P14.09 BORTEM-17: A Phase IB/II Single-Arm, Control Non-Randomized, Multicentre, Open Label Clinical Trial for Recurrent Glioblastoma with unmethylated MGMT promoter (NCT03643549)

BACKGROUND

Glioblastoma (GBM) is the most malignant primary brain tumor in adults where median survival in unselected patients is approximately 10 months. There is no standard treatment for patients who progress on temozolomide and patients are best treated within investigational clinical protocols. Patients harbouring tumours with functional O⁶ methylguanine DNA methyltransferase (MGMT) DNA repair enzyme have particularly poor prognosis with median overall survival of 12.7 months, compared to 21.7 months for patients with hypermethylated MGMT promoter. The pre-clinical studies have shown that Bortezomib depletes the MGMT enzyme, restoring the tumour ´s susceptibility to Temozolomide, if the chemotherapy is administered in the precise schedule when the MGMT enzyme is depleted. Additionally, Bortezomib shows an antitumour effect by blocking autophagy flux. Based on the promising pre-clinical results, a non-randomized, open label phase IB/II clinical trial was designed. The primary endpoints include assessment of safety of Bortezomib administered with Temozolomide for phase IB and median progression free survival, overall survival as well as progression free rate at 6 months.

MATERIAL AND METHODS

Recurrent glioblastoma patients with unmethylated MGMT promotor, progressing at least 12 weeks after completion of postoperative radiotherapy, with adequate organ function, performance status Karnofsky 70 or better and radiologically measurable lesions are screened for study inclusion. The experimental treatment consists of Bortezomib 1.3mg/m² administered IV on days 1, 4, 7, during each 4-week chemotherapy cycle with per oral Temozolomide at 200mg/m² 5 days/week every 4 weeks starting on day 3. Study group will be compared to historical controls on conventional management. The sample size was calculated to 63 patients, ten of them were included in the phase IB.

RESULTS

The phase IB of the trial was completed in 2019 and the combination of Temozolomide and Bortezomib was shown to be safe and well tolerated. Until April 2021 a total number of 23 patients were included into the trial. The patients are treated at 4 different referral university hospitals in Norway. A clinical treatment benefit with both radiological tumor volume response and stable disease were observed. The patient inclusion in the trial is delayed due COVID-19. The majority of observed side effects are mild or moderate. The grade 3 or 4 adverse effects included thrombocytopenia, ataxia, muscle weakness, delirium and hyperglycemia. Patients that progressed under the treatment received another line of therapy according to the institutional practice.

CONCLUSION

A combination of Bortezomib and Temozolomide administered in a defined time sequence to achieve sensitization of glioblastoma to alkylating agent is safe and feasible and may represent a novel treatment option for patients with this devastating disease.

Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines☆

•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.

Does chemotherapy improve health-related quality of life in advanced pancreatic cancer? A systematic review

Chemotherapy is increasingly being used in advanced pancreatic cancer, but side-effects are common. The aim of this systematic review was to assess whether chemotherapy improves health-related quality of life (HRQoL), pain or cachexia. Thirty studies were reviewed. Four of 23 studies evaluating HRQoL, 7 of 24 studies evaluating pain and 0 of 8 studies evaluating cachexia found differences between treatment arms. Change in HRQoL from baseline was evaluated in 14 studies: five studies reported an improvement in at least one treatment arm; three a worsening and the remaining stable scores. Change in pain intensity from baseline was evaluated in eight studies, and improvement was observed in seven. Of the four studies reporting improved survival, three reported improved HRQoL or pain. In conclusion, chemotherapy can stabilize HRQoL and improve pain control. Effects on cachexia are hard to elucidate. Improved survival does not come at the expense of HRQoL or pain control.

Genetic basis of interindividual susceptibility to cancer cachexia: selection of potential candidate gene polymorphisms for association studies

Cancer cachexia is a complex and multifactorial disease. Evolving definitions highlight the fact that a diverse range of biological processes contribute to cancer cachexia. Part of the variation in who will and who will not develop cancer cachexia may be genetically determined. As new definitions, classifications and biological targets continue to evolve, there is a need for reappraisal of the literature for future candidate association studies. This review summarizes genes identified or implicated as well as putative candidate genes contributing to cachexia, identified through diverse technology platforms and model systems to further guide association studies. A systematic search covering 1986-2012 was performed for potential candidate genes / genetic polymorphisms relating to cancer cachexia. All candidate genes were reviewed for functional polymorphisms or clinically significant polymorphisms associated with cachexia using the OMIM and GeneRIF databases. Pathway analysis software was used to reveal possible network associations between genes. Functionality of SNPs/genes was explored based on published literature, algorithms for detecting putative deleterious SNPs and interrogating the database for expression of quantitative trait loci (eQTLs). A total of 154 genes associated with cancer cachexia were identified and explored for functional polymorphisms. Of these 154 genes, 119 had a combined total of 281 polymorphisms with functional and/or clinical significance in terms of cachexia associated with them. Of these, 80 polymorphisms (in 51 genes) were replicated in more than one study with 24 polymorphisms found to influence two or more hallmarks of cachexia (i.e., inflammation, loss of fat mass and/or lean mass and reduced survival). Selection of candidate genes and polymorphisms is a key element of multigene study design. The present study provides a contemporary basis to select genes and/or polymorphisms for further association studies in cancer cachexia, and to develop their potential as susceptibility biomarkers of cachexia.

Validation of the Consensus-Definition for Cancer Cachexia and evaluation of a classification model--a study based on data from an international multicentre project (EPCRC-CSA)

BACKGROUND

Weight loss limits cancer therapy, quality of life and survival. Common diagnostic criteria and a framework for a classification system for cancer cachexia were recently agreed upon by international consensus. Specific assessment domains (stores, intake, catabolism and function) were proposed. The aim of this study is to validate this diagnostic criteria (two groups: model 1) and examine a four-group (model 2) classification system regarding these domains as well as survival.

PATIENTS AND METHODS

Data from an international patient sample with advanced cancer (N = 1070) were analysed. In model 1, the diagnostic criteria for cancer cachexia [weight loss/body mass index (BMI)] were used. Model 2 classified patients into four groups 0-III, according to weight loss/BMI as a framework for cachexia stages. The cachexia domains, survival and sociodemographic/medical variables were compared across models.

RESULTS

Eight hundred and sixty-one patients were included. Model 1 consisted of 399 cachectic and 462 non-cachectic patients. Cachectic patients had significantly higher levels of inflammation, lower nutritional intake and performance status and shorter survival. In model 2, differences were not consistent; appetite loss did not differ between group III and IV, and performance status not between group 0 and I. Survival was shorter in group II and III compared with other groups. By adding other cachexia domains to the model, survival differences were demonstrated.

CONCLUSION

The diagnostic criteria based on weight loss and BMI distinguish between cachectic and non-cachectic patients concerning all domains (intake, catabolism and function) and is associated with survival. In order to guide cachexia treatment a four-group classification model needs additional domains to discriminate between cachexia stages.

Is there a genetic cause for cancer cachexia? - a clinical validation study in 1797 patients

BACKGROUND

Cachexia has major impact on cancer patients' morbidity and mortality. Future development of cachexia treatment needs methods for early identification of patients at risk. The aim of the study was to validate nine single-nucleotide polymorphisms (SNPs) previously associated with cachexia, and to explore 182 other candidate SNPs with the potential to be involved in the pathophysiology.

METHOD

A total of 1797 cancer patients, classified as either having severe cachexia, mild cachexia or no cachexia, were genotyped.

RESULTS

After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and the cachexia groups. However, consistent with prior reports, two SNPs from the acylpeptide hydrolase (APEH) gene showed suggestive statistical significance (P=0.02; OR, 0.78).

CONCLUSION

This study failed to detect any significant association between any of the SNPs analysed and cachexia; although two SNPs from the APEH gene had a trend towards significance. The APEH gene encodes the enzyme APEH, postulated to be important in the endpoint of the ubiquitin system and thus the breakdown of proteins into free amino acids. In cachexia, there is an extensive breakdown of muscle proteins and an increase in the production of acute phase proteins in the liver.