Final results from a randomized phase 3 study of FOLFIRI {+/-} panitumumab for second-line treatment of metastatic colorectal cancer

BACKGROUND

The study 20050181 demonstrated significant improvements in progression-free survival (PFS), objective response, and a nonsignificant trend toward increased overall survival (OS) with panitumumab-FOLFIRI versus FOLFIRI alone for second-line wild-type (WT) KRAS metastatic colorectal cancer (mCRC). Updated long-term data from a prespecified descriptive analysis are reported.

PATIENTS AND METHODS

Patients receiving one prior mCRC treatment were randomly assigned (1:1) to panitumumab (6.0 mg/kg)-FOLFIRI versus FOLFIRI every 2 weeks. Co-primary end points (PFS and OS) were prospectively analyzed by tumor KRAS status.

RESULTS

One thousand one hundred and eighty-six patients were randomly assigned. In patients with WT KRAS tumors, panitumumab-FOLFIRI significantly improved PFS versus FOLFIRI [median 6.7 versus 4.9 months; hazard ratio (HR) 0.82 [95% confidence interval (CI) 0.69, 0.97]; P = 0.023]. A trend toward longer OS was observed (median 14.5 versus 12.5 months; HR 0.92 [95% CI 0.78, 1.10]; P = 0.37). Response rates improved from 10% to 36% (P < 0.0001). From post hoc analyses in patients receiving prior oxaliplatin-bevacizumab, panitumumab-FOLFIRI improved PFS (median 6.4 versus 3.7 months; HR 0.58 [95% CI 0.37, 0.90]; P = 0.014). PFS and OS appeared longer for worst-grade skin toxicity of 2-4, versus 0-1 or FOLFIRI. Safety results were as previously reported and consistent with the known toxicities with anti-epidermal growth factor receptor therapy.

CONCLUSIONS

These data confirm the primary efficacy and safety findings of this trial and support panitumumab-FOLFIRI as a second-line treatment of WT KRAS mCRC.

Phase III trial of nonpegylated liposomal doxorubicin in combination with trastuzumab and paclitaxel in HER2-positive metastatic breast cancer

BACKGROUND

Nonpegylated liposomal doxorubicin liposomal doxorubicin, (Myocet™; Sopherion Therapeutics, Inc Canada, and Cephalon, Europe) (NPLD; Myocet(®)) in combination with trastuzumabHerceptin(®) (Hoffmann-La Roche) has shown promising activity and cardiac safety. We conducted a randomized phase III trial of first-line NPLD plus trastuzumab and paclitaxel (Pharmachemie B.V.) (MTP) versus trastuzumab plus paclitaxel (TP) in patients with human epidermal growth factor 2 receptor (HER2)-positive metastatic breast cancer.

PATIENTS AND METHODS

Patients were randomly assigned to NPLD (M, 50 mg/m(2) every 3 weeks for six cycles), trastuzumab (T, 4 mg/kg loading dose followed by 2 mg/kg weekly), and paclitaxel (P, 80 mg/m(2) weekly) or T + P at the same doses until progression or toxicity. The primary efficacy outcome was progression-free survival (PFS).

RESULTS

One hundred and eighty-one patients were allocated to receive MTP, and 183 to TP. Median PFS was 16.1 and 14.5 months with MTP and TP, respectively [hazard ratio (HR) 0.84; two-sided P = 0.174]. In patients with estrogen receptor (ER)- and progesterone receptor (PR)-negative tumors, PFS was 20.7 and 14.0 months, respectively [HR 0.68; 95% confidence interval (CI) 0.47-0.99]. Median overall survival (OS) was 33.6 and 28.9 months with MTP and TP, respectively (HR 0.79; two-sided P = 0.083). In ER- and PR-negative tumors, OS was 38.2 and 27.9 months, respectively (HR 0.63; 95% CI 0.42-0.93). The frequency of adverse events was higher with MTP, but there was no significant difference in cardiac toxicity between treatment arms.

CONCLUSION(S)

The trial failed to demonstrate a significant clinical improvement with the addition of M to TP regimen. The clinical benefit observed in an exploratory analysis in the ER- and PR-negative population deserves consideration for further clinical trials.

CLINICAL TRIAL NUMBER

NCT00294996.

A statewide Medicaid enhanced prenatal care program: impact on birth outcomes

IMPORTANCE

Policy makers and practitioners need rigorous evaluations of state-based Medicaid enhanced prenatal care programs that provide home visiting to guide improvements and inform future investments. Effects on adverse birth outcomes are of particular interest.

OBJECTIVE

To test if participation in the Michigan statewide enhanced prenatal care program, the Maternal Infant Health Program (MIHP), accounting for program timing and dosage, reduced risk for low birth weight (LBW) and preterm birth, particularly among black women who are at greater risk for adverse outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Quasi-experimental cohort study. Data, including birth records, Medicaid claims, and monthly program participation, were extracted from the Michigan Department of Community Health warehouse. Participants included all 60 653 pregnant women who had a Medicaid-insured singleton birth between January 1 and December 31, 2010, in Michigan. The MIHP participants were propensity score-matched with nonparticipants based on demographics, previous pregnancies, socioeconomic status, and chronic disease.

EXPOSURE

An enhanced prenatal care program.

MAIN OUTCOMES AND MEASURES

Low birth weight, very low birth weight (VLBW), preterm birth, and very preterm birth.

RESULTS

In the propensity score-matched models, black women who enrolled and were screened in the MIHP by the end of the second trimester had lower odds of VLBW (odds ratio [OR], 0.76; 95% CI, 0.59-0.97) and very preterm births (OR, 0.68; 95% CI, 0.54-0.85) than matched nonparticipants. Black MIHP participants who enrolled and were screened in the program by the second trimester and had at least 3 additional prenatal MIHP contacts had lower odds of LBW (OR, 0.76; 95% CI, 0.65-0.89), VLBW (0.42; 0.30-0.61), preterm birth (0.71; 0.61-0.83), and very preterm birth (0.41; 0.30-0.57) compared with matched nonparticipants. The MIHP participants of other races and ethnicities who enrolled and were screened in the program by the second trimester and had at least 3 additional prenatal MIHP contacts had lower odds of LBW (OR, 0.78; 95% CI, 0.66-0.93), VLBW (0.38; 0.22-0.66), preterm birth (0.77; 0.66-0.89), and very preterm birth (0.63; 0.43-0.91) compared with matched nonparticipants.

CONCLUSIONS AND RELEVANCE

Participation in MIHP reduced the risk for adverse birth outcomes in a diverse, disadvantaged population. The study adds to the evidence base for enhanced prenatal care home visiting programs and informs state and federal investments.

Individual, provider, and system risk factors for breast and cervical cancer screening among underserved Black, Latina, and Arab women

BACKGROUND

Socioeconomic and racial/ethnic disparities in breast and cervical cancer screening persist. An exploratory study was conducted to better understand co-occurring risk factors in underserved groups that could inform interventions to improve screening adherence. The objective of this study was to examine associations between breast and cervical cancer screening adherence and co-occurring risk factors in three racial/ethnic groups of underserved women.

METHODS

Black, Latina, and Arab women (N=514), ages 21 to 70 years, were enrolled into the Kin Keeper(SM) randomized controlled trial in communities around Detroit, Michigan. We used participant baseline assessments (e.g., demographic characteristics, health literacy) to explore screening risks using an additive approach and multivariate logistic analyses.

RESULTS

For black women, having more health literacy risks were associated with reduced odds of a clinical breast exam (CBE), mammogram, and Papanicolaou (Pap) test; more competing priorities were associated with reduced odds of a Pap test; lack of doctor mammogram recommendation was significantly associated with decreased odds of CBE. For Latina women, lack of doctor recommendations were significantly associated with decreased odds of CBE, mammogram, and Pap test. For Arab women, lack of doctor recommendations were significantly associated with decreased odds of CBE, mammogram, and Pap test; more competing priorities were significantly associated with reduced odds of CBE and Pap test. All results were significant at p<0.05.

CONCLUSIONS

Characteristics associated with breast and cervical screening adherence differs among Black, Latina, and Arab underserved women. Interventions to improve screening should be tailored for racial/ethnic groups with particular attention to competing survival priorities, health literacy risks factors, and provider recommendations.

Global, multicenter, randomized, phase II trial of gemcitabine and gemcitabine plus AGS-1C4D4 in patients with previously untreated, metastatic pancreatic cancer

BACKGROUND

We evaluated AGS-1C4D4, a fully human monoclonal antibody to prostate stem cell antigen (PSCA), with gemcitabine in a randomized, phase II study of metastatic pancreatic cancer.

PATIENTS AND METHODS

Patients with Eastern Cooperative Oncology Group (ECOG) performance status 0/1 and previously untreated, metastatic pancreatic adenocarcinoma were randomly assigned 1:2 to gemcitabine (1000 mg/m(2) weekly seven times, 1 week rest, weekly three times q4weeks) or gemcitabine plus AGS-1C4D4 (48 mg/kg loading dose, then 24 mg/kg q3weeks IV). The primary end point was 6-month survival rate (SR). Archived tumor samples were collected for pre-planned analyses by PSCA expression.

RESULTS

Between April 2009 and May 2010, 196 patients were randomly assigned to gemcitabine (n = 63) or gemcitabine plus AGS-1C4D4 (n = 133). The 6-month SR was 44.4% (95% CI, 31.9-57.5) in the gemcitabine arm and 60.9% (95% CI, 52.1-69.2) in the gemcitabine plus AGS-1C4D4 arm (P = 0.03), while the median survival was 5.5 versus 7.6 months and the response rate was 13.1% versus 21.6% in the two arms, respectively. The 6-month SR was 57.1% in the gemcitabine arm versus 79.5% in the gemcitabine plus AGS-1C4D4 arm among the PSCA-positive subgroup and 31.6% versus 46.2% among the PSCA-negative subgroup.

CONCLUSIONS

This randomized, phase II study achieved its primary end point, demonstrating an improved 6-month SR with addition of AGS-1C4D4 to gemcitabine among patients with previously untreated, metastatic pancreatic adenocarcinoma. ClinicalTrials.gov identifier: NCT00902291.

Involvement of renal cytochromes P450 and arachidonic acid metabolites in diabetic nephropathy

Diabetic nephropathy (DN) is one of the most serious complications of type I and type II diabetes. DN is characterized by hyperfiltration, hypertrophy, extracellular matrix accumulation, and proteinuria. This advances into renal fibrosis and loss of renal function. Reactive oxygen species (ROS) and TGF-beta have been implicated in the pathogenesis of diabetic nephropathy. Early stages of diabetic nephropathy are also associated with alterations in renal sodium handling as well as hypertension; both are processes linked by involvement of the arachidonic acid (AA) metabolites, 20-hydroxyeicosatetraenoic acid (20-HETE, produced by cytochrome P450-4a, (CYP4A) and epoxyeicosatrienoic acids (EETs). Indeed, metabolism of AA is increased in a rat model of diabetes. In this study, we demonstrate that rats with streptozotocin-induced diabetes of 1 month duration develop renal hypertrophy and increased fibronectin and TGF-beta1 expression/cortical levels concomitant with an increase in CYP4A expression and 20 HETE production. These results were also paralleled by an increase in reactive oxygen species (ROS) production and NADPH oxidase activity. Treatment of diabetic rats with HET0016, selective inhibitor of CYP 4A, prevented all these changes. Our results suggest that diabetes-induced induction of CYP4A and 20-HETE production could be a major pathophysiological mechanism leading to activation of ROS through an NADPH dependent pathway and TGF-beta1 thus resulting in major renal pathology. Inhibitors of 20-HETE production could thus have an important therapeutic potential in the treatment of diabetic nephropathy.

Kin KeeperSM: design and baseline characteristics of a community-based randomized controlled trial promoting cancer screening in Black, Latina, and Arab women

BACKGROUND

Although breast and cervical cancer deaths have declined due to early screening, detection, and more effective treatment, racial and ethnic disparities persist. This paper describes the study design and baseline characteristics of a randomized controlled trial (RCT) evaluating the effectiveness of the Kin Keeper(SM) Cancer Prevention Intervention, a family-focused educational intervention for underserved women applied in a community-based setting to promote health literacy and screening adherence to address cancer disparities.

METHODS

Female public health community health workers (CHWs) were trained to administer the intervention. They recruited female clients from their public health program caseload and asked each to assemble two to four adult female family members for the breast and cervical cancer home-based education sessions the CHWs would deliver in English, Spanish or Arabic. We randomized the clients into the kin keeper group (treatment) or the participant client group (control).

RESULTS

Complete data were obtained on 514 Black, Latina, and Arab women. Close to half were unemployed and had yearly family income below $20,000. Thirty-four percent had no medical insurance, and 21% had diabetes. Almost 40% had no mammography in the last year. Treatment and control groups were similar on most sociodemographics but showed differences in breast and cervical screening history.

CONCLUSIONS

This innovative study demonstrates the implementation of an RCT using community-based participatory research, while delivering cancer prevention education across woman's life span with women not connected to the health care system.

S5-5: A Phase III, Randomized, Double-Blind, Placebo-Controlled Registration Trial To Evaluate the Efficacy and Safety of Pertuzumab + Trastuzumab + Docetaxel vs. Placebo + Trastuzumab + Docetaxel in Patients with Previously Untreated HER2−Positive Metastatic Breast Cancer (CLEOPATRA)

Background: Pertuzumab (P) is a fully humanized investigational monoclonal antibody that binds to human epidermal growth factor receptor 2 (HER2), preventing dimerization of HER2 with other HER family members and inducing antibody-dependent cell-mediated cytotoxicity. Its mechanisms of action are complementary to those of the anti-HER2 antibody trastuzumab (H) and the two antibodies combined have superior activity compared with either antibody alone in preclinical and clinical studies. In patients with advanced disease, P in combination with H has been shown to be active in patients whose disease has progressed while on H therapy (Baselga et al. J Clin Oncol 2010). Furthermore, P has been shown to improve the activity of H and docetaxel (T) in a randomized neoadjuvant study (Gianni et al. SABCS 2010, S3-2). No increase in overall toxicity and, in particular, no increase in cardiac events was observed with the addition of P to H and HT regimens.

Methods: In this double-blind Phase III study patients with centrally confirmed HER2−positive metastatic or locally recurrent, unresectable breast cancer were randomized to receive either placebo+H+T or P+H+T. Patients could have received one prior hormonal treatment for metastatic breast cancer and/or prior systemic neoadjuvant or adjuvant therapy including prior H and T. Patients had to have a baseline left ventricular ejection fraction ≥50% and no history of declines to &lt;50% during or after prior H therapy.

Study medication was as follows: P 840 mg loading dose followed by 420 mg q3w; H 8 mg/kg loading dose followed by 6 mg/kg q3w; T 75 mg/m2 q3w (with subsequent dose escalation to 100 mg/m2 if 75 mg/m2 was well tolerated). Patients were recommended to receive at least 6 cycles of T. In the case of chemotherapy discontinuation due to cumulative toxicity, antibody therapy was continued until disease progression, unacceptable toxicity, or withdrawal of consent.

Patients were stratified according to region and prior treatment status (adjuvant therapy or de novo metastatic breast cancer).

The primary endpoint for the study was progression-free survival (PFS) as determined by independent review. The primary analysis was planned to take place when approximately 381 independently confirmed PFS events had occurred. This would provide 80% power to detect a 33% improvement in PFS (HR=0.75) at the two-sided significance level of 5%. Secondary endpoints included overall survival, investigator-determined PFS, overall response rate, duration of response, safety, and quality of life.

Patient safety was monitored throughout the study by an independent data monitoring committee and a cardiac review committee.

This study is registered at ClinicalTrials.gov: NCT00567190.

Results: 808 patients were recruited between February 2008 and July 2010. The required number of PFS events for analysis of the primary endpoint has been reached and independent assessment PFS is currently being performed. Results of the primary analysis of efficacy and safety will be presented.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr S5-5.

Abstract P6-14-02: A Phase 3 Randomized, Controlled Trial of Myocet, Trastuzumab and Paclitaxel vs. Trastuzumab and Paclitaxel for 1st Line Therapy of HER2+ Metastatic Breast Cancer

Background: Myocet™ (M) is a non-pegylated liposomal doxorubicin which exhibits reduced cardiotoxicity as compared to conventional doxorubicin. A phase 1/2 non-randomized multi-site trial combining M, trastuzumab (H) and paclitaxel (T) has resulted in high response rate, prolonged time to progression and improved overall survival, with no clinical cardiac toxicity in patients (pts) with first line metastatic breast cancer (MBC) over-expressing human epidermal growth factor-2neu (HER2+) (Cortes et al Clin Cancer res 2009:15:307).

Methods: This multicenter study was designed to demonstrate the efficacy and cardiac safety of M+ H + T vs. the standard of care, H + T, in pts with HER2+ MBC with no prior chemotherapy for MBC. After stratification by hormone receptor status, prior or no prior anthracycline (A) therapy, age ≥50 or &gt;50 y and geography, patients were randomly allocated to receive either M (50 mg/m2 q 3 wks for 6 cycles), H (4 mg/kg loading dose followed by 2 mg/kg q wk) and T (80 mg/m2 q wk) or H + T until progression or toxicity. The primary efficacy outcome is progression-free survival (PFS), as determined by a blinded independent review committee (IRC). The primary safety outcome is the incidence of NYHA class 3 or 4 heart failure or cardiac death, independently adjudicated. Secondary endpoints are overall survival and tumor response, also determined by the IRC according to RECIST. 332 pts were needed to detect a 30% difference in PFS with 80% power.

Results: Between 2006 and 2009, 363 HER2+ women from 12 countries were enrolled. Median age is 53 yr (range 22-79); 80% are Caucasian; with ECOG performance status of 0 (62%) and 1 (38%); 42% are ER and/or PR positive; 40% received adjuvant chemotherapy, 24% hormone therapy, and 37% radiotherapy; 33% received prior A, median lifetime cumulativedoxorubicin and epirubicin dose (range) were 240 (45-360) mg/m2 and 360 (69-600) mg/m2, respectively. The final analysis of PFS is scheduled for 3Q10.

Conclusions: The safety and efficacy data will be presented at the meeting. Clinical Trials.Gov Identifier: NCT00294996

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-14-02.

Efficacy and safety of ipilimumab monotherapy in patients with pretreated advanced melanoma: a multicenter single-arm phase II study

BACKGROUND

This phase II study evaluated the safety and activity of ipilimumab, a fully human mAb that blocks cytotoxic T-lymphocyte antigen-4, in patients with advanced melanoma.

PATIENTS AND METHODS

Patients with previously treated, unresectable stage III/stage IV melanoma received 10 mg/kg ipilimumab every 3 weeks for four cycles (induction) followed by maintenance therapy every 3 months. The primary end point was best overall response rate (BORR) using modified World Health Organization (WHO) criteria. We also carried out an exploratory analysis of proposed immune-related response criteria (irRC).

RESULTS

BORR was 5.8% with a disease control rate (DCR) of 27% (N = 155). One- and 2-year survival rates (95% confidence interval) were 47.2% (39.5% to 55.1%) and 32.8% (25.4% to 40.5%), respectively, with a median overall survival of 10.2 months (7.6-16.3). Of 43 patients with disease progression by modified WHO criteria, 12 had disease control by irRC (8% of all treated patients), resulting in a total DCR of 35%. Adverse events (AEs) were largely immune related, occurring mainly in the skin and gastrointestinal tract, with 19% grade 3 and 3.2% grade 4. Immune-related AEs were manageable and generally reversible with corticosteroids.

CONCLUSION

Ipilimumab demonstrated clinical activity with encouraging long-term survival in a previously treated advanced melanoma population.

Results of a phase II study of picoplatin with docetaxel and prednisone in first-line treatment of castration-resistant prostate cancer (CRPC)

5140

Background: Picoplatin (Pico) was designed to overcome platinum resistance and has the potential for improved safety compared to other platinum agents. Previously, a PSA response rate of 25% was observed when Pico monotherapy was infused at 120 mg/m2 Q3W (N = 20). Recently, a 34-patient Phase I study was performed to investigate the safety and efficacy of Pico in combination with docetaxel (D) + prednisone (pred) as first-line therapy for metastatic CRPC. Picoplatin therapy was well-tolerated at a dose of 120 mg/m2 and 19 of 32 evaluable pts (59%) achieved a confirmed PSA response. Methods: 32 patients with chemotherapy-naïve CRPC and disease progression received Pico (120 mg/m2) and D (75 mg/m2) Q3W with pred 5 mg po bid for up to 10 cycles. PSA responses were defined as a reduction from baseline of at least 50% maintained for at least 4 weeks. CT and bone scans were also evaluated. Tumor response was measured using RECIST. Results: Patients received a median of 10 cycles (range = 1–10). Median baseline PSA was 340.8 ng/mL (range 5.6–3019). One pt had no baseline PSA data. Of the 24 patients with evaluable post-treatment PSA, 83% (95% CI 64–93%) had PSA decreases <50% of baseline, and in 8 of these (33% of the evaluable population), PSA reached normal levels (< 4 ng/mL). In the intent-to-treat population, the PSA response rate was 63% (95% CI 45–77%). 13 patients evaluated by CT scan had measurable disease; 6 pts had SD by RECIST, 4 had PD, and 3 were not evaluable. The most common adverse events were alopecia (36%), asthenia (32%), neutropenia (29%), increased creatinine (23%), and thrombocytopenia (19%). No neurotoxicity ≥ grade 2 was observed. Conclusions: Picoplatin was safely administered to patients with CRPC as 1st-line therapy at 120 mg/m2 Q3W with full doses of docetaxel and prednisone, resulting in a PSA response rate of 83% of evaluable patients. These results support further development of picoplatin as a novel combination with docetaxel for the treatment of CRPC.

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