Abstract P5-11-05: Influence of Demographic and Histopathological Characteristics on Compliance and Persistence in 4.923 Postmenopausal Women with Early Breast Cancer (EBC) - Results of the Patient's Anastrozole Compliance to Therapy Programme (PACT)

Introduction: According to recent retrospective studies, compliance to adjuvant endocrine therapy for early breast cancer (EBC) may drop below 70% after one year and to as low as 50% by year 4. The PACT-study aims investigate the effect of standardized information materials (brochures and motivational letters) to standard clinical care. Here we present the results for the primary endpoints compliance and persistence rates at 12 months as well as the influence of demographic and histopathological characteristics on compliance and persistence.

Methods: PACT is a prospective, randomised, parallel-group study with 60 months of follow-up (NCT00555867, sponsored by AstraZeneca Germany). Postmenopausal women on anastrozole (ANA) for hormone-receptor positive (HR+) EBC were randomized to routine clinical care alone or additional standardized information (educational arm) for the first 12 months of adjuvant therapy. Primary endpoints are compliance and persistence rates in the educational versus routine arm after 12 months. Secondary endpoints include influence of baseline demographic and histopathol. characteristics on compliance and persistence as well as influence of compliance on clinical outcome parameters (DFS, OS). Compliance is evaluated via patient questionnaires, prescription data and physician recall and was defined as intake of at least 80% of the total medication (292 ANA tablets in 12 months). Persistence is defined as“duration of time from initiation to discontinuation of therapy” (Cramer 2007). A patient was defined as persistent if the documentation supported the intake of ANA during the full first 12-months.

Results: PACT enrolled 4,923 patients at 109 breast centres and 1,361 registered specialist practices from Germany. 4,397 patients were evaluable for baseline characteristics. 2,707 patients had a visit documented at 12 months (≥9 to 18 months) and were evaluable for the primary endpoint. No difference in compliance could be shown between the standard (88.2%) and educational arm (88.3%) at 12 months (p=0.95, Fisher's exact test). In a modified analysis classifying patients not attending for a follow-up visit after 12 months as non-compliant, the compliance rate in both arms was sign. lower with 53.9% in the standard and 55.1% in the educational arm, yet no significant intergroup difference (p=0.43). Persistence rates were 40.3% for the standard and 43.0% for the educational arm (p=0.17). Influence of baseline demographic and histopathological characteristics on compliance and persistence are currently under review and will be presented at the meeting. Conclusion: The addition of standardized information materials to standard clinical care did not lead to increased compliance or persistence rates at 12 months. Data on the influence of baseline demographic and histopathological characteristics on compliance and persistence will be presented. PACT represents the largest prospective study to evaluate the influence of educational materials and baseline demographic and histopathol. characteristics on compliance and persistence to adjuvant endocrine therapy in postmenopausal patients with HR+ EBC.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-11-05.

First data from the the Patient's Anastrozole Compliance to Therapy Programme evaluating the influence of a standardized information service on compliance in postmenopausal women with early breast cancer

e11592

Background: Retrospective pharmacy data suggest that within the first year of therapy patients’ pick-up rate of aromatase inhibitor (AI) packs prescribed for early breast cancer (EBC) drops below 70%. Little is known about compliance to AI and patient motivation outside of clinical trials and the effect of compliance on patient outcome. Methods: The Patient´s Anastrozole Compliance to Therapy (PACT) programme, a two arm, randomized parallel group trial with 60 months follow-up, randomized postmenopausal women with HR+ EBC receiving anastrozole as adjuvant treatment and who consented to participate, to routine clinical care alone or additional standardized information consisting of 9 mailings of brochures and letters over the first 12 months following initiation of therapy. Primary endpoint is compliance rate in the standard versus intervention arm after 12 months, secondary endpoints include safety, reasons for non-compliance, influence of baseline characteristics, and of compliance on clinical outcome parameters. Compliance was evaluated by patient self reporting via standardized questionnaires, cross-checks of prescription data from hospital records and physician recall. QoL and patients’ satisfaction are assessed with standard questionnaires. Results: From Jul 2006 to Nov 2008, 4,924 patients were enrolled. Demographic data and baseline characteristics including median age, disease parameters, BMI, QoL at study start, co-morbidities and concomitant medication will be presented Conclusions: As of today, PACT is the largest prospective investigation on compliance to AI. It will provide valuable insights into the reasons for non-compliance to adjuvant AI therapy and demonstrate if a simple intervention such as standardized written information throughout the first treatment year may improve compliance and patient outcome.

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Trastuzumab treatment in elderly patients with advanced breast cancer (ABC) – results from a large observational study

Abstract #3144

Background: During the last decade, efficacy and safety of the HER2 antibody trastuzumab (T) has been established in a number of randomized clinical trials (RCT). However, both in the adjuvant and the palliative setting, inclusion of elderly patients (pts) in RCT is comparatively low in the light of the high prevalence of breast cancer in this group. Data on pts older than 65 years (y) were obtained from a prospective observation study that documents the routine usage of T as monotherapy, in combination with chemo- or with endocrine therapy for the treatment of ABC in Germany since 2001 outside the setting of RCT.
 Material and methods: Anamnestic and treatment records of 1316 pts from more than 150 German centres have currently been entered into the database, 910 of which form the basis of the interim analysis in this abstract. Additional information on long-term outcome, progression-free and overall survival (PFS, OS) were retrieved in a subgroup of 485 pts, in which the treatment documentation was finalized before July 2004. An update analysis is scheduled for Oct 2008.
 Results: 180 pts (20%) were older than 65y, with an increasing tendency during this study. 8% were >70y and only 2% >80y. The mean time from initial BC diagnosis was 4.1y in this subgroup compared to 3.6y in the whole population. 35% were ER and 47% PR negative. 37% suffered from hepatic involvement. Significantly less pts in the elderly group had received adjuvant chemotherapy compared to pts ≤65y (56% vs. 80%, p<0.0001).
 In the elderly group T was given distinctly more often as single drug (14% vs 11%) or in combination with endocrine treatment with only (14% vs 9%) and less frequent with chemotherapy (72% vs 80%)(p=0.034, across all groups). There was a slight trend towards a lesser use of taxanes. In the elderly more often capecitabine and vinorelbine were administered. Best overall response rate was 62% (CR: 15%), compared to 60% in the younger group. Long term results were rather similar in elderly/younger pts with medians for PFS of 12.9/9.9 months and, unexpectedly, also for OS with 27/26.6 months (p=0.66 and 0.65, respectively). The main focus was on reported adverse event percentages among elderly/younger pts: Infections 5/6, vomiting 6/4, diarrhea 5/5, neuropathy 8/6, arrhythmia 2/0.5, cardiac function 4/1, thromboembolic events 2/1, edema 5/3.
 Discussion: The observation of routine T treatment over 6 years revealed that the antibody is increasingly applied in elderly women, albeit more frequently without simultaneous chemotherapy when compared to younger pts. Short and long term efficacy outcomes are comparable to those in pts ≤65y. Toxicity profile in the elderly was unremarkable. Cardiovascular toxicity seems to be slightly increased, but remains clearly within expected and acceptable ranges. These data should encourage to use T in the recommended combination treatment for ABC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3144.

A global perspective on the use of aromatase inhibitors in early-stage breast cancer

Abstract #1144

Background: Aromatase inhibitors (AIs) are considered to be the standard of care for the adjuvant treatment of postmenopausal patients with hormone-receptor positive (HR+) early breast cancer (EBC). However, there is a lack of data on the use of these drugs in the non-trial setting and in regional practice around the world.
 Methods: This survey examined the use of endocrine therapies in breast cancer by physicians in 7 countries. From July 27 to October 8, 2007, 462 physicians in the United States, Germany, the United Kingdom, France, Spain, Italy, and Japan were surveyed, and information was collected via an internet Web site. Data included the physicians' reported activity during the last month, AI profiles, and patient profiles according to treatment stage.
 Results: Surveyed were 381 oncologists, 14 gynecologists, 36 surgeons, and 31 mammary gland clinicians. Physician perceptions were similar to the actual patient data. Half of all women being treated for breast cancer were HR+ and postmenopausal (less in Japan: 38%), and almost all of those patients (80-95%) were receiving endocrine therapy for the adjuvant treatment of EBC. AIs were the most common hormone agents used in the initial adjuvant setting of postmenopausal women with HR+ EBC across all countries surveyed (55-93%; median 88%). An upfront AI strategy was the most common practice overall, particularly in Japan, the United States, and France (89%, 86%, and 86%, respectively). Initial tamoxifen therapy was used predominantly in Germany (36%), the United Kingdom (51%), and Italy (55%). However, in the United Kingdom and Germany, the intent in nearly half of these patients was to switch to an AI following 2 years of tamoxifen therapy. The rates at which the 3 AIs were prescribed for different types of adjuvant treatment were generally consistent across countries. Guidelines were identified as a major decision-making factor in all countries.
 Conclusion: There are variations in practice across the surveyed countries despite the presence of international guidelines, eg, the American Society of Clinical Oncology and St. Gallen 2007. These practice trends may reflect the various guidelines in each region. Differences in treatment are particularly seen in Europe, which may reflect the number of varying guidelines and less descriptive nature of the guidelines.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1144.

Quantitative measurement of telomerase activity and localization of its catalytic subunit (hTERT) in chronic inflammation of capsule formation around various model implants and in sarcomas in a rat model

Telomerase is upregulated in some preneoplastic lesions and overexpressed in the majority of malignant tumors, but absent in most nonneoplastic somatic tissues. We analyzed telomerase activity using TRAP-assay in capsule tissues in a rat model with chronic inflammation and in tumor, and visualized the catalytic subunit of telomerase (hTERT) by immunhistochemistry. Significant elevated telomerase activity was found in tumor tissue compared with nonneoplastic tissue (p = 0.047). Cases with a strong inflammation in capsule tissue showed a specific telomerase activity. In these cases, there were no significant differences in telomerase activities compared with malignant tumor tissue. We demonstrate elevated telomerase activity and its diagnostic limits around model implants in a rat model, and visualize its expression not only in malignant tissue but also in inflammatory cells. So the quantitative measurement of telomerase activity should not be applied in general as a marker for malignancy in capsule tissue.

Estimating the magnitude of trastuzumab effects within patient subgroups in the HERA trial

BACKGROUND

Trastuzumab (Herceptin(R)) improves disease-free survival (DFS) and overall survival for patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer. We aimed to assess the magnitude of its clinical benefit for subpopulations defined by nodal and steroid hormone receptor status using data from the Herceptin Adjuvant (HERA) study.

PATIENTS AND METHODS

HERA is an international multicenter randomized trial comparing 1 or 2 years of trastuzumab treatment with observation after standard chemotherapy in women with HER2-positive breast cancer. In total, 1703 women randomized to 1-year trastuzumab and 1698 women randomized to observation were included in these analyses. Median follow-up was 23.5 months. The primary endpoint was DFS.

RESULTS

The overall hazard ratio (HR) for trastuzumab versus observation was 0.64 [95% confidence interval (CI) 0.54-0.76; P < 0.0001], ranging from 0.46 to 0.82 for subgroups. Estimated improvement in 3-year DFS in subgroups ranged from +11.3% to +0.6%. Patients with the best prognosis (those with node-negative disease and tumors 1.1-2.0 cm) had benefit similar to the overall cohort (HR 0.53, 95% CI 0.26-1.07; 3-year DFS improvement +4.6%, 95% CI -4.0% to 13.2%).

CONCLUSIONS

Adjuvant trastuzumab therapy reduces the risk of relapse similarly across subgroups defined by nodal status and steroid hormone receptor status, even those at relatively low risk for relapse.

Aromatase inhibitor-induced arthralgia: clinical experience and treatment recommendations

It is well documented that the aromatase inhibitors (AIs) are superior to tamoxifen as adjuvant endocrine therapy in postmenopausal women with hormone receptor-positive breast cancer. However, compared with tamoxifen, an elevated incidence of arthralgia has been observed during AI treatment. Concerns have been raised that AI-induced arthralgia may dissuade patients from completing their full AI treatment course, and may also deter physicians from prescribing an AI if they feel that patients may be at risk of permanent joint damage. Patient education about the possibility of experiencing arthralgia, and effective management of symptoms if they appear, are important in helping patients adhere to AI treatment, and consequently improving breast cancer outcomes. In this paper, we discuss the potential mechanisms behind AI-induced arthralgia, review the frequency with which arthralgia occurs, and propose for the first time an algorithm specifically for the treatment of AI-induced arthralgia. As with joint pain in non-breast cancer patients, a sequential approach to disease management is recommended, involving modifying the patient's lifestyle in addition to taking a stratified approach to pharmacological intervention with analgesia and anti-inflammatory medication. Knowing that joint symptoms can be managed in most patients may encourage patient-physician communication and treatment compliance.

Combination therapy with pegylated liposomal doxorubicin and carboplatin in gynecologic malignancies: a prospective phase II study of the Arbeitsgemeinschaft Gynäekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and Kommission Uterus (AGO-K-Ut)

OBJECTIVE

A multicenter non-randomized phase II study was initiated to evaluate tolerability and efficacy of pegylated liposomal doxorubicin (PLD) in combination with carboplatin in gynecologic malignancies.

METHODS

One hundred forty women with recurrent or advanced endometrial (n=31), cervical or vaginal cancer (n=31), uterine sarcomas (n=11), or recurrent platinum-sensitive ovarian cancer (n=67) received six courses of PLD 40 mg/m2 and carboplatin (AUC 6) every 28 days.

RESULTS

Hematological toxicities with NCI-CTC grade 3/4 were anemia in 8%, thrombocytopenia in 14%, neutropenia in 24%, and febrile neutropenia in 2% of 652 cycles. Grade 3/4 non-hematological toxicities included fatigue (14% of patients), pain (10%), dyspnea (9%), palmar-plantar erythrodysesthesia (7%), and nausea/vomiting (7%). Dose intensity reached 87.2% for PLD and 88.2% for carboplatin. Seventy-four percent of all non-progressive patients received at least 5 cycles. Overall response rates were (116 patients evaluable for response): ovarian cancer (n=54) 68%, endometrial cancer (n=27) 44%, uterine sarcomas (n=9) 33%, and cervical/vaginal cancer (n=26) 12%. Median progression-free survival was 11.6 months (95%CI 9.6-14.1) for ovarian cancer and 9.5 months (95%CI 6.6-12.6) for endometrial cancer. Median overall survival was 23.8 months (95%CI 19.0-30.2) and 21.4 months (95%CI 11.9-), respectively.

CONCLUSIONS

The combination of PLD and carboplatin was well tolerated and feasible in patients with gynecologic malignancies. Efficacy was low in cervical/vaginal cancer, but promising in patients with endometrial cancer. Efficacy was within the expected range in recurrent platinum-sensitive ovarian cancer and is currently under further investigation in a prospective randomized phase III trial comparing PLD/carboplatin with paclitaxel/carboplatin (CALYPSO-trial; AGO-OVAR 2.9).

Pegfilgrastim +/- ciprofloxacin for primary prophylaxis with TAC (docetaxel/doxorubicin/cyclophosphamide) chemotherapy for breast cancer. Results from the GEPARTRIO study

BACKGROUND

TAC (docetaxel/doxorubicin/cyclophosphamide) is associated with high incidences of grade 4 neutropenia and febrile neutropenia (FN). This analysis compared the efficacies of four regimens for primary prophylaxis of FN and related toxic effects in breast cancer patients receiving neoadjuvant TAC.

PATIENTS AND METHODS

Patients with stage T2-T4 primary breast cancer were scheduled to receive 6-8 cycles of TAC. Primary prophylaxis was: ciprofloxacin 500 mg orally twice daily on days 5-14 (n = 253 patients; 1478 cycles), daily granulocyte colony-stimulating factor (G-CSF) (filgrastim 5 microg/kg/day or lenograstim 150 microg/m(2)/day) on days 5-10 (n = 377; 2400 cycles), pegfilgrastim 6 mg on day 2 (n = 305; 1930 cycles), or pegfilgrastim plus ciprofloxacin (n = 321; 1890 cycles).

RESULTS

Pegfilgrastim with/without ciprofloxacin was significantly more effective than daily G-CSF or ciprofloxacin in preventing FN (5% and 7% versus 18% and 22% of patients; all P < 0.001), grade 4 neutropenia, and leukopenia. Pegfilgrastim plus ciprofloxacin completely prevented first cycle FN (P < 0.01 versus pegfilgrastim alone) and fatal neutropenic events.

CONCLUSION

Ciprofloxacin alone, or daily G-CSF from day 5-10 (as in common practice), provided suboptimal protection against FN and related toxic effects in patients receiving TAC. Pegfilgrastim was significantly more effective in this setting, especially if given with ciprofloxacin.