Real-world patient- and caregiver-reported outcomes in advanced breast cancer

Background

Advanced breast cancer (abc) represents a substantial burden for patients and caregivers. In the present study, we aimed to estimate quality of life (qol), utility, productivity loss, pain, health care resource utilization, and costs for patients with abc, and qol, utility, and productivity loss for their caregivers.

Methods

This multicentre prospective non-interventional study was conducted in Canada. Eligible participants were postmenopausal women with estrogen receptor-positive, her2-negative unresectable abc and their caregivers. Validated questionnaires were used to measure qol, utility, productivity loss, and pain. Patients and caregivers were classified into 4 health states typically used in oncology economic modelling: first-line progression-free (1l-pf), first-line progressive disease (1l-pd), second- or subsequent-line progression-free (≥2l-pf), and second- or subsequent-line progressive disease (≥2l-pd).

Results

Most patients and caregivers accepted to participate, with total recruitment of 202 patients and 78 caregivers. Compared with patients in pf, patients in pd had lower mean qol scores (52.9 ± 29.9 for 1l-pd vs. 68.2 ± 23.2 for 1l-pf, and 54.0 ± 23.6 for ≥2l-pd vs. 66.0 ± 22.1 for ≥2l-pf), lower mean utility values (0.64 ± 0.22 for 1l-pd vs. 0.73 ± 0.20 for 1l-pf, and 0.65 ± 0.25 for ≥2l-pd vs. 0.74 ± 0.18 for ≥2l-pf), and greater productivity loss (39.4 ± 27.7 for 1l-pd vs. 27.5 ± 30.1 for 1l-pf, and 37.6 ± 29.2 for ≥2l-pd vs. 32.0 ± 29.0 for ≥2l-pf). Compared with caregivers of patients in pf, caregivers of patients in pd had lower qol scores and utility values, and greater productivity loss.

Conclusions

Study results indicate that, for patients and caregivers, pd health states are associated with a deterioration of qol and utility and a decrease in productivity in both 1l and ≥2l.

A randomized phase II study of weekly paclitaxel with or without pelareorep in patients with metastatic breast cancer: final analysis of Canadian Cancer Trials Group IND.213

BACKGROUND

Pelareorep, a serotype 3 reovirus, has demonstrated preclinical and early clinical activity in breast cancer and synergistic cytotoxic activity with microtubule targeting agents. This multicentre, randomized, phase II trial was undertaken to evaluate the efficacy and safety of adding pelareorep to paclitaxel for patients with metastatic breast cancer (mBC).

METHODS

Following a safety run-in of 7 patients, 74 women with previously treated mBC were randomized either to paclitaxel 80 mg/m² intravenously on days 1, 8, and 15 every 4 weeks plus pelareorep 3 × 10¹⁰ TCID₅₀ intravenously on days 1, 2, 8, 9, 15, and 16 every 4 weeks (Arm A) or to paclitaxel alone (Arm B). Primary endpoint was progression-free survival (PFS). Secondary endpoints were objective response rate, overall survival (OS), circulating tumour cell counts, safety, and exploratory correlative analyses. All comparisons used a two-sided test at an alpha level of 20%. Survival analyses were adjusted for prior paclitaxel.

RESULTS

Final analysis was performed after a median follow-up of 29.5 months. Pelareorep was well tolerated. Patients in Arm A had more favourable baseline prognostic variables. Median adjusted PFS (Arm A vs B) was 3.78 mo vs 3.38 mo (HR 1.04, 80% CI 0.76-1.43, P = 0.87). There was no difference in response rate between arms (P = 0.87). Median OS (Arm A vs B) was 17.4 mo vs 10.4 mo (HR 0.65, 80% CI 0.46-0.91, P = 0.1).

CONCLUSIONS

This first, phase II, randomized study of pelareorep and paclitaxel in previously treated mBC did not show a difference in PFS (the primary endpoint) or RR. However, there was a significantly longer OS for the combination. Further exploration of this regimen in mBC may be of interest.

Abstract CT131: A randomized (RCT) phase II study of oncolytic reovirus (pelareorep ) plus standard weekly paclitaxel (P) as therapy for metastatic breast cancer (mBC)

Background: Pelareorep is a Dearing strain of reovirus serotype 3, with demonstrated in vitro and in vivo activity in many cancers and synergistic cytotoxic activity with microtubule targeting agents, including taxanes. This study was designed to determine the efficacy and safety of pelareorep + P compared to P alone in mBC. Materials and Methods: This randomized, open-label, phase II study enrolled subjects who had mBC previously exposed to chemotherapy (CT). Subjects were randomized 1:1 between Arm A (P 80 mg/m2 day 1, 8 and 15 q 28 days plus pelareorep 3 x 1010 TCID50 day 1,2,8,9,15,16 q 28 days) and Arm B (P 80 mg/m2 day 1, 8 and 15 q 28 days). Treatment was continued until disease progression (PD) or unacceptable toxicity. Objective response was assessed every 8 weeks. Primary endpoint was progression free survival (PFS). The study had 90% power to detect an improvement of PFS from 4 to 7.5 months (HR 0.5, two-sided α=0.2). All p-values are two-sided. Results: Between July 2012 and April 2016, 81 subjects were accrued: 7 to the safety run-in for arm A, 36 to Arm A and 38 to Arm B. All had received prior CT, 59 as adjuvant treatment and 48 for mBC. Patients in Arm A had more favorable prognostic features, including lower LDH and less prior therapy. The median cumulative dose of P was 960 mg/m2 for arm A vs. 828 mg/m2 for arm B. Similar numbers of subjects in both arms required dose reductions, predominantly for myelosuppression. The median duration of treatment was 16.1 weeks for pelareorep and P in arm A and 14.1 weeks for P in arm B. With a median follow-up of 29.5 months, the median PFS was 3.78 mo for arm A and 3.38 mo for arm B (HR 1.04, 80% CI 0.76-1.43, p=0.87). Median OS was 17.4 mo for arm A and 10.4 mo for arm B (HR 0.65, 80% CI 0.46-0.91, p=0.1). Response rates (RR) were 25% for arm A and 23.7% for arm B (p=0.87). Pre-specified subset analysis found statistically significant differences in OS in patients with ECOG 1 or 2, aged < 65 yr, and no prior P treatment. Exploratory analysis of biomarkers found significant differences in OS in patients with wild type PIK3CA, KIT, APC, PTEN, ATM, AKT1, mutated TP53, and both wild type and mutated MET, although the number of pts was small. When grade 3 or higher adverse events (AE) were considered, only the incidence of fatigue was found in ≥10% (16% on Arm A vs 13%, arm B, p=0.76). Hematologic grade 3 or higher effects observed in ≥10% patients included lymphopenia (5% arm A vs 18% arm B, p=0.08), and neutropenia (23% arm A vs 26% arm B; p=0.8). There was a statistically significant difference in grade 3 or higher LDH (0% arm A vs 13% arm B, p=0.03). There were no treatment related deaths. Conclusions: This first, phase II, randomized study of pelareorep + P vs P in mBC previously exposed to CT, did not meet its primary endpoint of PFS. Despite similar PFS and RR there was a statistically significant improvement in OS for pelareorep + P pts. Given these data, further exploration of the role of pelareorep + P in mBC may be of interest.

Citation Format: Vanessa Bernstein, Susan Ellard, Susan F. Dent, Karen A. Gelmon, Sukhbinder K. Dhesy-Thind, Mihaela Mates, Muhammed Salim, Lawrence Panasci, Xinni Song, Mark Clemons, Dongsheng Tu, Linda J. Hagerman, Lesley Seymour. A randomized (RCT) phase II study of oncolytic reovirus (pelareorep ) plus standard weekly paclitaxel (P) as therapy for metastatic breast cancer (mBC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT131. doi:10.1158/1538-7445.AM2017-CT131

Immune related adverse events (irAE) with platinum chemotherapy (CT) with durvalumab (D) ± tremelimumab (T): CCTG IND226

3058

Background: CT is immunomodulatory and requires corticosteroids (CS) premedication. We hypothesized that the incidence of irAE may be lower when D ± T is given with CT or CS. Methods: Patients (pts) receive CT (pemetrexed, nabpaclitaxel, etoposide or gemcitabine + cisplatin or carboplatin; usual 4-6 cycles) with D ± T, followed by D ± T alone (1 year total); pts with ≥ g2 (selected) or ≥ g3 irAE discontinued D ± T. Cycles were coded as CT + D ± T or D ± T; pts could contribute to both. CS: high (dexamethasone > 10mg/day for 5 days) or low CS. irAE were D ± T related gastrointestinal (GI), skin, endocrine, neurologic, hypersensitivity, pneumonitis (PN) or other immune (nephritis (GN), pancreatitis, hepatitis). Biochemistry (BIO; all causality): creatinine, transaminases/bilirubin (LFTS) and amylase/lipase was summarised. Results: In this ongoing study, 118 pts received 723 cycles. Pts had good performance status (PS 0-1), 78 had thoracic malignancies and 84 no prior CT. 44 pts continue on D ± T alone; 32 pts continue on CT + D ± T while 76 pts discontinued D ± T primarily due to disease progression; 15 discontinued for ≥ g2 irAE [PN (3), hepatitis (1), GN (2), adrenal (1), myocarditis (1), GI (3), thrombocytopenia (1), hyperthyroidism (1), encephalitis (1), pt decision (1)]. 67 pts had high CS cycles while 78 pts had low. 50% pts had irAE and 10% had ≥ g3 irAE, most commonly skin and GI. GI (15 vs 11%), skin (26 vs 20%) and PN (3 vs 0%) were reported in more pts during CT + D ± T cycles (non significant (NS)) ; hypothyroidism was more common with D ± T alone (18 vs 10%; p = NS). IrAE rates and severity were similar between high (67 pts) or low CS (78 pts) except for GI (19 vs 10%; p = NS). BIO were more common during CT + D ± T (74% of pts vs 48% p = 0.003); rates in high CS were similar to low CS. LFTs (ALT/AST - 41% vs 16%; 38% vs 9%; p = 0.005) and amylase/lipase (18 vs 9%; 19 vs 14%; p = NS) were more common in pts with CT + D ± T cycles vs pts with D ± T alone cycles. Conclusions: There is no evidence that CT or CS abrogates irAE in this exploratory analysis. GI, skin, pneumonitis, LFTS and amylase/lipase were more common during CT + D ± T suggesting additive/multifactorial causes; hypothyroidism is more common in D ± T cycles, which may reflect time on treatment. Clinical trial information: NCT02537418.

Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer: A Cancer Care Ontario and American Society of Clinical Oncology Clinical Practice Guideline

Purpose To make recommendations regarding the use of bisphosphonates and other bone-modifying agents as adjuvant therapy for patients with breast cancer. Methods Cancer Care Ontario and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature. Results Adjuvant bisphosphonates were found to reduce bone recurrence and improve survival in postmenopausal patients with nonmetastatic breast cancer. In this guideline, postmenopausal includes patients with natural menopause or that induced by ovarian suppression or ablation. Absolute benefit is greater in patients who are at higher risk of recurrence, and almost all trials were conducted in patients who also received systemic therapy. Most studies evaluated zoledronic acid or clodronate, and data are extremely limited for other bisphosphonates. While denosumab was found to reduce fractures, long-term survival data are still required. Recommendations It is recommended that, if available, zoledronic acid (4 mg intravenously every 6 months) or clodronate (1,600 mg/d orally) be considered as adjuvant therapy for postmenopausal patients with breast cancer who are deemed candidates for adjuvant systemic therapy. Further research comparing different bone-modifying agents, doses, dosing intervals, and durations is required. Risk factors for osteonecrosis of the jaw and renal impairment should be assessed, and any pending dental or oral health problems should be dealt with prior to starting treatment. Data for adjuvant denosumab look promising but are currently insufficient to make any recommendation. Use of these agents to reduce fragility fractures in patients with low bone mineral density is beyond the scope of the guideline. Recommendations are not meant to restrict such use of bone-modifying agents in these situations. Additional information at www.asco.org/breast-cancer-adjuvant-bisphosphonates-guideline , www.asco.org/guidelineswiki , https://www.cancercareontario.ca/guidelines-advice/types-of-cancer/breast .

A phase-I study of lapatinib in combination with foretinib, a c-MET, AXL and vascular endothelial growth factor receptor inhibitor, in human epidermal growth factor receptor 2 (HER-2)-positive metastatic breast cancer

BACKGROUND

The mechanisms of resistance to anti-human epidermal growth factor receptor 2 (HER 2) therapies are unclear but may include the tyrosine-protein kinase Met (c-Met), vascular endothelial growth factor (VEGF) and AXL pathways. Foretinib is an inhibitor of c-Met, VEGF receptor 2 (VEGFR-2), platelet-derived growth factor receptor beta (PDGFRB), AXL, Fms-like tyrosine kinase 3 (FLT3), angiopoiten receptor (TIE-2), RET and RON kinases. This phase Ib study sought to establish the associated toxicities, pharmacokinetics (PK) and recommended phase II doses (RP2D) of foretinib and lapatinib in a cohort of HER-2-positive patients with metastatic breast cancer (MBC).

METHODS

Women with HER-2 positive MBC, Performance status (PS 0-2), and no limit on number of prior chemotherapies or lines of anti-HER-2 therapies were enrolled. A 3 + 3 dose escalation design was utilized. Four dose levels were intended with starting doses of foretinib 30 mg and lapatinib 750 mg orally once a day (OD) on a 4-weekly cycle. Assessment of c-MET status from the primary archival tissue was performed.

RESULTS

We enrolled 19 patients, all evaluable for toxicity assessment and for response evaluation. Median age was 60 years (34-86 years), 95% were PS 0-1, 53% were estrogen receptor-positive and 95% had at least one prior anti-HER-2-based regimen. The fourth dose level was reached (foretinib 45 mg/lapatinib 1250 mg) with dose-limiting toxicities of grade-3 diarrhea and fatigue. There was only one grade-4 non-hematological toxicity across all dose levels. There were no PK interactions between the agents. A median of two cycles was delivered across the dose levels (range 1-20) with associated progression-free survival of 3.2 months (95% CI 1.61-4.34 months). By immunohistochemical assessment with a specified cutoff, none of the 17 samples tested were classified as positive for c-Met.

CONCLUSIONS

The RP2D of the combined foretinib and lapatinib is 45 mg and 1000 mg PO OD, respectively. Limited activity was seen with this combination in a predominantly unselected cohort of HER-2-positive patients with MBC.

Comparing effectiveness with efficacy: outcomes of palliative chemotherapy for non-small-cell lung cancer in routine practice

INTRODUCTION

Randomized controlled trials (rcts) are the "gold standard" for establishing treatment efficacy; however, efficacy does not automatically translate to a comparable level of effectiveness in routine practice. Our objectives were to □ describe outcomes of palliative platinum-doublet chemotherapy (ppdc) in non-small-cell lung cancer (nsclc) in routine practice, in terms of survival and well-being; and□ compare the effectiveness of ppdc in routine practice with its efficacy in rcts.

METHODS

Electronic treatment records were linked to the Ontario Cancer Registry to identify patients who underwent ppdc for nsclc at Ontario's regional cancer centres between April 2008 and December 2011. At each visit to the cancer centre, a patient's symptoms are recorded using the Edmonton Symptom Assessment System (esas). Score on the esas "well-being" item was used here as a proxy for quality of life (qol). Survival in the cohort was compared with survival in rcts, adjusting for differences in case mix. Changes in the esas score were measured 2 months after treatment start. The proportion of patients having improved or stable well-being was compared with the proportion having improved or stable qol in relevant rcts.

RESULTS

We identified 906 patients with pre-ppdcesas records. Median survival was 31 weeks compared with 28-48 weeks in rcts. After accounting for deaths and cases lost to follow-up, we estimated that, at 2 months, 62% of the cohort had improved or stable well-being compared with 55%-63% who had improved or stable qol in rcts.

CONCLUSIONS

The effectiveness of ppdc for nsclc in routine practice in Ontario is consistent with its efficacy in rcts, both in terms of survival and improvement in well-being.

Abstract P3-09-08: Patterns of oncotype DX testing and adjuvant chemotherapy use in a tertiary care centre

Introduction:

The Oncotype DX Recurrence Score (RS) is a 21-gene signature, retrospectively validated prognostic marker and predictor of response to adjuvant chemotherapy (ACT) in estrogen receptor (ER) positive breast cancer (BC). In 2010 RS became publicly funded in Ontario for patients with estrogen-positive, HER2 negative and node negative breast cancer. The aim of our study was to explore the pattern of RS testing and use of adjuvant chemotherapy at the Cancer Centre of Southeastern Ontario (CCSEO) since the introduction of RS testing. Additionally we compared the RS tested patients with a matched cohort treated for early BC prior to 2010.

Methods:

A retrospective paper and electronic chart review was undertaken of patients with early BC (stage 1 and 2) with the following pathologic features: T1-T2, N0/N1mic, ER positive and Her-2neu negative. We collected patient demographics, co-morbidities, surgical data, tumour characteristics, ACT use, Adjuvant! mortality estimates and breast cancer outcomes. Cohort A included patients who underwent RS testing (2010 – 2013) and cohort B patients treated prior to 2010. The two cohorts were compared using chi-square tests for categorical data, and independent samples t-tests and the Mann-Whitney U for continuous data.

Results:

160 patients were included in our analysis of which 83 underwent RS testing. Compared to cohort B, cohort A was older (median age 60 versus (vs) 48, p<0.001); had higher postmenopausal status (77 vs 34%, p<0.001); higher rates of breast conserving surgery (88 vs 74%, p=0.024) and sentinel node biopsy (94 vs 26%, p<0.001). Cohort A also had larger tumors (T2 23 vs 5%, p=0.010), higher stage (stage 2 - 24 vs 6%, p=0.002) and higher Adjuvant! mortality estimates above 15% (18 vs 8%, p=0.054). Despite this the use of ACT decreased significantly (20 vs 98%, p<0.001). The majority of patients received adjuvant endocrine treatment (> 90% in both cohorts). Of the 83 patients in cohort A 55 (66%) had low risk RS (0-17), 18 (22%) intermediate risk (18-30) and 10 (12%) high risk RS. ACT was received by 2 of 55 patients with low RS; 6 of 18 patients with intermediate RS and 9 of 10 with high RS. Median follow-up was only 16 months in cohort A vs 74 months in cohort B. 92% of patients in cohort B remain recurrence free. To date only 2 patients in cohort A have recurred, both of which had high RS scores and received ACT.

Conclusion:

In patients with early BC undergoing RS testing at CCSEO we observed a higher proportion of low risk RS as compared to the literature. Additionally, despite larger tumors, higher stage disease and higher Adjuvant! mortality estimates above 15%, the proportion of patients undergoing ACT has significantly decreased since the introduction of RS testing. So far this has not translated into a negative long-term disease outcome although longer follow-up is needed for real-world validation.

Citation Format: Gautam Sudan, Mihaela Mates, Hopman Wilma. Patterns of oncotype DX testing and adjuvant chemotherapy use in a tertiary care centre [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-09-08.

Systemic targeted therapy for her2-positive early female breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline

BACKGROUND

This systematic review addresses the question "What is the optimal targeted therapy for female patients with early-stage human epidermal growth factor receptor 2 (her2)-positive breast cancer?"

METHODS

The medline and embase databases were searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major guideline organizations were also searched.

RESULTS

Sixty publications relevant to the targeted therapy portion of the systematic review were identified. In four major trials (hera, National Surgical Adjuvant Breast and Bowel Project B-31, North Central Cancer Treatment Group N9831, and Breast Cancer International Research Group 006), adjuvant trastuzumab for 1 year was superior in disease-free survival (dfs) and overall survival (os) to no trastuzumab; trastuzumab showed no benefit in one trial (pacs 04). A shorter duration of trastuzumab (less than 1 year compared with 1 year) was evaluated, with mixed results for dfs: one trial showed superiority (finher), one trial could not demonstrate noninferiority (phare), another trial showed equivalent results (E 2198), and one trial is still ongoing (persephone). Longer trastuzumab duration (hera: 2 years vs. 1 year) showed no improvement in dfs or os and a higher rate of cardiac events. Newer her2-targeted agents (lapatinib, pertuzumab, T-DM1, neratinib) have been or are still being evaluated in both adjuvant and neoadjuvant trials, either by direct comparison with trastuzumab alone or combined with trastuzumab. In the neoadjuvant setting (neoaltto, GeparQuinto, Neosphere), trastuzumab alone or in combination with another anti-her2 agent (lapatinib, pertuzumab) was compared with either lapatinib or pertuzumab alone and showed superior or equivalent rates of pathologic complete response. In the adjuvant setting, lapatinib alone or in combination with trastuzumab, compared with trastuzumab alone (altto) or with placebo (teach), was not superior in dfs. The results of the completed aphinity trial, evaluating the role of dual her2 blockade with trastuzumab and pertuzumab, are highly anticipated. Ongoing trials are evaluating trastuzumab as a single agent without adjuvant chemotherapy (respect) and in patients with low her2 expression (National Surgical Adjuvant Breast and Bowel Project B-47).

CONCLUSIONS

Taking into consideration disease characteristics and patient preference, 1 year of trastuzumab should be offered to all patients with her2-positive breast cancer who are receiving adjuvant chemotherapy. Cardiac function should be regularly assessed in this patient population.

Adjuvant chemotherapy for early female breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline

BACKGROUND

The Program in Evidence-Based Care (pebc) of Cancer Care Ontario recently created an evidence-based consensus guideline on the systemic treatment of early breast cancer. The evidence for the guideline was compiled using a systematic review to answer the question "What is the optimal systemic therapy for patients with early-stage, operable breast cancer, when patient and disease factors are considered?" The question was addressed in three parts: cytotoxic chemotherapy, endocrine treatment, and human epidermal growth factor receptor 2 (her2)-directed therapy.

METHODS

For the systematic review, the medline and embase databases were searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major oncology guideline organizations were also searched. The basic search terms were "breast cancer" and "systemic therapy" (chemotherapy, endocrine therapy, targeted agents, ovarian suppression), and results were limited to randomized controlled trials (rcts), guidelines, systematic reviews, and meta-analyses.

RESULTS

Several hundred documents that met the inclusion criteria were retrieved. The Early Breast Cancer Trialists' Collaborative Group meta-analyses encompassed many of the rcts found. Several additional studies that met the inclusion criteria were retained, as were other guidelines and systematic reviews. Chemotherapy was reviewed mainly in three classes: anti-metabolite-based regimens (for example, cyclophosphamide-methotrexate-5-fluorouracil), anthracyclines, and taxane-based regimens. In general, single-agent chemotherapy is not recommended for the adjuvant treatment of breast cancer in any patient population. Anthracycline-taxane-based polychemotherapy regimens are, overall, considered superior to earlier-generation regimens and have the most significant impact on patient survival outcomes. Regimens with varying anthracycline and taxane doses and schedules are options; in general, paclitaxel given every 3 weeks is inferior. Evidence does not support the use of bevacizumab in the adjuvant setting; other systemic therapy agents such as metformin and vaccines remain investigatory. Adjuvant bisphosphonates for menopausal women will be discussed in later work.

CONCLUSIONS

The results of this systematic review constitute a comprehensive compilation of the high-level evidence that is the basis for the 2014 pebc guideline on systemic therapy for early breast cancer. Use of cytotoxic chemotherapy is presented here; the results addressing endocrine therapy and her2-targeted treatment, and the final clinical practice recommendations, are published separately in this supplement.

Emergency Room Visits and Hospital Admission Rates After Curative Chemotherapy for Breast Cancer

The authors conclude that over half of all patients receiving curative chemotherapy for breast cancer visited the emergency room at least once, and 13% required hospital admissions.

Adjuvant endocrine therapy for early breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline

BACKGROUND

Cancer Care Ontario's Program in Evidence-Based Care (pebc) recently created an evidence-based consensus guideline on the systemic treatment of early breast cancer. The evidence for the guideline was compiled using a systematic review to answer the question "What is the optimal systemic therapy for patients with early-stage, operable breast cancer, when patient and disease factors are considered?" The question was addressed in three parts: cytotoxic chemotherapy, endocrine treatment, and her2 (human epidermal growth factor receptor 2)-targeted therapy.

METHODS

For the systematic review, the literature in the medline and embase databases was searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major oncology guideline organizations were also searched. The basic search terms were "breast cancer" and "systemic therapy" (chemotherapy, endocrine therapy, targeted agents, ovarian suppression), and results were limited to randomized controlled trials (rcts), guidelines, systematic reviews, and meta-analyses.

RESULTS

Several hundred documents that met the inclusion criteria were retrieved. Meta-analyses from the Early Breast Cancer Trialists' Collaborative Group encompassed many of the rcts found. Several additional studies that met the inclusion criteria were retained, as were other guidelines and systematic reviews.

SUMMARY

The results of the systematic review constitute a comprehensive compilation of high-level evidence, which was the basis for the 2014 pebc guideline on systemic therapy for early breast cancer. The review of the evidence for systemic endocrine therapy (adjuvant tamoxifen, aromatase inhibitors, and ovarian ablation and suppression) is presented here; the evidence for chemotherapy and her2-targeted treatment-and the final clinical practice recommendations-are presented separately in this supplement.

Optimal systemic therapy for early breast cancer in women: a clinical practice guideline

The Breast Cancer Disease Site Group of Cancer Care Ontario identified the need for new guidelines for the adjuvant systemic therapy of early-stage breast cancer. The specific question to be addressed was "What is the optimal adjuvant systemic therapy for female patients with early-stage operable breast cancer, when patient and disease factors are considered?" A systematic review was prepared based on literature searches conducted using the medline and embase databases for the period January 2008 to March 5, 2012, and updated to May 12, 2014. Guidelines were located from that search, from the Standards and Guidelines Evidence directory of cancer guidelines, and from the Web sites of major guideline organizations. The literature located was subdivided into the broad categories of chemotherapy, hormonal therapy, and therapy targeted to her2 (human epidermal growth factor receptor 2). Although several of the systemic therapies discussed in this guideline can be considered in the neoadjuvant setting, the review focused on trials with rates of disease-free and overall survival as endpoints and thus excluded several trials that used pathologic complete response as a primary endpoint. Based on the systematic review, the working group drafted recommendations on the use of chemotherapy, hormonal therapy, and targeted therapy; based on their professional experience, they also drafted recommendations on patient and disease characteristics and recurrence risk. The literature review and draft recommendations were circulated to a consensus panel of medical oncologists who had expertise in breast cancer and who represented the regions of Ontario. Items without initial consensus were discussed at an in-person consensus meeting held in Toronto, November 23, 2012. The final recommendations are those for which consensus was reached before or at the meeting. Some of the key evidence was revised after the updated literature search. Evidence reviews for systemic chemotherapy, endocrine therapy, and targeted therapy for her2-positive disease are reported in separate articles in this supplement. The full three-part 1-21 evidence-based series, including complete details of the development and consensus processes, can be found on the Cancer Care Ontario Web site at https://www.cancercare.on.ca/toolbox/qualityguidelines/diseasesite/breast-ebs.

Abstract P6-06-56: Emergency room visits and hospital admission rates after curative chemotherapy for breast cancer. A retrospective single center experience

Purpose:Patients undergoing curative (adjuvant or neoadjuvant) chemotherapy (CT) for breast cancer in the Southeast Ontario Local Heath Integration Network (LHIN) have higher rates of emergency room (ER) visits and hospital admissions (HA) compared to other LHINs in Ontario, Canada. This study is to determine factors associated with ER visits and HA after curative chemotherapy for breast cancer in a tertiary Ontario hospital.

Methods:A retrospective study was conducted of all patients who completed at least one cycle of curative CT for breast cancer at the Cancer Centre for Southeastern Ontario (CCSEO) in 2011 and 2012. We recorded all ER visits and/or HA within 30 days of any cycle of CT. Data collected included demographics, co-morbidities, type and date of surgery, pathologic tumour characteristics (stage, grade and receptor status), type of CT (adjuvant or neoadjuvant) and number of cycles, use and type of granulocyte-colony stimulating factors (G-CSF). We recorded dates and reasons for ER visits, referring patterns to the ER, date of admission and length of stay. Chi-square and t-tests were calculated to determine factors associated with ER visits and HA.

Results:149 patients received curative CT at the CCSEO in 2011 and 2012. Mean age was 58 (range 31-88). 97.3% of patients were female. Comorbidities included hypertension (28.4%), diabetes (10.1%), dyslipidemia (10.1%), coronary artery disease (4.7%) and COPD (2%). Stage distribution was: 4.3% stage 1, 48.6% stage 2 and 36.4% stage 3. 60.8% of patients had grade 3 tumors. 69.8% were ER positive and 61.1% were PR positive. 26.2% were Her2 positive. 62.4% had breast conserving surgery and 56.4% had sentinel lymph node biopsy. Most patients received adjuvant CT (85.2%). The most common CT regimen was FEC-D (89.9%), followed by TC (5.4%) and CMF (4%). 88.6% of patients received G-CSF (either Neupogen or Neulasta) at some point during CT. 53% (n = 79) of patients were seen in the ER at least once within 30 days of CT while 13.4% (n = 20) were admitted to hospital. 36.7% (n = 29) had multiple ER visits. There were a total of 133 ER visits. The most common causes of ER visits were fever without neutropenia (23.3%), pain (13.5%) and febrile neutropenia (9%). Most ER visits occurred on weekdays (74%). We analyzed the following factors associated with ER visits and HA rates: age, gender, comorbidities, TNM staging, grade, receptor status, type of surgery and CT (adjuvant versus neoadjuvant). The only statistically significant factor associated with a higher likelihood of ER visits was stage IIIC breast cancer (p = 0.045). Statistically significant factors associated with HA were tumor size with T2 more likely to be admitted (p = 0.019), adjuvant CT (p = 0.045) and number of CT cycles (p = 0.017).

Conclusions:Over half of all patients receiving curative CT for breast cancer at the CCSEO in 2011 and 2012 visited the ER at least once and more than 1/3 required multiple visits. The only factor associated with ER visits included stage of disease. Factors associated with HA were tumour size, adjuvant CT and number of CT cycles. While most patients received G-CSF at some point during their CT, febrile neutropenia was still the third most common reason for ER visits.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-56.