Chemoprevention for breast cancer

Despite the progress that has been made in breast cancer diagnosis and treatment, this disease is still a major health problem, being the most frequently diagnosed cancer and the first leading cause of cancer death among women both in developed and economically developing countries. In some developed countries incidence rate start to decrease from the end of last millennium and this can be explained, at least in part, by the decrease in hormone replacement therapy use by post-menopausal women. Chemoprevention has the potential to be an approach of utmost importance to reduce cancer burden at least among high-risk populations. Tamoxifen and raloxifene are both indicated for the prevention of breast cancer in women at high risk for the development of the disease, although raloxifene may have a more favorable adverse-effect profile, causing fewer uterine cancers and thromboembolic events. Aromatase inhibitors will most probably become an additional prevention treatment option in the near future, in view of the promising results observed in adjuvant trials and the interesting results of the very recently published first chemoprevention trial using an aromatase inhibitor.(2) Despite impressive results in most clinical trials performed to date, chemoprevention is still not widely used. Urgently needed are better molecular risk models to accurately identify high-risk subjects, new agents with a better risk/benefit ratio and validated biomarkers.

Subjective cognitive complaints one year after ceasing adjuvant endocrine treatment for early-stage breast cancer

BACKGROUND

In the BIG 1-98 trial objective cognitive function improved in postmenopausal women 1 year after cessation of adjuvant endocrine therapy for breast cancer. This report evaluates changes in subjective cognitive function (SCF).

METHODS

One hundred postmenopausal women, randomised to receive 5 years of adjuvant tamoxifen, letrozole, or a sequence of the two, completed self-reported measures on SCF, psychological distress, fatigue, and quality of life during the fifth year of trial treatment (year 5) and 1 year after treatment completion (year 6). Changes between years 5 and 6 were evaluated using the Wilcoxon signed-rank test. Subjective cognitive function and its correlates were explored.

RESULTS

Subjective cognitive function and the other patient-reported outcomes did not change significantly after cessation of endocrine therapy with the exception of improvement for hot flushes (P=0.0005). No difference in changes was found between women taking tamoxifen or letrozole. Subjective cognitive function was the only psychosocial outcome with a substantial correlation between year 5 and 6 (Spearman's R=0.80). Correlations between SCF and the other patient-reported outcomes were generally low.

CONCLUSION

Improved objective cognitive function but not SCF occur following cessation of adjuvant endocrine therapy in the BIG 1-98 trial. The substantial correlation of SCF scores over time may represent a stable attribute.

1st International consensus guidelines for advanced breast cancer (ABC 1)

The 1st international Consensus Conference for Advanced Breast Cancer (ABC 1) took place on November 2011, in Lisbon. Consensus guidelines for the management of this disease were developed. This manuscript summarizes these international consensus guidelines.

P1-07-06: High Concordance of Protein (by IHC), Gene (by FISH; HER-2 Only) and Microarray Readout (by TargetPrint) of ER/PR/HER2: Results from the MINDACT Trial

Background

Previously, the micro-array readout of ER, PR and HER2 by TargetPrint was shown to be strongly correlated with high quality immunohistochemistry (IHC)/FISH assessment, especially for ER and HER2. Concordance rates were 93% (k=0.79) for ER; 83% (k=0.65) for PR and 96% for HER2 (k=0.88) in 636 patients (Roepman et al., Clin Cancer Res, 2009).

This study analysis was undertaken to further determine the correlation of microarray readout with IHC/FISH assessment both locally and centrally determined in the 1st 800 pts enrolled in the MINDACT trial. This work is essential to determine the quality of biological data in the two risk assessment methods used in MINDACT based upon which adjuvant chemotherapy decision is made, in order to exclude bias.

Methods: ER/PR/HER2 IHC assessment was performed on the 1st 800 primary breast cancers (BC) of pts enrolled in the MINDACT study. The assessment was performed locally at each center (n=800) and by central review at the laboratory of the European Institute of Oncology (n=626). A tumor was classified positive for ER and PR when 1% of tumor cells showed positive staining. HER2 IHC status was scored as 0, 1+, 2+ or 3+; a score of 3+ was considered positive. In 2+ cases FISH was performed to assess final HER2 status. Gene expression data for ER, PR and HER2 were obtained by TargetPrint stratified as receptor positive or negative using previously determined and validated thresholds for ER, PR and HER2 mRNA levels (n=800).

Results: Comparison of local assessment (IHC & FISH for HER2) with central review indicated highly similar results for receptor readout with a concordance of 98% (k=0.90) for ER; and 96% for HER2 (k=0.80) and slightly lower for PR (90% (k=0.72)).

Comparison of central assessment (IHC & FISH for HER2) with micro array readout by TargetPrint indicated highly similar results for receptor readout with a concordance of 97% (k=0.88) for ER and 95% for HER2 (k=0.76). For PR the concordance was lower but still quite acceptable (85% (k=0.62)).

Conclusion: Local and centrally assessed ER, PR and HER2 status in the first 800 MINDACT patient samples indicate a high level of quality for pathology in the local participating hospitals. These results exclude any bias induced by a lower quality of “traditional” pathology results as compared to the centrally assessed MammaPrint, both used for risk assessment and adjuvant chemotherapy decision in the MINDACT trial. The microarray-based assessment of ER, PR and HER2 gives results comparable to IHC & FISH and provides an objective and quantitative assessment of tumor receptor status. These results indicate that TargetPrint can serve as a second pathology assessment for locally assessed parameters, especially since TargetPrint is part of a multi-profile platform for breast cancer treatment management. This work was funded by the Breast Cancer Research Foundation and the EU Framework Program VI.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-06.

Triple negative breast cancer: proposals for a pragmatic definition and implications for patient management and trial design

In trials in triple negative breast cancer (TNBC), oestrogen and progesterone receptor negativity should be defined as < 1% positive cells. Negativity is a ratio of <2 between Her2 gene copy number and centromere of chromosome 17 or a copy number of 4 or less. In routine practice, immunohistochemistry is acceptable given stringent quality assurance. Triple negativity emerging after neoadjuvant treatment differs from primary TN and such patients should not enter TNBC trials. Patients relapsing with TN metastases should be eligible even if their primary was positive. Rare TN subtypes such as apocrine, adenoid-cystic and low-grade metaplastic tumours should be excluded. TN and basal-like (BL) signatures overlap but are not equivalent. Since the significance of basal cytokeratin or EGFR overexpression is not known and we lack validated assays, these features should not be used to subclassify TN tumours. Tissue collection in trials is mandatory so the effect on outcome of different tumour phenotypes and BRCA mutation can be explored. No prospective studies have established that TN tumours have particular sensitivity or resistance to any specific chemotherapy agent or radiation. TNBC patients should be treated according to tumour and clinical characteristics.

Evaluation of fatigue in Parkinson's disease using the Brazilian version of Parkinson's Fatigue Scale

OBJECTIVE

Fatigue is common in Parkinson's disease (PD). However, factors associated with fatigue in PD are still controversial. This study aimed to translate the Parkinson's Fatigue Scale (PFS) into Brazilian-Portuguese, to test its psychometric properties, and to assess the severity of fatigue in PD as well as its relation to demographic and clinical features, depression, anxiety, excessive daytime sleepiness and cognitive performance.

METHODS

We translated and assessed the internal consistency of the Brazilian version of the PFS. After, we assessed 87 PD patients with several neurological and psychopathological instruments.

RESULTS

The Brazilian version of PFS had good internal consistency (Cronbach's alpha = 0.939). Clinical significant fatigue was present in 36 patients (41.4%). A logistic regression analysis showed that fatigue was better explained by dysthymia (P = 0.006), more severe symptoms of depression as assessed by the Hamilton Depression Rating Scale (P = 0.027), daytime sleepiness (P = 0.022) and female gender (P = 0.031).

CONCLUSIONS

Fatigue is a common non-motor symptom in PD and seems to be associated with female gender, dysthymia, severity of depression and daily somnolence.

Abstract P3-12-10: Is the Biology of Breast Cancer (BC) Changing through Time? Results of a Two-Decade Single Belgium Institution Study

Background: Some available data suggest a change in the biology of BC particularly an increase in the proportion of ER+ disease. These changes in biology could be a result of an increase diagnosis of screen-detected BC or to a true change in biology. Screening was introduced in Belgium in the 80's and systematic screening in 2001.

Methods: From the invasive BC pts treated at IJB between 1987 and 2004, only pts with a postal code from the region of Brussels were selected, to avoid bias from heterogeneous geographic evolution during the accrual period. For each year, 30 pts with available tumor block and FU information were randomly selected and stratified by trimester. Pts files were reviewed and demographic, staging and outcome data were collected. A central pathology review was performed by two experienced pathologists in a ISO15189-accredited laboratory, with construction of TMAs for the analysis of histologic type and grade, ER, PgR, HER2, Ki67 (all by IHC). HER-2 2+ cases were confirmed by FISH. A pilot phase of 20 cases was done to verify consistency between the 2 pathologists. To investigate if there was statistical evidence for an increase or decrease of each marker over time, time was divided in 3 periods (87-92, 93-98, 99-04) and the Mantel-Haenszel chi-square test was used.

Results: In total, 505 pts were included with a median FU of 6 years. Due to technical issues, we currently have grade assessed in 407 cases, ER in 346 cases, PR in 328 cases, HER2 in 328 cases and Ki-67 (on TMA) in 302 cases (275 pts with complete biological assessment). Missing markers are being reassessed and more complete data will be available for the meeting. We found no statistical evidence for a consistent evolution over time for age at diagnosis (P=0.12) or lymph node status (P=0.86). A decrease in the number of postmenopausal (PM) pts (P=0.02) and in tumor size (P=0.04), and an increase in lobular type (P=0.05) in the more recent years were seen. There was an increase of high proliferative (P&lt;0.001) and PgR positive (P=0.03) tumors but no significant difference in ER (P=0.38) and HER2 (P=0.37) expression. There was an increase in grade 1 tumors (P&lt;0.001) but 72% of all cases were grade 2. Between 1987 and 2000, 5-year overall survival seems to be increasing (P=0.01).

Discussion: Screening for BC in Belgium is organized for ≥ 50 years-old; therefore, increased screening should increase age at diagnosis and proportion of PM pts, which we do not observe. These results could be interpreted as a concomitant increase of BC in younger pts. Some changes seen can be justified by increased use of screening (i.e. grade 1) but others can not (i.e. lobular and Ki67). Therefore, there seems to be a true change in the biology of BC over the last 2 decades. Funded by an unrestricted educational grant from Astra-Zeneca.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-12-10.

An Exploratory Study of Sunitinib (SU) Plus Docetaxel (D) and Trastuzumab (T) for First-Line Therapy of HER2+ Advanced Breast Cancer (ABC)

Background: T + D is a standard 1st-line treatment (tx) for HER2+ ABC (locally recurrent or metastatic BC). SU is an oral, multitargeted tyrosine kinase inhibitor of VEGFRs, PDGFRs, KIT, RET, and FLT3 with single-agent activity in previously treated ABC. In this study, a SU/D/T combination was investigated as 1st-line tx for pts with HER2+ ABC.Materials and methods: Female pts (≥18 yrs, ECOG PS ≤1) with HER2+ ABC were enrolled. Starting doses were D: 75 mg/m2, q3w, iv, day 1; T q1w: 4 mg/kg, day 1, followed by 2 mg/kg q1w, iv or q3w: 8 mg/kg, day 1, followed by 6 mg/kg q3w, iv; SU: 37.5 mg/d, Schedule 2/1, po, day 2. The primary objective was safety. Antitumor activity and pharmacokinetics were secondary endpoints. On discontinuation of D, responsive pts (PR or SD) could continue SU + T until disease progression.Results: As of Mar 2009, 25 pts were enrolled. 1 pt did not receive tx, 1 pt received a dose of D/T (pt died from multiorgan failure after T administration), and 23 pts received ≥1 dose of SU/D/T; data from the latter group are reported. 12 pts (52%) were chemo-naïve. 5 pts continue on study tx; 18 have discontinued (8 due to PD, 2 due to pt decision, 7 due to AEs, 1 due to global deterioration). Pts received 201/128/211 cycles of SU/D/T, respectively, with a median of 9/6/10 cycles/pt (range: 1–18/1–12/1–18). The 37.5 mg/d SU dose was reduced to 25 mg/d in 14/23 pts and interrupted in 17/23 pts. AEs led to SU dose reductions/interruptions in 17 pts, most frequently grade (G) 3/4 neutropenia (n=8) and G3 febrile neutropenia, G3 fatigue, and G3 diarrhea (each n=2). In 23 evaluable pts, the most frequent non-hematologic G3 AEs were fatigue/asthenia (26%), diarrhea (13%), and stomatitis, vomiting, and dyspnea (each 9%). G4 AEs were transaminase increase, accidental overdose of SU, and intestinal perforation (each n=1). 1 cardiac AE was reported (G3 supraventricular tachycardia) and transient G1/2 LVEF decline was seen in 2 pts (9%). G3/4 neutropenia was reported in 20 pts (91%); 5 pts (22%) had febrile neutropenia. 2 pts (9%) had G3 anemia and 1 pt (4%) had G3 thrombocytopenia. G-CSF was administered to 11 pts without complications. Preliminary median steady-state levels of SU and its metabolite: 40.6 and 15.6 ng/mL, respectively; end D infusion: 993 ng/mL; T levels: &lt;20 µg/mL. In 19 evaluable pts, ORR was 79% (1 CR [5%], 14 confirmed PRs [74%], 2 SD [11%]). Preliminary median PFS was 10.5 months (95% CI: 8.1–13.6) and median DR was 9.0 months (95% CI: 7.3–12.3).Conclusions: The combination of SU/D/T, given as 1st-line tx to HER2+ pts with ABC, is feasible. AEs were manageable through dose delay/reduction, and no new, unexpected AEs occurred. SU and D levels were consistent with known single-agent levels; evaluation of T levels is ongoing. Preliminary evidence of antitumor activity is encouraging and warrants further evaluation.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6088.

Duplication of Chromosome 17 CEP Predicts for Anthracycline Benefit: A Meta-Analysis of 4 Trials

ABSTRACT WITHDRAWN: This abstract was withdrawn by the authors prior to the start of the Symposium.

Background: Current evidence for HER2/TOP2A as predictive biomarkers of anthracycline response is conflicting. An interim meta-analysis (Di Leo et al Cancer Res;69:99S SABCS2009) suggested a weak, statistically significant, association between TOP2A and anthracycline benefit. We previously showed duplication of chromosome 17 alpha satellite (CEP17) predicted sensitivity to anthracyclines independently in three trials (BR9601, NEAT and MA.5, Bartlett et al Cancer Res 69:74S/364S). We performed a retrospective meta-analysis, incorporating data from 4 trials (including the Belgium study), to test the hypothesis that CEP17 is a predictive biomarker for anthracycline benefit in order to provide a unifying hypothesis in trials for which previous biomarker data is conflicting.Methods: FISH was performed in 2 labs (Bartlett lab for BR9601/NEAT & Belgian studies & O'Malley lab for MA5). ER/PgR (IHC) etc were collected from trial Case Report Forms. BR9601/NEAT and Belgian study tumors were scored counting all cells with a minimum of one CEP17 signal/cell: in MA.5 a minimum of 2 CEP17 signals were required for cells to be scored. These methodological differences did not affect HER2/CEP17 ratios but necessitated different definitions for CEP17 duplication defined as &gt;1.86 observed copies/cell for BR9601, NEAT and JB (Watters BCRT 2003 77:109-14) and &gt;2.25 for MA.5 (Goetz 2004).Results: FISH was successful in 85% (2531/2975) of cases. CEP17 duplication was detected in 27.5% of tumors (BR9601=37.6%, NEAT=20.0%, MA5=40.2% & JB=28.5%) and was associated with poorer RFS & OS (HR 0.80 95%CI 0.7-0.92 p=0.011 & HR 0.79, 95%CI 0.68-9.92, p=0.018, respectively).A significant treatment*marker interaction was observed in a meta-analysis of all data (2531 cases) as univariate(p&lt;0.005) & multivariate adjusted for treatment, grade, size, ER, nodes CEP17, CEP17*treatment & HER2 and for recurrence free (HR 1.67 95%CI 1.25-2.22, p=0.0006) & overall (1.63 95%CI 1.18-2.25, p=0.003) survival. In the two largest studies, NEAT (n=1462) and MA5 (n=622), this treatment*marker interaction (CEP17) was significant for RFS (p&lt;0.05) in all other analyses non-significant trends for RFS & OS were seen. (Trial specific HRs with 95%CIs RFS: 1.37 (0.56-3.15), 1.77 (1.07-2.90), 1.62 (1.02-2.58) & 1.69 (0.43-6.68), OS: 1.35 (0.54-3.38), 1.64 (0.96-2.80), 1.67 (0.99-2.84) & 2.05 (0.43-9.69); BR9601, NEAT, MA5 & Belgian respectively) analyses.Conclusions: Combined meta-analysis of 4 adjuvant trials demonstrated a highly significant treatment by marker effect for CEP17 duplication as a predictor of benefit from anthracyclines for both RFS in both univariate and multivariate regression analyses. HER2 (all 4 trials) and TOP2A (NEAT/BR9601) did not show any significant interactions. CEP17 duplication may reflect either chromosomal instability or polyploidy and further analysis is warranted to explore the underlying mechanisms for this effect. CEP17 is readily assessed in ISH analysis of HER2 status and may represent a clinically useful biomarker for selection of patients likely to benefit from anthracycline containing chemotherapies.

The 70-Gene Profile (MammaPrintTM) Is an Independent Predictor of Breast Cancer Specific Survival for Women 65 Years of Age or Older

Background: One-half of all new breast cancer diagnoses occur in women age 65 years or older. In this age group, the use of adjuvant chemotherapy is largely influenced by co-morbidity and little is known about the applicability of prognostic multi-gene assays. The 70-gene profile (MammaPrint) is an independent prognostic indicator in early breast cancer, however, its performance in women with breast cancer 65 years or older has not been systematically studied.Methods: Women 65 years or older who were diagnosed at the Jules Bordet Institute and the Netherlands Cancer Institute between 1987 and 2003 with primary breast cancer with 0-3 involved lymph nodes who received either no adjuvant systemic therapy or adjuvant hormonal therapy alone were selected. MammaPrint test results were compared with clinical-pathological risk assessment using Adjuvant!Online.Results: Of 204 women aged 65 years or older (median age 70 years), 129 (63.2%) were classified as genomic low risk and 75 (36.8%) as genomic high risk. After a median follow-up of 8.6 years (range 0.3-17.9), the 5- and 10-year breast cancer specific survival (BCSS) for the genomic low risk group was 96% (SE 2%) and 86% (SE 4%) versus 82% (SE 4%) and 66% (SE 6%) for the genomic high risk group (log-rank p=0.001). In univariate analysis, MammaPrint was prognostic for 5-year BCSS (HR=5.0, 95%CI 1.8-14.1, p=0.002) and 10-year BCSS (HR=3.1, 95%CI 1.6-6.0, p=0.001). In a multivariate model adjusted for 10-year risk predicted by Adjuvant!Online, MammaPrint was independently prognostic for 5-year BCSS (HR=4.4, 95%CI 1.6-12.7, p=0.005) and 10-year BCSS (HR=2.5, 95%CI 1.3-5.0, p=0.009). As in prior validation series, the performance of MammaPrint was time dependent, with improved prognostication for early BCSS (≤5 years).Conclusion: Although a smaller proportion of breast cancers diagnosed in women 65 years or older are classified as high-risk by MammaPrint, it is an independent prognostic indicator that may be useful to select patients that can safely forego adjuvant chemotherapy. Additional data from patients over 70 years of age will be available at the time of the meeting. If these data are confirmatory, the ongoing prospective MINDACT trial will be amended to include older women.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4049.

A Phase II Study (FINDER 2) Comparing Three Dosing Regimens of Fulvestrant in Postmenopausal Women with Estrogen Receptor-Positive Advanced Breast Cancer

Background: The Faslodex Investigation of Dose evaluation in Estrogen Receptor-positive (ER+) advanced breast cancer (FINDER) 2 study investigated the efficacy, safety, and pharmacokinetic (PK) profile of 3 fulvestrant dosing regimens in postmenopausal women with ER+ advanced breast cancer, recurring/progressing after prior endocrine therapy.Objectives: Primary: to evaluate the objective response rate (ORR). Secondary included assessment of: time to progression (TTP), clinical benefit rate (CBR), duration of response (DOR), tolerability, and PK parameters.Methods: This randomized, double-blind, parallel-group, multicenter, Phase II study, evaluated patients (pts) randomized 1:1:1 to different doses of fulvestrant: 250 mg (approved dose [AD]; given on Days 0, 28 and every 28 days thereafter), 250 mg plus loading dose (LD; 500 mg on Day 0, then 250 mg on Days 14, 28 and every 28 days thereafter), and 500 mg (high dose [HD]; Days 0, 14 and 28 and every 28 days thereafter). Treatment continued until disease progression, or until any other criterion for discontinuation was met.Results: In total, 144 pts were randomized from 34 centers in 8 countries and 143 received treatment: fulvestrant AD (n=47); LD (n=50); HD (n=46). ORRs were: 8.5% (95% confidence interval [CI] 2.4-20.4%), 5.9% (1.2-16.2%), and 15.2% (6.3-28.9%) in the AD, LD, and HD arms, respectively. CBRs were: 31.9% (95% CI 19.1-47.1%), 47.1% (32.9-61.5%), and 47.8% (32.9-63.1%) for the AD, LD, and HD arms, respectively. Median TTP was numerically longer for the HD (6.0 months) and LD (6.1 months) arms vs the AD arm (3.1 months). The low number of responders in all treatment arms prevented DOR assessment. The incidence of adverse events (AEs) was similar in all groups (76.6% AD, 72.0% LD, 69.6% HD); few pts experienced serious AEs (4 pts AD, 9 LD, 4 HD) with no clustering of event type. AEs with an incidence of ≥10% (in any arm) were back pain, arthralgia, fatigue, injection-site pain, nausea, dyspnea, cough, and hot flash. Concentrations in the AD arm approached steady state in the 3rd month of dosing and within the 1st month for LD and HD. Exposure (AUC, Cmin and Cmax) appeared to be linear across the dose range studied and, for the 250mg arms, similar to that previously reported in Western populations (Studies 9238IL/0020 & 0021).Conclusion: No statistically significant differences in efficacy could be proven between AD, LD and HD given the widely overlapping CIs for median TTP. The tolerability profile was similar across the three dosing regimens. Steady-state concentrations were achieved earlier with LD and HD. A parallel study in Japanese pts will be used for comparisons of fulvestrant efficacy and tolerability in Japanese and non-Japanese pts.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4095.

Cognitive function in postmenopausal women receiving adjuvant letrozole or tamoxifen in the Breast International Group (BIG) 1–98 trial

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Background: Hormonal therapy for breast cancer (BC) may affect cognition. Methods: Post-menopausal women with hormone receptor positive, early-stage BC were randomized to receive either: A) tamoxifen for 5 years; B) letrozole for 5 years; C) tamoxifen for 2 years followed by letrozole for 3 years; or D) letrozole for 2 years followed by tamoxifen for 3 years, as adjuvant endocrine treatment. During the fifth year of trial treatment, objective cognitive function (speed of psychomotor function, visual attention, working and verbal memory, learning) was evaluated by computerized tests. The difference in the composite score for patients taking letrozole (B+C; N= 65) versus tamoxifen (A+D; N = 55) at the time of testing was the primary comparison. Scores for each domain were standardized according to age-specific norms. Two-way ANOVA controlling for language was used to test the effect of treatment on cognitive function. Self-reported subjective cognitive function, psychological distress, fatigue and quality of life were also assessed. Results: Patient characteristics were balanced between groups. Both groups performed below age norms on most domains. The group taking letrozole had better overall cognitive function than the tamoxifen group (difference in mean composite scores = 0.278, p = 0.038, 95% CI: 0.015–0.540) and outperformed patients on tamoxifen for all domains (n.s.). Comparison of monotherapy arms A versus B supported better cognitive function among letrozole patients. Subjective cognitive function, psychological distress, fatigue, and quality of life did not differ between groups. Conclusions: Although letrozole results in lower circulating estrogen levels than tamoxifen, in this study BC patients taking adjuvant letrozole during the fifth year of treatment had better cognitive functioning than those taking tamoxifen.

[Table: see text]

Bortezomib/docetaxel combination therapy in patients with anthracycline-pretreated advanced/metastatic breast cancer: a phase I/II dose-escalation study

The aim of this study was to determine the dose-limiting toxicities (DLTs) and maximum tolerated dose (MTD) of bortezomib plus docetaxel in patients with anthracycline-pretreated advanced/metastatic breast cancer. Forty-eight patients received up to eight 21-day cycles of docetaxel (60-100 mg m(-2) on day 1) plus bortezomib (1.0-1.5 mg m(-2) on days 1, 4, 8, and 11). Pharmacodynamic and pharmacokinetic analyses were performed in a subset of patients. Five patients experienced DLTs: grade 3 bone pain (n=1) and febrile neutropenia (n=4). The MTD was bortezomib 1.5 mg m(-2) plus docetaxel 75 mg m(-2). All 48 patients were assessable for safety and efficacy. The most common adverse events were diarrhoea, nausea, alopecia, asthenia, and vomiting. The most common grade 3/4 toxicities were neutropenia (44%), and febrile neutropenia and diarrhoea (each 19%). Overall patient response rate was 29%. Median time to progression was 5.4 months. In patients with confirmed response, median time to response was 1.3 months and median duration of response was 3.2 months. At the MTD, response rate was 38%. Pharmacokinetic characteristics of bortezomib/docetaxel were comparable with single-agent data. Addition of docetaxel appeared not to affect bortezomib inhibition of 20S proteasome activity. Mean alpha-1 acid glycoprotein concentrations increased from baseline at nearly all time points across different bortezomib dose levels. Bortezomib plus docetaxel is an active combination for anthracycline-pretreated advanced/metastatic breast cancer. The safety profile is manageable and consistent with the side effects of the individual agents.

HER-2 overexpression/amplification and its interaction with taxane-based therapy in breast cancer

Breast cancer (BC) is the most common cancer in women and it is incurable when metastases are diagnosed. Taxanes, namely docetaxel and paclitaxel, are effective chemotherapeutic agents in the metastatic, neoadjuvant and adjuvant settings. HER-2 overexpression/amplification is detected in 25-30% of BCs and confers aggressive tumor behavior as well as resistance to some systemic treatments; nevertheless, its association with response to taxane-based chemotherapy is still unclear, with conflicting results in both in vitro and in vivo preclinical studies. This review will address the impact of HER-2 overexpression/amplification in BC patients treated with taxanes. Prospective, randomized trials incorporating important biological hypotheses are either ongoing or just closed, and their results will hopefully help to shed more light on this issue.

Oxaliplatin and 5-fluorouracil in heavily pretreated patients with ovarian carcinoma: A well tolerated and efficient treatment

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Background: Recurrent ovarian cancer is an incurable disease. The prognosis of patients with platinum refractory disease is dismal. We present data from heavily pretreated patients with recurrent ovarian cancer to whom the Folfox regimen was administered. Methods: Patients with recurrent, resistant or refractory, pretreated ovarian carcinoma were eligible for this compassionate use program of oxaliplatin (85 mg/m2 in 2 hours) and leucovorin (200 mg/m2 in 1 hour) on day 1, followed by a continuous infusion of 5FU (2,600 mg/m2 in 48 hours), every 2 weeks. The objectives of the study were primarily to assess response rate and secondarily to evaluate the safety profile. Results: Fourteen patients were treated. Median age: 56 years (49–70). Performance status: 0 (n=4) and 1 (n=10). Median number of previous chemotherapy regimens: 5 (3–10) and previous platinum-based regimens: 2 (1–3). Median chemotherapy-free interval: 9.5 weeks (1–39). Median administered cycles of Folfox/patient: 8 (2–11 cycles). Responses according to RECIST criteria: 2 CR (14.5%), 2 PR (14.5%), 4 SD (29%) and 6 PD (43%). Responses according to CA125 Rustin's criteria: 4 CR (29%), 2 PR (14.5%), 5 SD (35.5%) and 3 PD (21%). Grade 1/2 and 3 peripheral neuropathy: 10 (71%) and 2 (14.5%), respectively. There were no grade 4 adverse events or deaths due to the treatment. Conclusions: Folfox is a valuable option for heavily pre-treated patients with ovarian cancer, with an overall response rate of 29% (95% CI 15.2% to 41.8%), disease stabilization in an additional 29%, and a manageable toxicity profile. These results support the use of Folfox as salvage treatment for patients with ovarian carcinoma.

No significant financial relationships to disclose.

Ki-67 as prognostic marker in early breast cancer: a meta-analysis of published studies involving 12,155 patients

The Ki-67 antigen is used to evaluate the proliferative activity of breast cancer (BC); however, Ki-67's role as a prognostic marker in BC is still undefined. In order to better define the prognostic value of Ki-67/MIB-1, we performed a meta-analysis of studies that evaluated the impact of Ki-67/MIB-1 on disease-free survival (DFS) and/or on overall survival (OS) in early BC. Sixty-eight studies were identified and 46 studies including 12 155 patients were evaluable for our meta-analysis; 38 studies were evaluable for the aggregation of results for DFS, and 35 studies for OS. Patients were considered to present positive tumours for the expression of Ki-67/MIB-1 according to the cut-off points defined by the authors. Ki-67/MIB-1 positivity is associated with higher probability of relapse in all patients (HR=1.93 (95% confidence interval (CI): 1.74–2.14); P<0.001), in node-negative patients (HR=2.31 (95% CI: 1.83–2.92); P<0.001) and in node-positive patients (HR=1.59 (95% CI: 1.35–1.87); P<0.001). Furthermore, Ki-67/MIB-1 positivity is associated with worse survival in all patients (HR=1.95 (95% CI: 1.70–2.24; P<0.001)), node-negative patients (HR=2.54 (95% CI: 1.65–3.91); P<0.001) and node-positive patients (HR=2.33 (95% CI: 1.83–2.95); P<0.001). Our meta-analysis suggests that Ki-67/MIB-1 positivity confers a higher risk of relapse and a worse survival in patients with early BC.

p-53 gene mutations as a predictive marker in a population of advanced breast cancer patients randomly treated with doxorubicin or docetaxel in the context of a phase III clinical trial

BACKGROUND

Preclinical data indicate that p-53 gene mutations predict resistance to doxorubicin (A) but not to docetaxel (Taxotere) (T). In the TAX 303 trial, A and T have been compared with advanced breast cancer patients.

PATIENTS AND METHODS

Primary tumor samples from patients participating in the TAX 303 trial were collected. p-53 gene mutations were evaluated by denaturing high-performance liquid chromatography (DHPLC) and confirmed by sequencing. Topoisomerase II alpha (topo II alpha) protein levels were evaluated by immunohistochemistry. Clinical and biological data were correlated.

RESULTS

Tumor samples for DHPLC analysis were available for 108 of 326 patients from the clinical trial. p-53 gene mutations were observed in 20% of patients. In patients with a mutated p-53 gene, a trend for a lower percentage of responders was observed in the A arm (17%) compared with the T arm (50%). In the wild-type p-53 cohort, response rates to A and T were 27% and 36%, respectively. Of the 16 patients carrying wild-type p-53- and topo II protein-positive tumors, seven (44%) responded to anthracyclines, while response rate to the same drug was 13% in the remaining cohorts [odds ratio 5.06 (95% confidence interval 1.19-21.41), P = 0.03]. The combination of the two markers had no predictive value in patients treated with docetaxel.

CONCLUSIONS

(i) p-53 gene analysis indicates that gene mutations may compromise the efficacy of A while they do not interfere with the antitumor activity of T; and (ii) the evaluation of multiple molecular markers including p-53 and proliferation markers as topo II protein levels looks more promising in predicting response to anthracyclines.

[Towards an individualization of systemic treatment of breast tumors]

Clinical trials of adjuvant treatment of breast cancers have been limited for a long time to overall comparisons of heterogeneous populations. A new generation of clinical trials should be implemented, with especially the selection of the patients as a function of the molecular characteristics of their tumour. Unquestionable biological data must be taken into account to raise relevant questions, such as the role of topoisomerase II in the response to anthracyclines or the role of p53 in the response to taxanes. Microarrays technology, which allows the establishment of expression profiles of the whole genome, are very powerful tools which have allowed to reclassify breast tumours and to obtain "molecular signatures" characteristic for the risk of metastatic recurrence. A large randomised prospective study has been recently initiated with the aim of comparing the prognostic value of this signature to that of classical histopathologic criteria. In the next future, it will be possible to consider an individualisation of the prescription of cancer chemotherapies on molecular validated bases.

Botulinum toxin in blepharospasm and oromandibular dystonia: comparing different botulinum toxin preparations

Amongst all regions of the body, the craniocervical region is the one most frequently affected by dystonia. Whilst blepharospasm--involuntary bilateral eye closure--is produced by spasmodic contractions of the orbicularis oculi muscles, oromandibular dystonia may cause jaw closure with trismus and bruxism, or involuntary jaw opening or deviation, interfering with speaking and chewing. Both forms of dystonia can be effectively treated with botulinum toxin injection. This article summarizes injection techniques in both forms of dystonia and compares doses, potency and efficacy of different commercially available toxins, including Botox, Dysport, Xeomin and Myobloc/NeuroBloc.