The role of biological therapy in metastatic colorectal cancer after first-line treatment: a meta-analysis of randomised trials

PURPOSE

Biologic agents have achieved variable results in relapsed metastatic colorectal cancer (mCRC). Systematic meta-analysis was undertaken to determine the efficacy of biological therapy.

METHODS

Major databases were searched for randomised studies of mCRC after first-line treatment comparing (1) standard treatment plus biologic agent with standard treatment or (2) standard treatment with biologic agent with the same treatment with different biologic agent(s). Data were extracted on study design, participants, interventions and outcomes. Study quality was assessed using the MERGE criteria. Comparable data were pooled for meta-analysis.

RESULTS

Twenty eligible studies with 8225 patients were identified. The use of any biologic therapy improved overall survival with hazard ratio (HR) 0.87 (95% confidence interval (CI) 0.82-0.91, P<0.00001), progression-free survival (PFS) with HR 0.71 (95% CI 0.67-0.74, P<0.0001) and overall response rate (ORR) with odds ratio (OR) 2.38 (95% CI 2.03-2.78, P<0.00001). Grade 3/4 toxicity was increased with OR 2.34. Considering by subgroups, EGFR inhibitors (EGFR-I) in the second-line setting and anti-angiogenic therapies (both in second-line and third-line and beyond settings) all improved overall survival, PFS and ORR. EGFR-I in third-line settings improved PFS and ORR but not OS.

CONCLUSIONS

The use of biologic agents in mCRC after first-line treatment is associated with improved outcomes but increased toxicity.

Developing a national database for metastatic colorectal cancer management: perspectives and challenges

BACKGROUND

The changing treatment landscape for metastatic colorectal cancer creates multiple potential treatment strategies. An Australian-centric database capturing comprehensive information across a range of treatment locations would create a valuable resource enabling multiple important research questions to be addressed.

AIMS

To establish a collection of a consensus dataset capturing treatment and outcomes at multiple public and private hospitals across Australia.

METHODS

An electronic database was developed by a panel of clinicians, to capture an agreed dataset for patients with newly diagnosed metastatic colorectal cancer. Of particular interest were clinician decision-making, the impact of comorbidities and the frequency of major adverse events.

RESULTS

Since July 2009, data collection has been established at six public and eight private hospitals across three Australian states and territories. Successful linkage and analysis, with support from BioGrid Australia, of selected data on the initial 864 patients demonstrates that data can be captured from diverse sites, including public and private practice, that multiple factors impact on treatment delivered and outcomes achieved and that comprehensive data on rare but important adverse events can be captured. As a clinical research tool, the project has been highly successful, generating multiple presentations at national and international conferences related to a diverse range of research questions.

CONCLUSIONS

Multistate, project-specific data collection involving large numbers of patients is achievable. Providing invaluable insight into the routine clinical management of metastatic colorectal cancer in the era of targeted therapies, this also creates a significant resource for research, including many questions not being addressed by clinical trials.

Bisphosphonates as a supplement to exercise to protect bone during long-duration spaceflight

We report the results of alendronate ingestion plus exercise in preventing the declines in bone mass and strength and elevated levels of urinary calcium and bone resorption in astronauts during 5.5 months of spaceflight.

INTRODUCTION

This investigation was an international collaboration between NASA and the JAXA space agencies to investigate the potential value of antiresorptive agents to mitigate the well-established bone changes associated with long-duration spaceflight.

METHODS

We report the results from seven International Space Station (ISS) astronauts who spent a mean of 5.5 months on the ISS and who took an oral dose of 70 mg of alendronate weekly starting 3 weeks before flight and continuing throughout the mission. All crewmembers had available for exercise a treadmill, cycle ergometer, and a resistance exercise device. Our assessment included densitometry of multiple bone regions using X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) and assays of biomarkers of bone metabolism.

RESULTS

In addition to pre- and post-flight measurements, we compared our results to 18 astronauts who flew ISS missions and who exercised using an early model resistance exercise device, called the interim resistance exercise device, and to 11 ISS astronauts who exercised using the newer advanced resistance exercise device (ARED). Our findings indicate that the ARED provided significant attenuation of bone loss compared with the older device although post-flight decreases in the femur neck and hip remained. The combination of the ARED and bisphosphonate attenuated the expected decline in essentially all indices of altered bone physiology during spaceflight including: DXA-determined losses in bone mineral density of the spine, hip, and pelvis, QCT-determined compartmental losses in trabecular and cortical bone mass in the hip, calculated measures of fall and stance computed bone strength of the hip, elevated levels of bone resorption markers, and urinary excretion of calcium.

CONCLUSIONS

The combination of exercise plus an antiresoptive drug may be useful for protecting bone health during long-duration spaceflight.

A randomised, double-blind, placebo-controlled phase 2 study of trebananib (AMG 386) in combination with FOLFIRI in patients with previously treated metastatic colorectal carcinoma

Background:

This phase 2 study evaluated trebananib (AMG 386), an investigational peptide-Fc fusion protein that neutralises the interaction between angiopoietins-1/2 and the Tie2 receptor, plus FOLFIRI as second-line treatment for patients with metastatic colorectal cancer.

Methods:

Patients had adenocarcinoma of the colon or rectum with progression within 6 months of receiving only one prior fluoropyrimidine/oxaliplatin-based chemotherapy regimen for metastatic disease. All patients received FOLFIRI and were randomised 2 : 1 to also receive intravenous trebananib 10 mg kg⁻¹ once weekly (QW) (Arm A) or placebo QW (Arm B). The primary end point was investigator-assessed progression-free survival (PFS).

Results:

One hundred and forty-four patients were randomised (Arms A/B, n=95/49). Median PFS in Arms A and B was 3.5 and 5.2 months (hazard ratio (HR) 1.23; 95% CI, 0.81–1.86; P=0.33) and median overall survival (OS) was 11.9 and 8.8 months, respectively (HR 0.90; 95% CI; 0.53–1.54; P=0.70). Objective response rate (ORR) was 14% and 0% in Arms A and B, respectively. Incidence of grade ⩾3 adverse events was similar between treatment arms (Arm A, 61% Arm B, 65%) and included pulmonary embolism (1%/4%), deep vein thrombosis (5%/2%), and hypertension (1%/0%).

Conclusion:

Administration of trebananib plus FOLFIRI did not prolong PFS compared with placebo plus FOLFIRI. Toxicities were manageable and consistent with those known for FOLFIRI and trebananib.

The GOFURTGO Study: AGITG phase II study of fixed dose rate gemcitabine-oxaliplatin integrated with concomitant 5FU and 3-D conformal radiotherapy for the treatment of localised pancreatic cancer

Background:

Locally advanced inoperable pancreatic cancer (LAPC) has a poor prognosis. By increasing intensity of systemic therapy combined with an established safe chemoradiation technique, our intention was to enhance the outcomes of LAPC. In preparation for phase III evaluation, the feasibility and efficacy of our candidate regimen gemcitabine–oxaliplatin chemotherapy with sandwich 5-fluorouracil (5FU) and three-dimensional conformal radiotherapy (3DCRT) needs to be established.

Methods:

A total of 48 patients with inoperable LAPC without metastases were given gemcitabine (1000 mg m⁻² d1 + d15 q28) and oxaliplatin (100 mg m⁻² d2 + d16 q28) in induction (one cycle) and consolidation (three cycles), and 5FU 200 mg m⁻² per day over 6 weeks during 3DCRT 54 Gy.

Results:

Median duration of sustained local control (LC) was 15.8 months, progression-free survival (PFS) was 11.0 months, and overall survival was 15.7 months. Survival rates for 1, 2, and 3 years were 70.2%, 21.3%, and 12.8%, respectively. Global quality of life did not significantly decline from baseline during treatment, which was associated with modest treatment-related toxicity.

Conclusion:

Fixed-dose gemcitabine and oxaliplatin, combined with an effective and safe regimen of 5FU and 3DCRT radiotherapy, was feasible and reasonably tolerated. The observed improved duration of LC and PFS with more intensive therapy over previous trials may be due to patient selection, but suggest that further evaluation in phase III trials is warranted.

Adoption of health information exchange by emergency physicians at three urban academic medical centers

OBJECTIVES

Emergency physicians are trained to make decisions quickly and with limited patient information. Health Information Exchange (HIE) has the potential to improve emergency care by bringing relevant patient data from non-affiliated organizations to the bedside. NYCLIX (New York CLinical Information eXchange) offers HIE functionality among multiple New York metropolitan area provider organizations and has pilot users in several member emergency departments (EDs).

METHODS

We conducted semi-structured interviews at three participating EDs with emergency physicians trained to use NYCLIX. Among "users" with > 1 login, responses to questions regarding typical usage scenarios, successful retrieval of data, and areas for improving the interface were recorded. Among "non-users" with ≤1 login, questions about NYCLIX accessibility and utility were asked. Both groups were asked to recall items from prior training regarding data sources and availability.

RESULTS

Eighteen NYCLIX pilot users, all board certified emergency physicians, were interviewed. Of the 14 physicians with more than one login ,half estimated successful retrieval of HIE data affecting patient care. Four non-users (one login or less) cited forgotten login information as a major reason for non-use. Though both groups made errors, users were more likely to recall true NYCLIX member sites and data elements than non-users. Improvements suggested as likely to facilitate usage included a single automated login to both the ED information system (EDIS) and HIE, and automatic notification of HIE data availability in the EDIS All respondents reported satisfaction with their training.

CONCLUSIONS

Integrating HIE into existing ED workflows remains a challenge, though a substantial fraction of users report changes in management based on HIE data. Though interviewees believed their training was adequate, significant errors in their understanding of available NYCLIX data elements and participating sites persist.

Gene expression profiling in psoriatic scalp hair follicles: clobetasol propionate shampoo 0.05% normalizes psoriasis disease markers

BACKGROUND

Clobetasol propionate shampoo is effective and safe in treatment of scalp psoriasis (SP). Gene expression profiling of psoriatic skin biopsies led to the identification of numerous disease-related genes. However, it remained unknown whether the gene expression profile of hair follicles of SP patients was also affected.

OBJECTIVES

To determine whether psoriasis-related genes are differentially regulated in the hair follicles of SP patients and whether the modulation of these genes can be correlated with clinical severity scores.

METHODS

A single arm, open study was conducted in three centres. SP patients received daily treatment with clobetasol propionate shampoo. At Baseline, Weeks 2 and 4, investigators assessed clinical severity parameters and collected scalp hair follicles in anagen phase. Total RNA extracted from hair follicles was used to determine the expression level of 44 genes, which were reported previously to be upregulated in the skin of psoriasis patients.

RESULTS

RNA of good quality and sufficient quantity was obtained from hair follicles of psoriasis patients and healthy volunteers (HV). The expression level of 10 inflammation-related genes was significantly increased in psoriatic hair follicles. The patient's exploratory transcriptomic score, defined as the mean fold modulation of these 10 genes compared with HV, correlated with clinical severity scores. Clobetasol propionate shampoo was effective in decreasing both the exploratory transcriptomics and the clinical severity scores.

CONCLUSION

Hair follicles of SP patients are affected by the inflammatory process. The change in the expression level of inflammation-related genes correlates with the severity of the disease.

High-Rate Laboratory Filtration with Buchner Funnels

A method is described for greatly increasing the efficiency of Büchner funnels by utilizing a much larger fraction of the filter paper surface. The method also makes it possible to use Millipore filters efficiently on Büchner funnels.

Management of hirsutism

Hirsutism is a relatively common condition affecting about 5%-O10% of women of childbearing age. Herein, we present an overview of hirsutism with emphasis on its etiology and therapeutic options.

GOFURTGO trial (GFG): An AGITG multicenter phase II study of fixed dose rate gemcitabine-oxaliplatin (Gem-Ox) integrated with concomitant 5FU and 3-D conformal radiotherapy (5FU-3DRT) for the treatment of locally advanced pancreatic cancer (LAPC)

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Background: Our previous study of Gem with sandwich 5FU-3DRT for LAPC was encouraging (Br J Cancer 2007: 97, 464–471). Gem-Ox has higher response rate than Gem, improved progression free survival (PFS) but not overall survival (OS). Its use in LAPC may improve local control (LC) and delay systemic spread. GFG is a study of induction (ind) Gem-Ox, then 5FU-3DRT, then consolidation (con) Gem-Ox. Primary outcome is feasibility using proportion of patients (pts) receiving > 80% planned dose for each component. Secondary outcomes are safety, activity and QOL. Methods: Pts with previously untreated inoperable LAPC, M0, measurable disease, ECOG 0–2 were given Gem (1000mg/m2 d1 + d15 q28), Ox (100mg/m2 d2 + d16 q28) in both ind (1 cycle) & con (3 cycles), & 5FU 200mg/m2/d over 6 weeks during RT of 54Gy in 30 fractions of 1.8Gy. Results: 48 pts were enrolled, median age 61y (44–81y), PS 0/1=96%, regional lymph nodes=44%, T4=46%. Worst grade (G) for anaemia (10%); fatigue, nausea (8%); diarrhoea, vomiting, neutropenia, infection (4%); stomatitis, anorexia (2%) was G3. Thrombocytopenia was G3=2% G4=2%; liver function was G3=23% G4=6%; late radiation toxicity was G3=2% G4=2% (both gastric bleeding). Half of all pts completed all planned cycles (24 pts); 29% of pts received >80% of all treatment (14 pts); 70% of pts received >80% of all chemoradiation (33 pts). Pts ceased treatment for toxicity (16%), PD (21%) or doctor/pt preference (4/2%). Global QOL did not significantly change from baseline. Median duration of LC, PFS, OS were 15.8, 9.9, 15.4m at median follow up of 29.7m. Exploratory analysis of age, disease stage, PS, CA19–9 or WCC found no univariate predictors of PFS or treatment completion. 8/48 pts survived >24m. Conclusions: Compared to our previous study using the same radiation schedule, addition of oxaliplatin was associated with improved LC, PFS & OS (prev. 11.9, 7.1 & 11.7m) without significant offset by toxicity. The extended duration of LC and a subset who had a very prolonged benefit may be due to patient selection but equally may suggest an incremental benefit from more intensive systemic therapy requiring further study in controlled trials.

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Psoriasis and chronic obstructive pulmonary disease: a case-control study

BACKGROUND

Previous reports have demonstrated an association between psoriasis and the metabolic syndrome. Chronic obstructive pulmonary disease (COPD) has also been associated with the metabolic syndrome.

OBJECTIVES

To assess the association between psoriasis and COPD in a population-based case-control study.

METHODS

A case-control study was performed utilizing the database of Clalit Health Services, a large healthcare provider organization in Israel. Patients over the age of 20 years who were diagnosed with psoriasis ('cases') were compared with a sample of age- and gender-matched enrollees without psoriasis ('controls') regarding the prevalence of COPD. Group matching was performed. Data on health-related lifestyles and other comorbidities were collected. Chi(2) tests, t-tests and logistic regression models were used to compare between study groups.

RESULTS

The study included 12,502 psoriasis cases and 24,287 controls. The prevalence of COPD was significantly higher in patients with psoriasis [5.7% vs. 3.6%, P < 0.001, odds ratio (OR) 1.63, 95% confidence interval (CI) 1.47-1.81]. A multivariate logistic regression model demonstrated that psoriasis was significantly associated with COPD, after controlling for confounders, including age, sex, socioeconomic status, smoking and obesity (adjusted OR 1.27, 95% CI 1.13-1.42, P < 0.001).

CONCLUSIONS

In this large, population-based case-control study, psoriasis was found to be associated with COPD. Dermatologists caring for patients with psoriasis should be aware of this association, consult an internist or pulmonologist, and advise the patients to stop smoking and reduce additional risk factors for COPD.