A randomized placebo-controlled trial of rush preseasonal depigmented polymerized grass pollen immunotherapy

BACKGROUND

Specific subcutaneous immunotherapy (SCIT) for seasonal rhinoconjunctivitis with unmodified allergen extracts is effective, but limited by risk of side-effects and involves treatment over 3 years. We examined a depigmented polymerized grass pollen extract for immunogenicity and for clinical efficacy in a rush preseasonal regimen.

METHODS

Depigmented polymerized grass pollen extract was tested for proliferation and cytokine production by peripheral blood mononuclear cells. A prospective, double-blind, placebo-controlled trial of 195 grass pollen allergic patients treated with preseasonal rush immunotherapy using depigmented polymerized allergenic extract of mixed grass pollen was performed over 2 years. Primary outcome was combined symptom and medication score (SMS) during the peak of the second grass pollen season. Secondary outcomes included combined score over the whole season, during the first grass pollen season, individual symptom and medication scores, quality of life, well days/hell days and responder analysis. Adverse events were classified using the EAACI scale. Grass pollen-specific IgE and IgG4 were measured before and during treatment.

RESULTS

Depigmented polymerized extract stimulated dose-dependent T-cell proliferation and cytokine production. Patients treated with preseasonal SCIT showed improved combined scores during peak season at year 2 (median 3.93, interquartile range 0.77-6.27 vs median 5.86 for placebo, 3.11-8.36, P < 0.01). Most secondary outcomes were significantly better for active treatment. Side-effects were minimal, with no grade 3 or 4 reactions.

CONCLUSIONS

Depigmented polymerized grass pollen extract is immunogenic and clinically effective in rush preseasonal SCIT. This form of immunotherapy may be an attractive option for some patients.

Updated survival and outcomes for older adults with inoperable stage III non-small-cell lung cancer treated with cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel: analysis of a phase III trial from the Hoosier Oncology Group (HOG) and US Oncology

BACKGROUND

Concurrent chemoradiation with etoposide and cisplatin (EP/XRT) is standard treatment for inoperable stage III locally advanced non-small-cell lung cancer (LA-NSCLC). Consolidation docetaxel (D; Taxotere) after EP/XRT resulted in increased toxicity but no improvement in survival compared with observation (O). We report updated survival for the entire study population and include an analysis of efficacy and tolerability of EP/XRT with or without D in patients aged ≥ 70 years.

PATIENTS AND METHODS

Hoosier Oncology Group LUN 01-24 enrolled 243 patients with LA-NSCLC and randomized 166 after EP/XRT to three cycles of D versus O. the trial was terminated after an analysis of the first 203 patients demonstrated futility of D.

RESULTS

Median survival time (MST) for the overall study population was 21.5 months, and 3-, 4-, and 5-year survival rates were 30.7%, 18.0%, and 13.9%, respectively. No differences in MST or 3-year survival were noted between D and O arms. Older patients had similar MST (17.1 versus 22.8 months for younger patients, P = 0.15) but higher rates of grade 3/4 toxicity and hospitalization during induction.

CONCLUSIONS

Consolidation docetaxel after EP/XRT does not improve survival in LA-NSCLC. Fit older adults with LA-NSCLC benefit from concurrent chemoradiation similarly as younger patients but experience higher rates of hospitalization and toxicity.

Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis

OBJECTIVES

To provide an overview of methods to identify postnatal depression (PND) in primary care and to assess their validity, acceptability, clinical effectiveness and cost-effectiveness, to model estimates of cost, to assess whether any method meets UK National Screening Committee (NSC) criteria and to identify areas for future research.

DATA SOURCES

Searches of 20 electronic databases (including MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, DARE and CDSR), forward citation searching, personal communication with authors and searching of reference lists.

REVIEW METHODS

A generalised linear mixed model approach to the bivariate meta-analysis was undertaken for the validation review with quality assessment using QUADAS. Within the acceptability review, a textual narrative approach was employed to synthesise qualitative and quantitative research evidence. For the clinical and cost-effectiveness reviews methods outlined by the Centre for Reviews and Dissemination and the Cochrane Collaboration were followed. Probabilistic models were developed to estimate the costs associated with different identification strategies.

RESULTS

The Edinburgh Postnatal Depression Scale (EPDS) was the most frequently explored instrument across all of the reviews. In terms of test performance, postnatally the EPDS performed reasonably well: sensitivity ranged from 0.60 (specificity 0.97) to 0.96 (specificity 0.45) for major depression only; from 0.31 (specificity 0.99) to 0.91 (specificity 0.67) for major or minor depression; and from 0.38 (specificity 0.99) to 0.86 (specificity 0.87) for any psychiatric disorder. Evidence from the acceptability review indicated that, in the majority of studies, the EPDS was acceptable to women and health-care professionals when women were forewarned of the process, when the EPDS was administered in the home, with due attention to training, with empathetic skills of the health visitor and due consideration to positive responses to question 10 about self-harm. Suggestive evidence from the clinical effectiveness review indicated that use of the EPDS, compared with usual care, may lead to reductions in the number of women with depression scores above a threshold. In the absence of existing cost-effectiveness studies of PND identification strategies, a decision-analytic model was developed. The results of the base-case analysis suggested that use of formal identification strategies did not appear to represent value for money, based on conventional thresholds of cost-effectiveness used in the NHS. However, the scenarios considered demonstrated that this conclusion was primarily driven by the costs of false positives assumed in the base-case model.

CONCLUSIONS

In light of the results of our evidence synthesis and decision modelling we revisited the examination of PND screening against five of the NSC criteria. We found that the accepted criteria for a PND screening programme were not currently met. The evidence suggested that there is a simple, safe, precise and validated screening test, in principle a suitable cut-off level could be defined and that the test is acceptable to the population. Evidence surrounding clinical and cost-effectiveness of methods to identify PND is lacking. Further research should aim to identify the optimal identification strategy, in terms of key psychometric properties for postnatal populations. In particular, research comparing the performance of the Whooley and help questions, the EPDS and a generic depression measure would be informative. It would also be informative to identify the natural history of PND over time and to identify the clinical effectiveness of the most valid and acceptable method to identify postnatal depression. Further research within a randomised controlled trial would provide robust estimates of the clinical effectiveness.

The plasmonic engineering of metal nanoparticles for enhanced fluorescence and Raman scattering

We have investigated the effects of tuning the localized surface plasmon resonances (LSPRs) of silver nanoparticles on the fluorescence intensity, lifetime, and Raman signal from nearby fluorophores. The presence of a metallic structure can alter the optical properties of a molecule by increasing the excitation field, and by modifying radiative and nonradiative decay mechanisms. By careful choice of experimental parameters we have been able to decouple these effects. We observe a fourfold increase in fluorescence enhancement and an almost 30-fold increase in decay rate from arrays of Ag nanoparticles, when the LSPR is tuned to the emission wavelength of a locally situated fluorophore. This is consistent with a greatly increased efficiency for energy transfer from fluorophores to surface plasmons, resulting in a significant increase in quantum yield. Additionally, spatial mapping of the surface enhanced Raman scattering signal from a nanoparticle array reveals highly localized differences in the excitation field.

Personalized treatment planning

This chapter aims to outline a flexible framework which the dental team can use to bring together key elements of information about their patients and their patients' teeth in order to plan appropriate, patient-centred, caries management based on the application of best current evidence and practice. This framework can be enabled by the use of the International Caries Detection and Assessment System (ICDAS) clinical visual scoring systems for caries detection and activity, but also needs additional information about lesions and the patient to plan and then monitor the effectiveness of personalized caries care. The treatment planning process has evolved from restorative treatment decisions being largely made during clinical assessment as an examination of wet teeth proceeds, with limited charting and a minor role for patient factors. Best practice now involves a comprehensive examination being made systematically of clean dry teeth using sharp eyes and blunt probes. The ICDAS-enabled framework provides for information to be collected at the tooth/surface level (clinical visual lesion detection, lesion detection aids and lesion activity assessment) and at the patient level (patient caries risk assessment, dentition and lesion history and patient behavioural assessment). This information is then synthesized to inform integrated, personalized treatment planning which involves the choice of appropriate treatment options (background level care, preventive treatment options, operative treatment options) and then recall, reassessment and monitoring. Examples of international moves towards using integrated, personalized treatment planning for caries control are given, drawing on experiences in the UK, the USA and from the ICDAS Committee.

Dose-finding study of NKTR-102 in combination with cetuximab

e13503

Background: NKTR-102 is an advanced polymer conjugate of irinotecan with broad single agent activity and a unique pharmacokinetic (pk) profile. The apparent half-life of the active metabolite SN-38 in patients (pts) administered NKTR-102 is approximately 50 days. NKTR-102 in combination with cetuximab was evaluated in pts with refractory solid tumors to define the maximum tolerated dose (MTD). Methods: NKTR-102 was infused over 90 minutes every 3 weeks per cycle. Cetuximab was infused over 2 hours at 400mg/m2 on day 1 followed by a weekly 1 hour infusion at 250mg/m2. Cohorts of 3 -12 pts were treated with escalating doses of NKTR- 102. MTD was established based on the dose limiting toxicities observed in cycle 1 and safety data from subsequent cycles. Serial plasma samples were collected throughout the study for PK analysis. Results: Eighteen pts were enrolled: main tumor types include colon (5), pancreas (4), rectal (2), breast (2), gastric (1), other (4). Pts received 100 mg/m2 (12) or 125 mg/m2 (6) of NKTR-102 for a median of 2.5 cycles (range 1 to 11+). At 125 mg/m2, 3 pts had G3 diarrhea, 1 in cycle 1; 2 in cycle 2. At 100mg/m2, 1 pt had G3 diarrhea in cycle 1 and a further pt had G4 fatigue in cycle 2. Other G3 toxicities for all patients in both dose groups include nausea (3), vomiting (3) and neutropenia (2). No G3 rash was reported. Partial responses (PR) were observed in 3 pts at 100 mg/m2: confirmed (rectal, colorectal) and unconfirmed (gastric). Another pt with pancreatic cancer had a decrease in CA19–9 from 2000 at baseline to 157 U/ml with associated symptomatic benefit. NKTR-102 resulted in sustained exposure to SN-38 with no evidence of PK drug interactions between NKTR-102 and cetuximab. Conclusions: NKTR-102 shows evidence of clinical antitumor activity in combination with cetuximab. Toxicity is manageable; diarrhea and neutropenia are dose limiting. The recommended dose of NKTR-102 with cetuximab is 100mg/m2 every three weeks. Data support further evaluation of this combination in appropriate tumor types.

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An open-label, multicenter, phase II study of AT-101 in combination with rituximab (R) in patients with untreated, grade 1-2, follicular non-Hodgkin's lymphoma (FL)

8582

Background: Bcl-2 family proteins are overexpressed in the majority of patients with FL and contribute to resistance to therapy. AT-101 is a pan-Bcl-2 inhibitor (Bcl-2, Bcl-XL, Bcl-W, and Mcl-1) and potent inducer of proapoptotic proteins. It is active as a single agent and in combination with R in NHL tumor models. Methods: Patients with untreated FL who did not require immediate chemotherapy were eligible. Treatment consisted of an induction cycle of AT-101 (30mg po daily × 21) and R (375 mg/m2 weekly × 4) followed by up to 4 maintenance cycles of AT-101 (30mg po daily × 21) and R (375 mg/m2) every 8 weeks in nonprogressors. Endpoints evaluated the response rate (RR) at week 8 (primary), overall response rate (ORR), molecular response rate (BCL-2JH rearrangement in blood and bone marrow), and safety of the combination. A mini-Max, 2-stage design (52 pts planned) was used to detect >70% RR with power of 90% and alpha of 0.10. Results: 23 pts enrolled: median age 64 yrs; FLIPI 0–5: 0%/17%/65%/13%/4%; Grade 1/2: 61%/39%; bulky disease (>5cm3): 35%; stage: 1–4 4%/4%/30%/61%; bone marrow + 48%. All pts received induction and 18 pts received 1 or more maintenance cycles. RR following induction was 26% (95%CI=10.2–48.4), 4% CR and the best ORR was 70% (95%CI=47.1–86.8), 35% CR. Molecular response analysis is ongoing. Grade 3/4 AEs that occurred in ≥2 pts: nausea 4(17%), vomiting 2(9%), abdominal pain 2(9%), fatigue 2(9%), and small bowel obstruction 2(9%). AT-101 was reduced to 20mg daily x 21 which improved GI tolerability. Conclusions: The combination of AT-101 and R was well tolerated. The week 8 RR did not meet statistical criteria to enroll stage II. The best ORR is at the upper limit of reported ORR for R alone; therefore a randomized trial is required to definitively determine activity of the combination.

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Phase II study of single agent perifosine in patients with hepatocellular carcinoma (HCC)

e15505

Background: Perifosine (Peri) is a novel oral alkylphospholipid with effects on multiple signal transduction pathways including Akt, MAPK and JNK. Unresectable HCC continues to have dismal prognosis. In a phase III randomized study, sorafenib demonstrated a 2% partial response (PR) rate with a median time to symptomatic progression of 4.1 months (mos) and radiologic progression of 5.5 mos, however patients (pts) had not received prior systemic treatment. Hence, additional therapies are needed. Peri was evaluated in a phase II multi-disease trial where 558 pts were randomized to daily vs. weekly schedules of Peri (50/100 mg daily or 900/1,200 mg weekly) with 42 of the pts having HCC. The following are the efficacy and safety results of this sub-group. Methods: Pts with advanced measurable HCC, up to 3 prior systemic treatments allowed. Normal organ / marrow function required. Primary outcome analyses included median time to progression (TTP) and disease control rate (DCR; CR+PR+SD > 12 weeks). Results: Of the 42 HCC pts treated, the median age was 71 (range 26–83), 22 were male and 48% had received > 1 prior systemic therapy. Child-Pugh status not available. As of 12/08, 32/42 pts were evaluable for efficacy (5 withdrew consent < 30 days, 4 toxicity < 30 days, 1 lost to follow up). One patient achieved a PR (3%) and 15 (47%) had stable disease > 12 weeks; overall DCR of 50%. Median TTP was 14 wks (range 2–86). As of 12/08, one patient remains active at 12 mos. The daily dose was well tolerated. The weekly dose was significantly more toxic (3 of the 4 who came off treatment < 30 days due to toxicity were on weekly). Most common grade 1/2 toxicities were GI related and fatigue. Grade 3/4 drug-related toxicities > 10% included: abdominal pain (12%), elevated liver enzymes (10%) and fatigue (10%). Conclusions: Perifosine was well tolerated at the daily dose and overall demonstrates clinical benefit in patients with advanced HCC as reflected by an encouraging TTP. A combination study with sorafenib is ongoing and future randomized studies are under consideration.

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Randomized phase II study of perifosine in combination with capecitabine versus capecitabine alone in patients with second- or third-line metastatic colon cancer

4081

Background: Perifosine (Peri), a synthetic alkylphospholipid, inhibits or modifies a number of different signal transduction pathways (AKT, MAPK and JNK). Peri as a single agent or in combination with other cytotoxic agents, has shown clinical benefit with a manageable safety profile. In a phase I solid tumor trial, Peri was safely combined with capecitabine (Cap) and demonstrated interesting activity in patients (pts) with metastatic colorectal cancer (mCRC), with one patient progression-free for 49 weeks (wks). To assess the true effect of Peri, a phase II was initiated as an exploratory randomized double-blind, placebo controlled study where mCRC pts received Cap in combination with Peri or placebo. Methods: Pts with 2nd or 3rd line mCRC, not previously treated with single agent Cap. ECOG PS 0–1, normal organ/marrow function required. Dose for Cap was 825 mg/m2 BID d 1–14 q 3 weeks. Dose for Peri or placebo was 50 mg qd. Primary outcome analyses included median time to progression (TTP) and response rate (CR+PR). Results: 37 pts have been randomized. Median age 68 (range 32–83) and 57% were male. Median prior Rx was 2 (range 1 - 5). For the analyses, 25 pts were unblinded (12 too early) with 22/25 pts evaluable for response (2 pts off for toxicity at d 14, 46 and 1 patient off at d 4 for other disease; all 3 pts were on Cap + placebo). Results in table below. The log-rank p-value comparing active to placebo for TTP is 0.01. As of 12/08, all unblinded pts are off treatment and 11/12 that were too early remain on treatment with enrollment ongoing. Most frequent (>5%) grade 3 /4 adverse events for Cap + Peri was hand/foot syndrome (16%) and anemia (8%); for Cap + placebo was fatigue (8%). Conclusions: Perifosine in combination with capecitabine was well tolerated, clinically active and more than doubled median TTP over capecitabine alone in pts with advanced, metastatic CRC.

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A phase Ib study to evaluate the safety and efficacy of AMG 655 in combination with gemcitabine (G) in patients (pts) with metastatic pancreatic cancer (PC)

4501

Background: AMG 655 is an investigational, fully human agonist monoclonal antibody (IgG1) that binds human death receptor 5 (DR5), activates caspases, and induces apoptosis in sensitive tumor cells. In preclinical PC models, cooperative activity is observed when G is added to AMG 655. We performed a multi-center phase I trial to evaluate AMG 655 + G in metastatic PC pts. The primary endpoint was dose-limiting toxicity (DLT). Secondary endpoints included toxicity, pharmacokinetics, antibody formation, objective response rate, progression-free survival (PFS), 6-month and overall survival. Methods: Eligible pts had previously untreated metastatic PC and ECOG PS 0 or 1. Pts enrolled into sequential cohorts and received AMG 655 3 or 10 mg/kg IV days (D) 1 and 15 and G 1000 mg/m2 IV D 1, 8, and 15 every 28 D. CT scans were obtained Q8 weeks. Results: 13 pts (3 mg/kg cohort = 6; 10 mg/kg cohort = 7) enrolled from 7/07–11/07. Pt characteristics: females 61%; ECOG PS 1 69%; median age 65 (range 35–81); liver metastases 77%. Median number of cycles: 6 (range 2–12). There were no DLT. Nine (69%) pts had grade 3–4 toxicity, the most common were: thrombocytopenia (4 pts), neutropenia (2 pts), and abdominal pain (2 pts). No anti-AMG 655 antibodies were detected. After one 3 or 10 mg/kg dose of AMG 655 after G, the Cmax and AUC of AMG 655 were similar to those in the first- in-human single-agent study (LoRusso JCO 2007; 25: abstract 3534). Preliminary data indicate no effect of AMG 655 on PK of G. Partial response 31% (4 pts, 2 unconfirmed); stable disease 38%. Median PFS: 5.3 months (95% CI, 3.5, 6.2); 6-month survival rate: 76.2% (95% CI: 42.7%-91.7%). Conclusions: AMG 655 + G is well-tolerated and may have activity in metastatic pancreatic cancer. A randomized phase II trial of G ± AMG 655 at 10-mg/kg is currently enrolling.

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Results from phase Ib studies of PX-12, a thioredoxin inhibitor in patients with advanced solid malignancies

2571

Background: PX-12, a small-molecule inhibitor of Thioredoxin-1 (Trx-1) stimulates apoptosis, down-regulates HIF- 1α, VEGF in animal models. High levels of Trx-1 have been linked to chemoresistance in lung cancers. The phase 2 dose of PX-12 was 226 mg/m2 given by 3-h infusion IV x 5 days, q 21d (Ramanathan RK et al. CCR 13; 2109; 2007). Two Phase 1b trials of PX-12 in patients with advanced solid tumors have been completed to determine the safety, tolerability and optimal biologic dose when delivered by prolonged infusion. Methods: PX-12 was administered as a 24-h infusion every q7- 14d starting at 150 mg/m2/day (n=18); or a 72-h infusion q 21d, starting at 300 mg/m2/day (n=14) using a portable delivery pump. Results: Both the 24- or 72-h infusion of PX-12 were well tolerated in patients at doses up to 400 mg/m2/day. Common grade 1/2 AE's included fatigue, taste alteration, and odor caused by expired drug metabolite. In the 24 h study the maximal dose evaluated was 450 mg/m2. No DLTs were observed in this study. Since no MTD was reached on 24-h infusion up to 450 mg/m2 dose level, additional higher doses were explored utilizing 72-h infusion. DLT in the 72-h study at the highest dose administered (500 mg/m2/day) included reversible hypoxia with or without pneumonitis. Best response was stable disease in 3 pts (SD): liver cancer and colon cancer (24-h infusion) and rectal cancer (72-h infusion). Pharmacodynamics (PD): PX- 12 lowered circulating Trx-1 levels in patients who had starting Trx-1 levels 3-fold greater than that of the normal population (5.4 ng/mL) including all three SD. Circulating VEGF and FGF-2 levels were also lowered over multiple courses of treatment in these patients. The pharmacokinetics of PX-12 showed a dose dependent increase of Cmax and no accumulation over multiple cycles following a 24 h infusion. Conclusions: Dosing at 400 mg/m2/day appears safe and tolerable as a 24–72-h infusion. Extending the infusion time to 72h appears to decrease the intensity of cough and odor compared to bolus 1–3 h infusion. The PD effect produced by PX-12 was apparent only in those patients with elevated plasma Trx-1 levels. Patients with elevated TRX-1 levels appear to have the best probability of having SD. Supported by ProlX Pharmaceuticals/Oncothyreon through an award from the NCI.

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