Phase II trial of docetaxel, cisplatin and 5FU chemotherapy in locally advanced and metastatic penis cancer (CRUK/09/001)

BACKGROUND

Penis cancer is rare and clinical trial evidence on which to base treatment decisions is limited. Case reports suggest that the combination of docetaxel, cisplatin and 5-flurouracil (TPF) is highly active in this disease.

METHODS

Twenty-nine patients with locally advanced or metastatic squamous carcinoma of the penis were recruited into a single-arm phase II trial from nine UK centres. Up to three cycles of chemotherapy were received (docetaxel 75 mg m(-2) day 1, cisplatin 60 mg m(-2) day 1, 5-flurouracil 750 mg m(-2) per day days 1-5, repeated every 3 weeks). Primary outcome was objective response (assessed by RECIST). Fourteen or more responses in 26 evaluable patients were required to confirm a response rate of 60% or higher (Fleming-A'Hern design), warranting further evaluation. Secondary endpoints included toxicity and survival.

RESULTS

10/26 evaluable patients (38.5%, 95% CI: 20.2-59.4) achieved an objective response. Two patients with locally advanced disease achieved radiological complete remission. 65.5% of patients experienced at least one grade 3/4 adverse event.

CONCLUSION

Docetaxel, cisplatin and 5FU did not reach the pre-determined threshold for further research and caused significant toxicity. Our results do not support the routine use of TPF. The observed complete responses support further investigation of combination chemotherapy in the neoadjuvant setting.

Hyperglycaemia-induced chemoresistance of prostate cancer cells due to IGFBP2

Clinically relevant prostate cancer (PCa) is more frequent in Westernised societies and increasingly men have co-morbidities associated with a Western lifestyle, primarily diabetes, characterised by hyperinsulinaemia and hyperglycaemia. IGFs and their binding proteins (IGFBPs) are important mediators of the effects of nutrition on growth and play a key role in the development of PCa. We used DU145, PC3 and LNCaP PCa cell lines to examine how hyperglycaemia altered their response to docetaxel. Trypan Blue dye-exclusion assay was used to determine the percentage of cell death. Protein abundance was determined using western immunoblotting. Levels of IGFBP2 were measured using an ELISA. IGFBP2 gene silencing was achieved using siRNA technology. DNA methylation was assessed using combined bisulphide restriction analysis. Acetylation status of histones H3 and H4 associated with IGFBP2 gene was assessed using chromatin immunoprecipitation assay. Hyperglycaemia reduced docetaxel-induced apoptosis by 40% for DU145 cells and by 88% for LNCaP cells. This reduced cell death was mediated by a glucose-induced up-regulation of IGFBP2, as silencing IGFBP2 negated the survival effect of high glucose. Glucose increased IGFBP2 via increasing the acetylation of histones associated with the IGFBP2 gene promoter. This finding could have important implications in relation to therapeutic strategies as epigenetic modulation could be reversible.

Impact of cabazitaxel on 2-year survival and palliation of tumour-related pain in men with metastatic castration-resistant prostate cancer treated in the TROPIC trial

BACKGROUND

Cabazitaxel significantly improves overall survival (OS) versus mitoxantrone in patients with metastatic castration-resistant prostate cancer after docetaxel failure. We examined patient survival at 2 years and tumour-related pain with cabazitaxel versus mitoxantrone.

METHODS

Updated TROPIC data (cut-off 10 March 2010) were used to compare 2-year survival between treatment groups and assess patient demographics and disease characteristics. Factors prognostic for survival ≥2 years were assessed. Pain and Eastern Cooperative Oncology Group performance status were evaluated in the overall patient population.

RESULTS

Median follow-up was 25.5 months. After 2 years, more patients remained alive following cabazitaxel than mitoxantrone [odds ratio 2.11; 95% confidence interval (CI) 1.33-3.33]. Treatment with cabazitaxel was prognostic for survival ≥2 years. Demographics/baseline characteristics were balanced between treatment arms irrespective of survival. Pain at baseline and pain response were comparable between treatment groups. Average daily pain performance index was lower for cabazitaxel versus mitoxantrone (all cycles; 95% CI -0.27 to -0.01; P = 0.035) and analgesic scores were similar. Grade ≥3 peripheral neuropathies were uncommon and comparable between treatment groups.

CONCLUSIONS

Cabazitaxel prolongs OS at 2 years versus mitoxantrone and has low rates of peripheral neuropathy. Palliation benefits of cabazitaxel were comparable to those of mitoxantrone. The study was registered with www.ClinicalTrials.gov (NCT00417079).

Umbilical cord blood transplant for malignancies: a hope or hype

Cord blood is a rich and unlimited source of hematopoietic stem cells for allogeneic stem cell transplant to treat a variety of oncologic, genetic, hematologic, and immunodeficiency disorders. Since the first successful cord blood transplant in 1988, a large number of cord blood banks have been established world over for collection and storage of cord blood for future use. Majority of such transplants are performed in children, however, the number in adults have been growing steadily in recent years. Results from various transplant registries reveals that a single cord blood provides enough stem cells to provide short and long term engraftment, and has low incidence and less severity of graft versus host disease. With a high booming birth rate and a large genetic diversity, India has potential to become the largest supplier of cord blood stem cells in world. To meet the future transplant need of the country sincere efforts from various institutes and government agencies are needed to increase the number of public cord blood banks in the country. In this article the author will focus on the issue of public and private cord blood banking; the role of physicians in educating and counseling families with regard to the utility of cord blood for donor itself as well as the future of umbilical cord blood transplant in India.

Prevalence and trends of human papillomavirus in oropharyngeal cancer in a predominantly north Indian population

BACKGROUND

Human papillomavirus (HPV) prevalence in oropharyngeal squamous cell cancer (SCC) remains variable and studies have estimated that up to 60% may be positive.

METHODS

One hundred five treatment-naïve oropharyngeal SCC patients were included. HPV genotyping was done by consensus polymerase chain reaction (PCR) and reverse line-blot hybridization assay. HPV prevalence was co-related with sex, age, tobacco consumption, alcohol use, and high-risk sexual behavior.

RESULTS

HPV prevalence was 22.8%. No significant associations were seen between tobacco or alcohol consumption with HPV status. The mean number of lifetime sexual partners and indulgence in high-risk sexual behavior was significantly more in patients who are HPV positive. There were no significant associations between the 2 groups with respect to the stage of the tumor.

CONCLUSION

Results of this study confirms that patients who are HPV positive are younger, and with high-risk sexual behavior. We did not find any impact of smoking and alcohol consumption on HPV status.

The management of ductal carcinoma in situ: current controversies and future directions

The incidence of ductal carcinoma in situ (DCIS) has increased in recent decades, primarily due to the widespread implementation of breast cancer screening. Traditionally, the management of DCIS has mirrored that of invasive breast cancer, with a focus on adequate surgical excision, breast-conserving surgery, adjuvant radiotherapy and endocrine therapy. However, an increasing understanding of the biology of this spectrum of conditions many mean that some cases may be managed more conservatively, reserving aggressive therapies for those patients at high risk of progression to invasive disease, ultimately aiming for a personalised approach based on individual risk factors. This overview highlights the key evidence behind current practice and discusses the rationale for current and future clinical trials in DCIS.

Cost of skeletal-related events in European patients with solid tumours and bone metastases: data from a prospective multinational observational study

OBJECTIVES

Patients with bone metastases often experience skeletal-related events (SREs: radiation or surgery to bone, pathologic fracture, and spinal cord compression). This study examined health resource utilization and costs associated with SREs.

METHODS

Data presented are from the European cohort (Germany, Italy, Spain, and the UK) of patients with solid tumours enrolled in a multi-national, prospective, observational study in patients with solid tumours or multiple myeloma. Patients with Eastern Cooperative Oncology Group score 0-2 and life expectancy ≥6 months, who experienced an SRE up to 97 days before enrolment, were eligible. Health resource utilization associated with SREs (including number/length of inpatient stays, numbers of procedures and outpatient visits) were collected through chart review for up to 97 days before enrolment and prospectively during follow-up. Country-specific cost calculations were performed.

RESULTS

In total, 478 eligible patients contributed 893 SREs to this analysis. Radiation to bone occurred most frequently (66% of total). Spinal cord compression (7%) and surgery to bone (10%) were the least common events, but most likely to require inpatient stays. The most costly SREs were also spinal cord compression (mean per SRE across countries, €4884-€12,082) and surgery to bone (€3348-€9407). Inpatient stays were the main cost drivers.

LIMITATIONS

Health resource utilization used to calculate the costs associated with SREs may have been under-estimated as a result of exclusion of patients with low performance status or life expectancy; unavailable information and exclusion of resource consumption associated with pain. Thus, the estimate of associated costs is likely to be conservative.

CONCLUSIONS

SREs result in considerable health resource utilization, imposing a substantial financial burden driven by inpatient stays. Treatments that prevent/delay SREs may help ease this burden, thereby providing cost savings across European healthcare systems.

Autologous stem cell transplantation for multiple myeloma: identification of prognostic factors

INTRODUCTION

The purpose of this study was to evaluate the effect of prognostic factors on the outcome of patients with MM after ASCT.

PATIENTS AND METHODS

We analyzed results of 170 consecutive patients (121 male and 49 female) of MM who underwent ASCT. Patients' median age was 52 years (range, 26-68 years). High dose melphalan (200 mg/m(2)) was used for conditioning. One hundred thirty-two patients (77.6%) had evidence of chemosensitive disease before transplant. Response was assessed using European Group for Blood and Bone Marrow Transplantation criteria.

RESULTS

Post ASCT 44.7% of patients achieved CR, 24.7% had very good partial response (VGPR), and 21.2% had partial response (PR). Presence of pretransplant chemosensitive disease (CR, VGPR, and PR) and transplant within 12 months of diagnosis for years before 2006 were associated with higher response rates on multivariate analysis. At a median follow-up of 84 months, median overall (OS) and event-free survival (EFS) is 85.5 and 41 months, respectively. Estimated OS and EFS at 60 months is 62 ± 0.04% and 41 ± 0.04%, respectively. Patients who responded to transplant (CR, VGPR, and PR) had a longer OS (P < .001) and EFS (P < .001). Additionally, patients who achieved CR post transplant had a longer OS (P < .001) and EFS (P < .001). Patients who received novel agents for induction pretransplant had a longer OS (P < .001) and EFS (P < .002).

CONCLUSION

Outcome after ASCT is better for myeloma patients with pretransplant chemosensitive disease and those who achieve CR after transplant.

Dasatinib in chronic myeloid leukemia: a limited Indian experience

AIM

To report our experience of the use of dasatinib in various phases of chronic myeloid leukemia (CML).

METHODS

Ten patients in various phases of CML, not responding to imatinib and started on dasatinib, were included and analyzed. The baseline characteristics of the patients and their salient features including the duration and response to initial therapy as well as to dasatinib, were noted.

RESULTS

Before starting dasatinib three patients were in chronic phase of CML while seven others were in the progressive phase (accelerated and blast phase) of CML. Half the patients developed transient grade 3 and 4 toxicities to dasatinib. Overall, the tolerability of the drug in all 10 patients was acceptable and none discontinued treatment. Three patients died due to progressive disease while the remaining seven are continuing the drug with the disease still under cytogenetic or hematological remission. Of the 10 patients, seven achieved complete hematological response and two of the accelerated phase/blast crisis patients achieved complete cytogenetic response. Overall, dasatinib was able to control disease for a median of 20.6 months.

CONCLUSION

Despite small sample size and insufficient information on mutational analysis, dasatinib is effective in CML in India. Cost limits the use of second-generation tyrosine kinase inhibitors in India. Our observation is not suitable for survival analysis but the difference made by dasatinib in progressive disease and its tolerability needs to be acknowledged.

Prevalence, trends, and survival impact of human papillomavirus on oropharyngeal cancer in Indian population

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Background: Among oropharyngeal squamous cell carcinoma (OSCC), the true prevalence of HPV remains variable and studies have estimated that up to 60% may be HPV positive. Patients with HPV positive tumor are usuallyyounger in age, less likely to have history of tobacco or alcohol consumption and associated with a better prognosis but this information for Indian patients is largely unknown. Methods: 105 newly diagnosed patients of OSCC were enrolled. HPV genotyping was done on the biopsy specimen by consensus polymerase chain reaction and reverse line-blot hybridization assay. HPV prevalence was studied according to gender, age, tobacco and alcohol use and high risk sexual behavior. Results: Overall HPV prevalence was 22.8%. HPV positive patients were younger by 8 years as compared to negative patients (P=0.003). No significant correlation between tobacco consumption, alcoholic habits, and HPV status was observed. The mean number of life time sexual partners in HPV positive patients was 1.66 while, it was 1.33 in HPV negative patients (P=0.049). Incidence of high risk sexual behaviors was more in HPV positive patients (P<0.001). There were no significant associations between the two groups with respect to tumor size, nodal stage and the overall stage of the tumor. 16% of the base of tongue cancers and 40% of tonsillar carcinoma were positive (P = 0.02). Among positive samples, HPV 16 was the commonest (79%) followed by HPV 18 (12%). 96% of patients received treatment. At 18.8 months there was no significant difference in OS, EFS between HPV positive and negative OSCC (P = 0.97 and P= 0.51 respectively). Conclusions: The current study reconfirms that HPV positive OSCC patients are younger with high risk sexual behavior. Impact of smoking and alcohol consumption on HPV status was not found in this study. HPV positive rates were significantly higher for tonsillar cancer. Contrary to literature, we did not find any differences in OS or EFS between two groups. Small numbers of patients in the study group, short follow up period and significant tobacco smoking in HPV group may be the one of the reason for this.

P4-16-09: Health Resource Utilization (HRU) Associated with Skeletal-Related Events (SREs) in Advanced Breast Cancer Patients with Bone Metastases: Results from a Prospective Multinational Observational Study

Background Patients with advanced breast cancer and bone metastases suffer from skeletal complications (SREs, defined as spinal cord compression [SCC], surgery to bone [SB], pathologic fracture [PF] or radiation to bone [RB]). Planning future resource requirements and estimating the value of new treatment options requires prospective data on the health resource burden. However, there is a lack of these data in the literature.

Materials and Methods Patients had bone metastases secondary to advanced breast cancer and were eligible to be included in the study if they had: at least one SRE within 90 days prior to enrolment; life expectancy &gt;6 months; ECOG≤2. HRU (number and length of inpatient hospitalizations, outpatient visits, emergency room visits, number of procedures, etc) associated with SREs was collected retrospectively for 90 days prior to enrolment and prospectively for up to 18–21 months. Attribution of HRU to each SRE was determined independently by the investigators. This pooled European analysis includes data for breast cancer patients from centers in Germany, Italy, Spain and UK.

Results A total of 223 eligible patients with breast cancer and bone metastases were enrolled from the four countries. A total of 118 of 457 SREs (25.8%) were associated with inpatient stays with a mean duration of 18.2 (SD=15.7) days per inpatient stay (for the total 125 stays; a single SRE could contribute multiple hospitalizations). The length of inpatient stays varied by facility (i.e., oncology, radiation, surgical) and SRE type. The most common SRE requiring hospitalization was SB (42 of 54 events [77.8%]) with 45 inpatient stays requiring an average length of stay of 15.1 (SD=16.8) days. The least common SRE requiring hospitalization, RB (27 of 279 events [9.7%]), was still associated with 23 inpatient stays with an average of 16.7 (SD=12.4) days per inpatient stay. A total of 342 SREs (74.8%) required an outpatient visit and 159 (34.8%) required &gt;5 visits. As expected, RB was associated with the highest number of outpatient visits (239 of 279 [85.7%] SREs). SB and PF were associated with fewer outpatient visits with 23 of 54 (42.6%) of 54 SREs and 66 of 105 (62.9%) SREs requiring a visit, respectively. 22 of 457 (4.8%) SREs were associated with an emergency room visit.

Discussion SREs can lead to lengthy hospitalizations and numerous outpatient visits. Neither pain requiring opioid use nor changes in cancer therapy to treat bone pain were reported as SREs, although they may have led to additional inpatient and outpatient visits. Thus, HRU estimated in this study likely underestimates overall HRU associated with SREs in advanced breast cancer patients. Relatively low utilization of emergency room visits reported here may be due to emergency care provided directly by the specialist oncology unit or the patient visiting a different institution. Preventing SREs in advanced breast cancer patients may help to reduce the financial burden to the European healthcare systems.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-16-09.