessing response. However, PSA decline was also correlated with clinical status. RESULTS Seven patients demonstrated PSA declines of greater than 50% for 2 months or more, for an overall response rate of 22.5%. Responses were observed almost exclusively in patients treated with long-term flutamide as part of a complete androgen blockade regimen (43% response rate) in contrast to patients treated with androgen deprivation without flutamide (6% response rate). Of the 7 PSA responding patients bicalutamide resulted in a significant improvement in performance status and a decrease in analgesic requirement in 4 and 3 remained asymptomatic. Bicalutamide at 150 mg. a day was well tolerated, with the most frequent side effect being mild exacerbation of hot flashes. CONCLUSIONS Bicalutamide at this dose is modestly effective for some patients with androgen independent prostate cancer, particularly for those previously treated with long-term flutamide. This study indicates that previous antiandrogen therapy alters the response to subsequent hormonal agents.
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Affiliation(s)
- R Joyce
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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19
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Epstein AM, Hall JA, Fretwell M, Feldstein M, DeCiantis ML, Tognetti J, Cutler C, Constantine M, Besdine R, Rowe J. Consultative geriatric assessment for ambulatory patients. A randomized trial in a health maintenance organization. JAMA 1990; 263:538-44. [PMID: 2294326] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Previous studies have shown that comprehensive geriatric assessment and follow-up can improve the health of hospitalized elderly patients. To evaluate the effectiveness of consultative geriatric assessment and limited follow-up for ambulatory patients, we randomized 600 elderly patients who were enrolled in a health maintenance organization into three groups: (1) consultation by a geriatric assessment team, (2) consultation by a "second opinion" internist, and (3) only traditional health maintenance organization services (control patients). The geriatric assessment team identified previously unrecognized problems in 35% of patients and advised changes in medication regimens for more than 40%. Nevertheless, patients who received assessment achieved only a small benefit in cognitive function after 3 months, which was not sustained for 1 year. There was no difference among groups in other measures of health status. Consultative geriatric assessment with limited follow-up did not benefit most older ambulatory patients in a health maintenance organization; if such care can be used effectively for ambulatory patients, it will require either additional targeting or continuing care or both.
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Affiliation(s)
- A M Epstein
- Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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Vickery DM, Kalmer H, Lowry D, Constantine M, Wright E, Loren W. Effect of a self-care education program on medical visits. JAMA 1983; 250:2952-6. [PMID: 6358552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A prospective, randomized, controlled trial of self-care educational interventions was conducted in a health maintenance organization to determine their effect on ambulatory care utilization. Statistically significant decreases in total medical visits and minor illness visits were found in each of three experimental groups as compared with a control group. These decreases averaged 17% and 35%, respectively. These results were most clearly linked to a system of written communications emphasizing personal decision making about the use of medical care. The addition of a nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent ona nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent on the educational interventions. Self-care education systems may have important effects on medical care costs, physician satisfaction, and patient confidence.
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