Improvements in Survival and Clinical Benefit With Gemcitabine as First-Line Therapy for Patients With Advanced Pancreas Cancer: A Randomized Trial

PURPOSE

Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer.

PATIENTS AND METHODS

One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival.

RESULTS

Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated.

CONCLUSION

This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Abstract BS2-2: Roles of epigenetic regulation in breast cancer development

Changes to the genomic DNA sequence, called mutations, are known to play a critical role in the development of cancer. However, increasing evidence indicates that epigenetic changes (heritable cellular changes in gene expression that do not involve alterations in the DNA sequence) also make important contributions to tumorigenesis. For example, promoter hypermethylation plays a major role in cancer through transcriptional silencing of critical growth regulators such as tumor suppressor genes. Other chromatin modifications, such as histone ubiquitination, methylation and acetylation, affect local chromatin structure and regulate gene transcription. Using genome-wide RNA interference screens, we are uncovering epigenetic modulators that play important roles in breast cancer development and progression. The results of these studies are expected to shed light on the role of epigenetic regulation in breast cancer, and suggest new therapeutic approaches.

Citation Format: Green MR. Roles of epigenetic regulation in breast cancer development. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr BS2-2.

Mutation of chromatin modifiers; an emerging hallmark of germinal center B-cell lymphomas

Subtypes of non-Hodgkin's lymphomas align with different stages of B-cell development. Germinal center B-cell (GCB)-like diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL) and Burkitt's lymphoma (BL) each share molecular similarities with normal GCB cells. Recent next-generation sequencing studies have gained insight into the genetic etiology of these malignancies and revealed a high frequency of mutations within genes encoding proteins that modifying chromatin. These include activating and inactivating mutations of genes that perform post-translational modification of histones and organize chromatin structure. Here, we discuss the function of histone acetyltransferases (CREBBP, EP300), histone methyltransferases (KDM2C/D, EZH2) and regulators of higher order chromatin structure (HIST1H1C/D/E, ARID1A and SMARCA4) that have been reported to be mutated in ⩾5% of DLBCL, FL or BL. Mutations of these genes are an emerging hallmark of lymphomas with GCB-cell origins, and likely represent the next generation of therapeutic targets for these malignancies.

BSACI guideline for the diagnosis and management of cow's milk allergy

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.

A novel immunodeficiency disorder characterized by genetic amplification of interleukin 25

Many primary immunodeficiency disorders of differing etiologies have been well characterized, and much understanding of immunological processes has been gained by investigating the mechanisms of disease. Here, we have used a whole-genome approach, employing single-nucleotide polymorphism and gene expression microarrays, to provide insight into the molecular etiology of a novel immunodeficiency disorder. Using DNA copy number profiling, we define a hyperploid region on 14q11.2 in the immunodeficiency case associated with the interleukin (IL)-25 locus. This alteration was associated with significantly heightened expression of IL25 following T-cell activation. An associated dominant type 2 helper T cell bias in the immunodeficiency case provides a mechanistic explanation for recurrence of infections by pathogens met by Th1-driven responses. Furthermore, this highlights the capacity of IL25 to alter normal human immune responses.

Immediate impact of the FOLFIRINOX phase III data reported at the 2010 ASCO Annual Meeting on prescribing plans of American oncology physicians for patients with metastatic pancreas cancer (MPC)

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Background: Since 2005 we at Xcenda, LLC have studied prescribing plans of American medical oncologists for first-line therapy in patients with MPC. In 2008 we reported the steady growth of prescribing plans for the gemcitabine-erlotinib (GE) combination from 23% in late 2005 to 46% in 2007. In 2007, gemcitabine (G) alone was the second most common regimen planned (27%) (Green MR. Proc GI ASCO 2008). No cytotoxic doublet consistently garnered >10% prescribing share in this clinical setting. At ASCO 2010 Conroy et al. (J Clin Oncol. 2010;28(15s): Abstract 4010) reported a survival advantage for the FOLFIRINOX regimen compared to package insert dose and schedule of G alone as first-line therapy in patients with MPC and excellent PS (0-1).

Methods: Between 7/31 and 8/28/2010 we again used our extensively tested, live research vehicle, NMCR Challenging Cases, to assess current prescribing plans of over 370 American medical oncologists for first-line therapy in a patient with metastatic pancreas cancer and either PS 1 or PS 2.

Results: The FOLFIRINOX data have produced an immediate change in the distribution of planned first-line prescribing with 18% share for the PS 1 scenario, largely substituted for previous use of GE for this setting (Table). In PS 2, plans for FOLFIRINOX are minimal with G alone followed by GE as the dominant selections.

Conclusions: The recently reported phase III FOLFIRINOX data are impacting first-line prescribing plans for patients with MPC. We will continue to quantitate physician-prescribing plans to more fully understand the additional impact the FOLFIRINOX data may have on overall chemotherapy management of these patients.

[Table: see text]

[Table: see text]

BRAF V600E mutation and the tumour suppressor IGFBP7 in atypical genital naevi

BACKGROUND

Atypical genital naevi (AGN) are naevi of special sites with atypical histological features that overlap with those of malignant melanoma. Activating BRAF mutations, identified in the majority of banal melanocytic naevi and cutaneous melanomas, are reportedly uncommon in naevomelanocytic proliferations in nonsun-exposed sites. We have recently shown that constitutive activation of the BRAF-MEK-ERK signalling pathway in oncogenic BRAF-positive naevi increases expression and secretion of IGFBP7, which induces senescence and apoptosis.

OBJECTIVES

To ascertain the frequency of BRAF V600E mutations in AGN compared with banal naevi without atypia. An additional aim was to assess the expression of IGFBP7 in oncogenic BRAF-positive AGN.

METHODS

Genomic DNA was isolated per protocol from seven genital naevi without atypia and 13 AGN for BRAF genotyping. Immunohistochemical staining for IGFBP7 was performed on all cases.

RESULTS

The BRAF V600E mutation was identified in 43% of genital naevi without atypia and 23% of AGN (P = 0.61). In both groups, IGFBP7 expression was maintained in 67% of BRAF V600E-positive cases.

CONCLUSIONS

The prevalence of BRAF V600E in AGN suggests that ultraviolet exposure is not essential for generating the mutation. The BRAF V600E mutational status appears to be of limited diagnostic utility in distinguishing genital naevi that exhibit atypia from those that do not. Similar to oncogenic BRAF-positive common naevi without atypia, enhanced expression of the tumour suppressor IGFBP7 in oncogenic BRAF-positive AGN supports that they are biologically inert.

Clinical factors predictive of overall survival (OS) and the identification of prognostic groups in patients (pts) with unresectable stage III non-small cell lung cancer (NSCLC) treated with chemoradiotherapy on Cancer and Leukemia and Group B trial (CALGB) 39801

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Background: CALGB 39801 was designed to test whether treatment with induction chemotherapy and concurrent chemoradiotherapy (arm B) would improve OS in comparison to identical chemoradiotherapy alone (arm A), and demonstrated no significant benefit in OS for induction therapy. The objective of this analysis was to identify factors predictive of OS, and to use relevant factors to dichotomize pts into prognostic groups. Methods: Between July 1998 and May 2002, 331 pts were studied and included in a Cox proportional hazard regression analysis investigating previously identified prognostic factors: age (< 70 vs. ≥ 70 years), gender, race/ethnicity, hemoglobin (hgb) (< 13 vs. ≥13), performance status (PS) (0 vs.1), pretreatment weight loss (wt loss) (<5% vs. ≥ 5%), and treatment arm. Results: Cox regression analysis identified weight loss ≥ 5%, age ≥ 70, PS of 1, and hgb < 13 as predictive of worse survival (p<0.05), but not treatment arm (p=0.55). The median survival for pts with 0 (n=66), 1 (n=100), 2 (n=100), or ≥ 3 (n=65) risk factors were 24, 18, 10, and 8 months, respectively (p=0.0001). The pts were dichotomized into “poor prognosis” (PP) defined as ≥2 factors (n=165) and “good prognosis” (GP) defined as ≤ 1 factors (n=166). The hazard ratio (HR) for overall survival for the PP in comparison GP was 1.88 (95% CI, 1.49 to 2.37; p-value < 0.0001); the median survival times (MST) observed were 9 and 18 months, respectively (p<0.0001). The reasons for discontinuing treatment, and the rates of hematologic and non-hematologic adverse events were similar between the two groups. In the PP group the OS was similar between arms A (n=82) and B (n=83) (HR=0.97, 95% CI, 0.70 to 1.4; p=0.34); MST of 8.7 and 9.5 months, respectively. In the GP the OS was similar between arms A (n=79) and B (n=87) (HR=0.86, 95% CI, 0.63 to 1.1; p=0.87); MST of 19.3 and 17.6 months, respectively. Conclusions: Factors predictive of OS can be used to dichotomize pts into prognostic groups. Induction chemotherapy was not beneficial in either prognostic group.

No significant financial relationships to disclose.

Prescribing plans (PP) of American Oncologists for first-line therapy (Rx) for patients with stage III (wet)/IV non-small cell lung cancer (NSCLC) and PS 2: Overall selection and impact of gender and smoking status

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Background: Selection of oral EGFR inhibitors or chemotherapy as 2nd line in patients with NSCLC may be influenced by patients’ performance status (PS), smoking status, gender; tumor histology; tolerance/response to 1st-line Rx; and patient expectations/desires. Methods: Between February ’07 and October ’08, we used a core case scenario of stage IV mucin positive adenocarcinoma (Adeno ca) of lung in a 68-year-old former smoker (FS; stopped 6 years ago) with PS 2, to study patient related variations in PP of almost 800 American medical oncologists during 10 live research events [393 MDs/5 events during 2008]. Impact of gender or/and smoking history on 1st-line Rx selection was assessed. Results: In 2007–08, 97%/97%% MDs planned anti-tumor Rx: 53%/63% combination; 44%/34% single agent. PP for 2008 is shown in the table . [2007 PP data for erlotinb use included]. PP for erlotinib in these 4 scenarios are stable over the 2007 - 08 testing interval. Impact of smoking status dominates over gender. For a female NS with Adeno ca /PS2, ≥2/3 of MDs plan erlotinib 1st-line. In the absence of testing results for EGFR expression by IHC, EGFR gene copy number by FISH, EGFR gene mutation testing, or kras mutation testing, our data show a direct correlation of patient “phenotype” and PP for erlotinib as 1st-line Rx, a setting not specifically an approved indications for this agent. The impact of recently reported progression free survival data from an Asian phase III trial (IPASS: gefitinib or chemotherapy or as 1st-line therapy in non or former light-smoking patients with lung adenoca) on future prescribing plans in this clinical setting will be of great interest. Conclusions: By our observations, smoking status dominates over gender in PP of oncologists when treating wet IIIB/IV Adeno ca of lung. Therefore we plan to continue to assess American oncologists’ PP for this NSCLC setting during 2009.

[Table: see text]

[Table: see text]

Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study

OBJECTIVES

To assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes (PEG+E) for the treatment of chronic constipation in children.

DESIGN

Randomised, double blind, placebo controlled crossover trial, with two 2-week treatment periods separated by a 2-week placebo washout.

SETTING

Six UK paediatric departments.

PARTICIPANTS

51 children (29 girls, 22 boys) aged 24 months to 11 years with chronic constipation (lasting > or =3 months), defined as < or =2 complete bowel movements per week and one of the following: pain on defaecation on 25% of days; > or =25% of bowel movements with straining; > or =25% of bowel movements with hard/lumpy stools. 47 children completed the double blind treatment.

MAIN OUTCOME MEASURES

Number of complete defaecations per week (primary efficacy variable), total number of complete and incomplete defaecations per week, pain on defaecation, straining on defaecation, faecal incontinence, stool consistency, global assessment of treatment, adverse events and physical examination.

RESULTS

The mean number of complete defaecations per week was significantly higher for children on PEG+E than on placebo (3.12 (SD 2.05) v 1.45 (SD 1.20), respectively; p<0.001). Further significant differences in favour of PEG+E were observed for total number of defaecations per week (p = 0.003), pain on defaecation (p = 0.041), straining on defaecation (p<0.001), stool consistency (p<0.001) and percentage of hard stools (p = 0.001). Treatment related adverse events (all mild or moderate) occurred in similar numbers of children on PEG+E (41%) and placebo during treatment (45%).

CONCLUSIONS

PEG+E is significantly more effective than placebo, and appears to be safe and well tolerated in the treatment of chronic constipation in children.