Adjuvant Systemic Therapies in Patients with Colorectal Cancer: An Audit on Clinical Practice in Italy

Aims and Background

Rarely are conclusions from clinical trials summarized in international consensus conferences and promptly transferred to patient care. The adjuvant therapy for colorectal cancer used in daily clinical practice in Italy is described and compared with the recommendations of the 1990 NIH Consensus Conference.

Patients and Methods

We audited prescriptions of adjuvant systemic therapies for Italian colorectal cancer patients in 82 centers during a fixed one-week period.

Results

Among 434 patients receiving adjuvant chemotherapy there were 139 (42.5%) colon cancer patients with N- and 169 (51.7%) with N+ regional nodal involvement. Treatment at academic centers, a young age, T4 and a low total number of lymph nodes removed at surgery were the factors potentially justifying the decision for adjuvant chemotherapy in stage II colon cancer patients. The most common chemotherapy used was a bolus of 5-fluorouracil/folinic acid for 6 months (75.8%). Adjuvant radiotherapy was not administered to 37 (38.5%) of 96 patients with stage II and III rectal cancer.

Conclusions

The study shows that a substantial proportion of patients on adjuvant treatment at a certain time point in a large enough sample of Italian centers are stage II (potential over-treatment) and that an under-treatment of stage II and III rectal cancer patients (lack of radiotherapy) occurs too often in daily clinical practice in this country.

Adjuvant trastuzumab cardiotoxicity in patients over 60 years of age with early breast cancer: a multicenter cohort analysis

BACKGROUND

Adjuvant Trastuzumab with chemotherapy is the gold standard for human epidermal growth factor receptor 2 (HER2)-positive early breast cancer (HER2+ EBC). Older patients have been largely under-represented in clinical trials, and few data on Trastuzumab cardiotoxicity have been reported in this subgroup.

PATIENTS AND METHODS

Four hundred and ninety-nine consecutive HER2+ EBC patients were treated with adjuvant trastuzumab and chemotherapy (aTrastC) at 10 Italian institutions. We evaluated disease prevalence and patient characteristics in the patients older than 60 years of age (over-60), prevalence of aTrastC cardiotoxicity and risk factors.

RESULTS

There were 160 'over-60' patients (32%), in whom a higher prevalence of hypertension, diabetes, renal dysfunction, dyslipidemia and treatment with ACEi (40 versus 8%) and beta blockers (20 versus 8%) was found than in the younger patients (339 = 68%). Clinical heart failure occurred in 6% of the 'over-60' and in 2% of the younger patients. A reduction in left ventricular ejection fraction of >10 points was detected in 33% of the 'over-60' and in 23% of the younger patients (all P < 0.05). aTrastC was discontinued in 10% of the 'over-60' and in 4% of the younger patients (P = 0.003), restarted in 44% of the 'over-60' and in 58% of the younger women (P = ns).

CONCLUSION

In clinical practice, 32% of HER2+ EBC patients treated with aTrastC are 'over-60'. These patients have an increased cardiovascular risk profile and develop aTrastC cardiotoxicity commonly.

An induction dose of epoetin alpha of 40 000 IU daily for three consecutive days increases and maintains hemoglobin levels in anemic cancer patients undergoing chemotherapy

BACKGROUND

This pilot study was conducted to evaluate the feasibility, activity, and safety of an induction dose of epoetin alpha in cancer patients with moderate or severe anemia who were receiving chemotherapy.

PATIENTS AND METHODS

Thirty patients with solid tumors and hemoglobin (Hb) levels <11.0 g/dl were enrolled. Patients received single s.c. injections of epoetin alpha, 40 000 IU for three consecutive days, and were then observed for the following 30 days. The primary efficacy variable was the response rate (Hb increase > or=1 g/dl) at day 15. Secondary efficacy variables included the proportion of patients given blood transfusions between baseline and the end of study, the duration of response (Hb level > or=1 g/dl), and ability to maintain the planned chemotherapy dose (dose intensity).

RESULTS

At day 15, 23 of 30 (77%) patients had achieved increases in Hb levels of at least 1 g/dl. The mean Hb increase in responders was 2.0 g/dl [95% confidence interval (CI) = 1.7-2.3 g/dl]. The Hb increase was 2.3 +/- 0.7 g/dl in responders with baseline Hb levels <9.5 g/dl (median Hb value), and 1.7 +/- 0.6 g/dl in those with higher Hb levels (P = 0.012). The median duration of response was 6.1 weeks (95% CI = 1.6-10.6 weeks). Hematologic parameters were not significantly changed in nonresponders. Multivariate analysis detected no significant differences in Hb increase at day 15 on the basis of age, sex, weight, baseline Hb levels, type or stage of tumor, or treatment with platinum-based chemotherapy. No serious adverse event related to epoetin alpha treatment was observed.

CONCLUSIONS

We conclude that a higher initial dosing of epoetin alpha appears to be an efficient schedule for treating anemia in cancer patients undergoing chemotherapy, conferring higher response rates than those seen with standard doses. Further evaluation of these and other epoetin alpha dosage regimens is warranted.

Exemestane (Exe) as primary treatment in hormonosensible early breast cancer of the elderly: Preliminary results of a phase II multicenter open Italian study

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Background: In the late 90s two large phase III trials (GRETA & CRC) showed that tamoxifen as sole treatment was a possible alternative to surgery in old women. Two Phase III neoadjuvant trials showed recently that letrozole is superior and anastrozole is not inferior to tamoxifen.A few phase II and a small fase III trials showed interesting results also with the steroidal inactivator exemestane. Methods: We are running a fase II open trial in early breast cancer patients aged over 70 with receptor rich tumors, treated with exemestane 25 mgs/day for 6 months before surgery. Primary endpoints are clinical response, breast conservative surgery (BCS) rate and safety. Results: Of the planned 100 patients we report preliminary results on 50 patients (mean age 81 , range 70–92) evaluable for clinical and mammographic response. 33/50 had a partial response (66%), 2/50 PD on treatment. Clinical basal mean size of tumors was 4.4 cms (4,81 in responders) and 2,67 cms the final in responders patients. Eight patients refused surgery, 12 are too early, 23/30 underwent BCS where 17 of them (74%) were unfit for BCS at basal evaluation. No remarcable exemestane related toxicity was recorded. Conclusions: As expected from published data of phase III trials in metastatic and adjuvant setting, exemestane appears to be very active also in the neoadjuvant setting. Probably there is no more need of large phase III trials in order to consider exemestane in the preoperative setting in rich receptor tumors. In old and frail patients this could also be considered as sole treatment.

[Table: see text]

Tamoxifen alone versus adjuvant tamoxifen for operable breast cancer of the elderly: long-term results of the phase III randomized controlled multicenter GRETA trial

BACKGROUND

To evaluate the efficacy of tamoxifen as primary treatment in women aged over 70 years with operable breast cancer versus surgery followed by adjuvant tamoxifen.

PATIENTS AND METHODS

Patients randomly received tamoxifen alone (160 mg day 1, then 20 mg/day) for 5 years or surgery followed by tamoxifen (20 mg/day) for 5 years. Overall survival was the main study end point; secondary objectives included breast cancer survival and local control of the disease.

RESULTS

Between 1987 and 1992, 239 patients were assigned to surgery plus tamoxifen and 235 to tamoxifen alone. Treatment arms were comparable for tumor size, clinical nodal status and performance status. At a median follow-up of 80 months 274 patients had died. No difference between groups had emerged in overall and breast cancer survival. There were 27 local progressions in the surgery plus tamoxifen group and 106 in the tamoxifen-alone group (P = 0.0001). In the surgery plus tamoxifen group, no difference in overall survival had emerged according to the extension of operation.

CONCLUSIONS

The long-term results of the study confirm the 3-year interim analysis already reported. Surgery (radical or minimal) followed by adjuvant tamoxifen does not modify overall and breast cancer survival as compared with tamoxifen alone in early breast cancer of older women. Because of the high rate of local progressions with tamoxifen alone, minimal surgery followed by tamoxifen appears to be the appropriate treatment in such patients. More extensive surgery is not useful. Tamoxifen alone is an adequate alternative treatment in very old or frail patients.

A phase II study of cisplatin and vinorelbine in patients with metastatic breast cancer

BACKGROUND

To evaluate the efficacy and safety of the combination of cisplatin and vinorelbine in metastatic breast cancer.

PATIENTS AND METHODS

Cisplatin (80 mg/m(2) day 1) and vinorelbine (25 mg/m(2) days 1 and 8) were administrated every 3 weeks to 52 patients (mean age 57 years; range 35-75 years) with metastatic breast cancer. Thirty-two patients were previously untreated for metastatic disease. Treatment was repeated for a maximum of six cycles.

RESULTS

Objective responses were obtained in 27 patients (52.9%; complete response 9.8%). The response rate was similar in pretreated and untreated patients (50% and 54.7%, respectively; P = 0.7). ECOG performance status was good (grade 0 or 1) in 55.7% of patients at baseline assessment and in 90.3% at the end of treatment (P = 0.0001). Median time to progression was 8.5 months (8.5 months in first-line and 8.7 months in second-line patients). Median survival was 16.6 months (21.2 months in first-line and 16.1 months in second-line patients). Grade 3/4 toxicity included neutropenia (44% in first-line, 60% in second-line patients), nausea (17.3%), anemia (17%), asthenia (3.8%) and thrombocytopenia (1.9%). There were no cases of febrile neutropenia or treatment-related deaths. Alopecia did not develop in any of the patients.

CONCLUSIONS

Cisplatin plus vinorelbine is active and tolerable in metastatic breast cancer, in untreated and pretreated patients.

La Gastroprotezione Nel Paziente Oncologico: Approccio Razionale, Ruolo Dei Farmaci Antisecretori Ed Eventuali Ulteriori Prospettive in Oncologia

In view of the large number of cancer patients treated with FANS and/or corticosteroids for long periods of time, Authors discuss how the use of antisecretory drugs for gastroprotection has become common practice in spite of the lack of clear scientific evidence. The paper analyses the principal mechanisms of gastrotoxicity of FANS, essentially associated with the inhibition of prostaglandins and consequent reduction of the secretion of mucous and bicarbonate. It also discusses the numerous controlled trials evaluating the efficacy of ranitidine for gastroprotection versus placebo and versus the analogous synthetic substance, misoprostole, derived from prostaglandin E1. This analysis shows that misoprostole provides significant protection against both gastric and duodenal ulcers, whilst the antisecretory drug protects only against localised duodenal ulcer. The conclusion is that optimum protection against FANS is provided by misoprostole. In any case more than 30% of patients are destined to develop ulcerous or minor lesions for which treatment with antisecretory drugs is correct.

After analysis of the available literature on the gastrotoxicity of corticosteroids, it is clear that this risk is real only for a small sub-population of patients (treated in dual therapy with FANS, for long periods, with high doses or in presence of ulcer anamnesis). It is not known in these cases whether prophylactic treatment is suitable, nor which would be the best prophylactic treatment. In other cases the problem does not arise since the number of patients developing ulcers is similar with corticosteroids treatment or with placebo.

Some further interesting features of ranitidine compared to cimetidine (its better pharmacological profile due to the lack of side effects, lack of medullary depression, lack of interference with the immunological system, lack of antiandrogen effects) are also discussed.

Particularly interesting is the lack of interference with cyclophosphamide metabolism, such interference having shown for cimetidine.

Studies involving ranitidine treatment in association with Interleukin-2 for renal carcinoma and metastatic melanoma are also of interest although no statistically significant results are available as yet.

[Effectiveness of sequential administration of G-CSF and GM-CSF after antineoplastic chemotherapy in patients with advanced tumors: results of a randomized trial]

Recent in vitro data have shown that growth factors are more effective when used in combination. This synergy between cytokines, when translated in a clinical setting, should permit a reduction of dosage, and therefore of toxicity. We sought to determine whether the sequential administration of low doses of G-CSF followed by low doses of GM-CSF could be effective both in protecting from neutropenia, and in reducing side effects. A randomized single blind phase III study was carried out. Patients considered to be eligible for the study were designated to receive a minimum of 3 chemotherapy cycles for treatment of metastatic or locally advanced cancer. Patients were randomized to receive, from the 8th day to the 13th day of cycle, G-CSF, 2.5 micrograms/kg/day s.c., or G-CSF, 2.5 micrograms/kg/day s.c. for the first 3 days, followed by GM-CSF, 2.5 micrograms/kg/day s.c. for the last 3 days. The number of delays in relation to the number of cycles, the number of patients whose therapies were deferred, and the total number of days of delay in relation to the total number of days of observation were significantly different, with far fewer delays in the group treated with the G-GM sequence. Our study confirms that the sequential administration of G-CSF and GM-CSF is highly synergistic. This synergy allows clinicians to administer chemotherapy treatments to pre-treated and/or elderly patients, with minimal risk of toxicity and no need for delays or dosage reduction.

The combination of metoclopramide, methylprednisolone and ondansetron against antiblastic-delayed emesis: a randomised phase II study

The aim of the study was to verify whether the combination of an antiserotoninergic, metoclopramide, and a steroid could improve the complete control (CC) of delayed emesis, a contraversial issue, 105 patients undergoing highly-emetogenic chemotherapy, receiving Ondansetron (O) 8 mg + Dexamethasone 20 mg i.v. for the prevention of acute emesis, were randomly treated p.o for three further days with a) Metoclopramide 10 mg x 3 b) the same as a) + Methylprednisolone 4 mg c) the same as b) + O 8 mg x 3. CC (acute+delayed emesis) over three cycles was: a) 0.b) 12.5%, c) 38.5% (p = 0.02). Days with nausea/vomiting: 59%, 51%, 29.7% of the total observed period, respectively (b vs c p = 0.0000). CC of acute emesis was similar in the first cycle (about 85%), remained unchanged in the following cycles (c) and decreased to 30% and 68% in the third cycle (a and b) (p = 0.01). The three drug combination significantly improved complete control of acute and delayed emesis over successive chemotherapy cycles.

[Suicide in Italy 1955-1980: description and epidemiological analysis]

The alarming increase in the number of suicides among young people urges a number of researchers to try to find out the motivations that, by provoking a partial and temporary loss of the intellectual faculties, drive people to the self-injuring act. We believe it is significant to mention that the difference between males and females regarding suicide and attempted suicide (the first historically characteristical of the male sex, the second to the female sex) is getting less and less noticeable, owing to, probably, the equalization which is taking place between males and females. Since 1970, in fact, we have been witnessing the trend towards the increase of the female suicide, whereas the trend of the male suicide decreases; constantly until 1976, at the end of the time interval 1955-1980 the trend shows a slower increase of about 23.3% compared to the increase of suicide for the females. We have proof of this equalization taking place between males and females by examining the tendency of the "attempted suicide" phenomenon (table 3) which shows for the same interval of time an initial, steady increase for the female until 1969 and, after a decrease of less than one-third in 1970--in connection with the beginning of the trend towards the increase of the cases of female suicide for the same year--, it shows a steady decrease compared to the starting values of the beginning of the time interval. In 1980 the decrease of the cases of female "attempted suicide" is nearly identical to the decrease of the cases of male "attempted suicide"; (51.5% for the females, 53.8% for the males). A considerable contribution in trying to explain the reasons of this self-injuring action is being given by medicine that, thanks to the progresses in the intensive care area, has often allowed to transform a suicide into an attempted suicide, giving therefore the possibility of questioning thoroughly the people who tried to take their own life in order to understand better their motivations and the meaning of the action. An important element which suicides seem to have in common is the bivalence of the action, in fact, far from being ack of love towards oneself; it is, on one hand, an injury inflicted on other people, and on the other hand it is also--and very often it assumes a blackmail-like quality expressed in a rather aggressive--an appeal to them.(ABSTRACT TRUNCATED AT 400 WORDS)

[Yersinia enterocolitica: biotypes and serotypes isolated from horticultural products]

A survey has been carried out for the presence of Yersinia enterocolitica (Y.e.) in horticultural products. 100 samples of these vegetables have been examined among the families of Compositae (lettuce, prickly lettuce, cabbage lettuce, common chicory, artichoke), Umbrelliferae (curly parsley, carrot, celery, fennel), Cruciferae (garden cabbage, red radish), Liliaceae (onion), and Solanaceae (tomato). 12 strains have been recorded in carrots (serotype 0:6.30), 1 strain in curly parsley (0:4.32), 3 in celery (0:7.8 and 0:6.30), and 1 in red radish (NAG). 0:6.30--the most commonly serotype found in the horticultural products--can be of special significance in human pathology, since the reference strain (IP 102) has been first isolated from man; besides, 0:6.30 has been recovered from four cases of human infection, and represents the most frequently isolated serotype from humans in Canada, together with 0:3, 0:5.27 and 0:9. According to other Authors, in can be assumed that "environmental" strains of Y.e. may also acquire virulence and cause infection in man. Moreover, a high number of environmental biotypes in foods may mask the presence and recovery of such strains involved in human pathology.