Clinical management and resolution of stomatitis in BOLERO-2

558

Background: In BOLERO-2, adding everolimus (EVE) to exemestane (EXE) more than doubled progression-free survival without affecting quality of life vs EXE alone in postmenopausal women with hormone-receptor–positive advanced breast cancer who had recurrence or progression on/after nonsteroidal aromatase inhibitor therapy. Although mTOR inhibitors are generally well tolerated, stomatitis is one of their most clinically relevant and potentially dose-limiting toxicities (Sonis Cancer2010). The incidence, grade, and clinical course of stomatitis among patients (pts) participating in the BOLERO-2 study are described. Methods: Pts were randomized 2:1 to receive EVE+EXE or placebo (PBO)+EXE. Stomatitis incidence, severity, consequent dose interruptions/adjustments, study drug discontinuations, and time to resolution were recorded. Results: The median duration of EVE+EXE treatment exposure was 30 wk (range, 1-123 wk). Stomatitis (any grade) occurred more frequently with EVE+EXE than with PBO+EXE (59% vs 12%, respectively). Grade 3 stomatitis occurred in 8% vs 1% of pts receiving EVE+EXE vs PBO+EXE, respectively; no grade 4 was reported. Onset of grade ≥2 stomatitis after treatment initiation was earlier in the EVE+EXE arm vs the PBO+EXE arm: median time was 15d vs 24d, respectively. In the EVE+EXE arm, 97% of pts with grade 3 stomatitis (n=38) improved to ≤1 after a median of 13 d. Complete resolution was observed in 82% of these pts after a median of 38 d. In the PBO+EXE arm, all pts with grade 3 stomatitis (n=2) improved to ≤1 after a median of 18 d. Complete resolution was observed after a median of 29 d. Overall, 24% of pts in the EVE+EXE arm required dose interruptions/adjustments vs 1% of pts in the PBO+EXE arm, and 3% of pts (n=13) discontinued EVE+EXE vs <1% of pts (n=1) discontinuing PBO+EXE, all related to stomatitis. Conclusions: The BOLERO-2 data foster a new era of combining targeted and endocrine therapies. In the study, treatment-emergent stomatitis was of mild to moderate intensity, occurred shortly after treatment initiation, and was generally reversible. Most incidents were successfully managed with palliative interventions and temporary dose modifications. Oral hygiene and other preventive measures are recommended. Clinical trial information: NCT00863655.

First-, second-, third-line therapy for metastatic renal cell carcinoma (mRCC): Benchmarks for trials design from the International mRCC Database Consortium (IMDC)

4586

Background: Limited data exists on outcomes for mRCC patients treated with multiple lines of therapy. Benchmarks for survival are required for patient counseling and clinical trial design. Methods: Outcomes of mRCC patients from the IMDC treated with 1, 2, or 3+ lines of targeted therapy (TT) were compared and adjusted by proportional hazards regression. Overall survival (OS) and progression-free survival (PFS) benchmarks were calculated using different population inclusion criteria. OS and PFS are calculated from the line of therapy under consideration unless otherwise specified. Results: 2,705 patients were treated with TT of which 1,533 (57%) received only 1st-line TT, 734 (27%) received 2 lines of TT, and 438 (16%) received 3+ lines of TT. The median OS of patients that received 1, 2 or 3+ lines of TT starting from initial TT was 14.9, 21.0, and 39.2 months, respectively (p<0.0001). On multivariable analysis adjusting for baseline Heng prognostic factors, the use of 2nd-line and 3rd-line therapy were each independently associated with better OS (HR=0.738 and 0.626, respectively, both p<0.0001). Survival benchmarks derived from patients in the IMDC using selected inclusion criteria as seen in contemporary mRCC clinical trials are shown below. Conclusions: Patients that are able to receive more lines of TT live longer. Survival benchmarks provide context and perspective when interpreting and designing new clinical trials. [Table: see text]

Outcome of metastatic sarcomatoid renal cell carcinoma (sRCC): Results from the International mRCC Database Consortium

4565

Background: Sarcomatoid differentiation in metastatic RCC (sRCC) is associated with poor prognosis. Robust data regarding outcome in the targeted therapy era is lacking. Methods: Clinical features, prognostic factors, and treatment outcomes in mRCC patients with and without sarcomatoid histology treated with targeted therapy were retrospectively analyzed and compared. Results: 2,286 patients were identified (non-sRCC(n=2,056); sRCC(n=230)). sRCC patients had significantly worse Heng prognostic group distribution compared to non-sRCC (11% vs 19% favorable risk, 49% vs 57% intermediate risk, and 40% vs 24% poor risk; p<0.0001). Time from original diagnosis to relapse (excluding synchronous metastatic disease) in the sRCC patients was 18.8 months compared to 42.9 months in non-sRCC group; p<0.0001. There was no significant difference in the incidence of CNS metastases (6-8%) or underlying clear cell histology (87-88%). Greater than 93% of patients received VEGF inhibitors as first line therapy; 21% achieved an objective response in the sRCC group as compared to 26% in the non-sRCC group with significantly more sRCC patients (43% vs. 21%) having primary refractory disease (p<0.0001, for both). sRCC patients had significantly less use of second-line (p=0.018) and third-line (p=0.0004) systemic therapy. The median PFS / OS was 4.5 months / 10.4 months in sRCC patients and 7.8 months / 22.5 months in non-sRCC patients (p<0.0001 for both). Sarcomatoid histology was associated with a significantly worse PFS and OS after adjusting for the individual Heng risk factors in multivariable analysis (HR 1.5, p<0.0001 for both). Conclusions: Patients with sRCC have worse baseline prognostic criteria, a shorter time to relapse and worse clinical outcome to targeted therapy compared to patients with non-sRCC. Additional insight into the biology of sRCC is needed to develop alternative therapeutics.

Risk and predictors of suicide in colorectal cancer patients: A SEER analysis

9596

Background: Colorectal cancer (CRC) patients have a higher risk of suicide as compared with the general population. Due to differences in the sites/morbidity of recurrences as well as ostomy rates, we sought to evaluate the distribution and predictors of suicide among patients with colon and rectal cancer. Methods: A retrospective analysis was undertaken using the Surveillance, Epidemiology, and End Results (SEER) database from 1973-2009. Patients included were >18yrs and had confirmed adenocarcinoma of the colon or rectum. Results: Included in this analysis were 187,996 rectal cancer and 443,368 colon cancer patients. Colon cancer patients were older (median age 71 vs. 67 yrs, p <0.001) and included more females (51 vs. 43%, p <0.001) as compared to rectal cancer patients. Suicide rates were similar (611 [0.14%] vs. 337 [0.18%], p <0.001), as was the median time to suicide for colon vs. rectal cancer patients respectively (37 vs.32 months, p = 0.13). On univariate analysis, having rectal cancer was a predictor of suicide (HR 1.26; 95% CI: 1.10-1.43). However after adjustment for age, sex, race, marital, primary site surgery, stage and one primary, rectal cancer was not a predictor of suicide (HR 1.05; CI: 0.83- 1.33). In the combined CRC cohort, independent predictors of suicide included age >70 (HR 1.55; CI: 1.23-1.94), male gender (HR 7.56; CI: 5.34-10.70), being single (HR 1.56; CI: 1.14- 2.13), distant metastases at diagnosis (HR 1.58; CI: 1.13- 2.21), and white race (HR 3.21; CI: 1.75- 5.88). Also, lack of resection of primary tumor was associated with increased risk of suicide (HR 2.83; CI: 1.97- 4.05). Among colon cancer cohort, older age, male gender, and white race as well as lack of primary resection were independent predictors of suicide. Similarly, the aforementioned predictors as well as metastatic disease on presentation were the independent predictors of suicide in the rectal cohort. Conclusions: The suicide risk in CRC patients is low (< 0.2%) and no difference was found based on location of primary tumor. Gender, age, distant spread of disease, intact primary tumour and race are the main predictors of suicide among colorectal patients. Future studies and interventions are needed to target these high risk groups.

First-line mTOR inhibition in metastatic renal cell carcinoma (mRCC): An updated analysis from the International mRCC Database Consortium (IMDC)

e15518

Background: FDA approval of the mTOR inhibitors (mTORi) in mRCC was based on efficacy in poor risk patients (pts) in the first line setting for temsirolimus (T) and in VEGF inhibitor-refractory pts for everolimus (E). Little is known about T’s effectiveness in good and intermediate risk patients and E’s outcomes in the first line setting. Methods: We interrogated the IMDC for the outcomes of pts who received mTORi as first-line targeted therapy. Results: 127 pts received a first line mTORi; the majority received T (93 T, 34 E). The main reasons for T administration were poor risk (38%), non-clear cell histology (27%), and clinical trial (15%) whereas clinical trial (82%) and non-cc histology (6%) drove E use. Of the T and E pts, 58% and 32% were poor risk, respectively. Median age was 61 years and median KPS was 80%. 68% had prior nephrectomy (62% T vs. 82% E). Median progression-free survival (PFS) and overall survival (OS) are detailed below. In the 97 pts with response data, 5% and 53% for T and 8% and 58% for E achieved partial responses and stable disease, respectively. Progressive disease as best response occurred in 41% for T and 33% for E. Second line therapy was captured in 52 pts (41%), of whom 48 received VEGF inhibitors. Conclusions: Given the different populations in which they were administered, direct comparisons of the frontline efficacy of T vs. E cannot be made. The majority of T pts were poor risk, which their dismal PFS and OS reflect. The better outcomes in the E pts highlight that the majority were not poor risk and were healthy enough for clinical trials. While limited by small numbers, this data characterizes a real world experience of mTORi in the first line setting. [Table: see text]

A phase I study of nivolumab (anti-PD-1; BMS-936558; ONO-4538) in combination with sunitinib, pazopanib, or ipilimumab in patients (pts) with metastatic renal cell carcinoma (mRCC)

TPS4593

Background: Vascular endothelial growth factor receptor-tyrosine kinase inhibitors are established therapies for mRCC. However, sunitinib and pazopanib rarely elicit durable responses. Programmed death-1 receptor (PD-1) is an immune checkpoint modulator that suppresses T-cell activation by interacting with its ligands (PD-L1/2) on antigen presenting cells and some tumor cells. Nivolumab, a PD-1 receptor blocking antibody, has shown durable responses in previously treated pts with mRCC in Phase 1 and 2 trials. Ipilimumab is an immune checkpoint inhibitor (anti-CTLA-4 antibody) already approved for the treatment of advanced melanoma. We describe an ongoing Phase 1 dose-escalation and expansion study evaluating combination of nivolumab with sunitinib, pazopanib or ipilimumab in pts with mRCC. Methods: Patients with histologically confirmed mRCC are treated on 4 parallel arms: nivolumab 2.0 or 5.0 mg/kg + sunitinib standard dosing (Arm S), nivolumab 2.0 or 5.0 mg/kg + pazopanib standard dosing (Arm P), nivolumab 3 mg/kg + ipilimumab 1 mg/kg as induction (Arm I-1), and nivolumab 1 mg/kg + ipilimumab 3 mg/kg as induction (Arm I-3) with nivolumab 3 mg/kg maintenance for both arms. Arms S and P are being conducted in 2 phases: nivolumab dose-escalation phase for previously treated pts (≤18 pts/arm) and then dose-expansion phase for treatment-naïve pts (20 pts/arm) if the maximum tolerated dose is ≥5 mg/kg. Arms I-1 and I-3 are fixed-dose cohorts (20 pts/arm) including both treatment-naïve and previously treated pts. Most of the study population consists of pts with clear-cell histology; non-clear cell mRCC pts are allowed in the dose-escalation cohorts of Arms S and P. The primary objectives are to assess safety and tolerability, and to determine the recommended Phase 2 dose in pts with mRCC. The secondary objective is to assess preliminary antitumor activity (objective response rate and response duration per RECIST 1.1). Exploratory objectives are to evaluate overall survival, pharmacodynamics, and predictive biomarkers for the combinations, and pharmacokinetics and immunogenicity of nivolumab. Clinical trial information: NCT01472081.

Treatment response and survival outcome of patients with late relapse (LR) from renal cell carcinoma (RCC) in the era of targeted therapy

4578

Background: A small subset of localized RCC patients will experience disease recurrence ≥5 years after nephrectomy. Clinical outcome of patients with LR has not been well characterized. Methods: Patients with mRCC treated with targeted therapy were retrospectively characterized according to time to relapse. Replase was defined as diagnosis of recurrent metastatic disease >3 months after initial diagnosis. Patients with synchronous metastatic disease at presentation were excluded. Patients were classified as Early Relapsers (ER) if they recurred within 5 years while Late Relapsers (LR) recurred after 5 years. Demographics and outcomes were compared. Results: 1210 mRCC patients were identified; 903 (74.6%) with relapse within the first 5 years, 200 (16.5%) within >5-10 years, and 107 (8.8%) after 10 years (range 10-35 years). Baseline characteristics are presented in the Table. Overall response rates to targeted therapy were better in LR vs. ER (35% vs. 24%; p=0.009). LR patients had significant longer progression free- (10.7 vs. 8.5 months; log rank p=0.004) and overall survival (34.0 vs. 27.3 months; log rank p=0.003). Conclusions: One quarter of patients that eventually developed metastatic disease treated with targeted therapy relapsed over 5 years from initial diagnosis. The proportion of patients that relapse after five years is substantial. mRCC patients presenting with LR have more favorable prognostic features, treatment response, and overall survival. [Table: see text]

Concordance between abstracts, virtual meeting (VM) presentations, and final publication of phase III clinical trials presented at the Annual Meeting of the American Society of Clinical Oncology

6622

Background: Phase III clinical trial results described in abstracts in the ASCO Annual Meeting Proceedings often differ from final results seen in publication. We hypothesize that the abstracts may act only as place holders, while the results presented at the ASCO Annual Meeting are more highly concordant with the final publication. Methods: A retrospective review of all abstracts submitted to the ASCO Annual Meeting in 2005 to 2007 was conducted. Inclusion Criteria: randomized, prospective phase III clinical trials of greater than 200 patients with at least one quantitative primary endpoint such as OS or PFS. For each abstract, we viewed the VM presentation and searched Pubmed and Medline for the corresponding publications. Data regarding the clinical trials was extracted from all three sources and statistical comparisons were made. Results: A total of 7,900 abstracts were screened from the ASCO 2005 and 2007 Annual Meetings, of which 124 met the inclusion criteria. An additional 43 studies were excluded due to absence of either a VM presentation or publication. The majority (96%) of these trials were presented as either an oral presentation or poster discussion. Key comparisons of the concordance between the abstract or VM presentation and the final publication are shown in the Table below. Conclusions: While the statistical significance of the primary endpoint and conclusions from all three sources are very similar, the results reported in VM presentations at ASCO Annual Meetings are a better representation of the final publication compared to the abstract. When relying on clinical trial results from these meetings to change clinical practice, physicians should refer to the VM presentation rather than the abstract. [Table: see text]

Impact of bone and liver metastases (BM, LM) in patients with metastatic renal cell carcinoma (mRCC) treated with molecularly targeted agents (MTAs): Results from the International mRCC Database Consortium (IMDC)

394

Background: The skeleton and liver are frequently involved sites of metastases in patients with mRCC. Their impact on survival outcomes of patients treated with currently approved MTAs is largely unknown. The purpose of this study was to analyze patient outcomes based on the presence or absence of BM and/or LM in the era of MTAs. Methods: We conducted a review from the IMCD of 2,027 patients with mRCC treated from April 2003 to August 2012. Statistical analyses were performed using Cox regression and the Kaplan-Meier method. Results: Median follow-up was 21 months. 1,978 were treated with first-line VEGF targeted therapy and 49 were treated with first-line mTOR inhibitors. Presence of BM was 34% overall and 27%, 33%, and 43% in favorable, intermediate, and poor-risk disease, respectively, by IMDC criteria (p < 0.001). Presence of LM was 19% overall and higher in poor-risk patients (23%) compared to favorable (20%) or intermediate-risk groups (16%) (p = 0.003). Other sites of metastases include lung, lymph node, adrenal, soft tissue, and/or brain. Among patients with a single metastatic site, those with BM or LM had a worse overall survival (OS) when compared to metastases at other sites (Table). Among patients with ≥ 2 sites of metastases, those with BM and LM had a shorter time to treatment failure (4.2 vs. 7.3 months, p < 0.0001) and worse OS (Table) when compared to patients with metastases at other sites. In multivariable analyses adjusting for IMDC criteria, BM and LM independently predicted poorer survival (HR=1.38 for BM vs. other metastases, 1.37 for LM vs. other metastases, and 1.82 for concomitant BM and LM, respectively, p < 0.0001). Conclusions: BM and LM in mRCC patients have significant clinical relevance and may possibly be used for risk-stratification of patients with mRCC. [Table: see text]

Incidence and risk of treatment-related mortality in patients with renal cell cancer (RCC) and non-RCC treated with mammalian target of rapamycin (mTOR) inhibitors

347

Background: Inhibition of the mammalian target of rapamycin (mTOR) is an established therapeutic modality for multiple malignancies including renal cell carcinoma (RCC). Agents that target mTOR have been sporadically associated with an increased risk of potentially life-threatening adverse events. We performed an up-to-date meta-analysis to determine the risk of fatal adverse events (FAEs) in cancer patients treated with mTOR inhibitors, including RCC. Methods: MEDLINE/PubMed, conferences and clinicaltrials.gov databases were searched for articles reported from January 1966 to June 2012. Eligible studies were limited to trials of US Food and Drug Administration—approved mTOR inhibitors (everolimus and temsirolimus) that reported on patients with cancer, randomized design, and adequate safety profiles. Data extraction was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Statistical analyses were conducted to calculate the summary incidence, relative risk (RR), and 95% Confidence Intervals (CIs) by using random-effects or fixed-effects models on the basis of the heterogeneity of included studies. Results: In all 2,990 patients from 8 randomized controlled trials (RCTs) were included, 2033 from everolimus trials and 957 from temsirolimus trials. The incidence of FAEs related to mTOR inhibitors use was 3.4% (95% CI, 1.9-6.0) with a RR of 2.33 (95% CI, 1.32 to 4.10; P = .003) compared to control patients. On subgroup analysis, no difference in the rate of FAEs was found between everolimus and temsirolimus or between tumor types (RCC vs. non-RCC). No evidence of publication bias was observed. Conclusions: The use of mTOR inhibitors is associated with an increased risk of FAEs in RCC and non-RCC patients, compared with control patients.

A multicenter population-based experience with abiraterone acetate (AA) in patients with metastatic castration resistant prostate cancer (mCRPC)

113

Background: The COU-AA-301 trial showed that abiraterone (AA), an oral cytochrome p450 CYP17 inhibitor, improved survival for men with mCRPC progressing after docetaxel. AA is now a standard treatment in this setting. In order to better understand the non-clinical trial experience with AA, we undertook a multicenter retrospective analysis of patients (pts) treated with AA. Methods: Consecutive pts with mCRPC from 5 tertiary cancer centers in Canada who had received AA post-docetaxel were identified using centralized pharmacy records for each center. Pts who received AA for approved indications or within expanded access programs were included. Demographics, prognostic factors, treatment outcomes and toxicity profiles were collected. Results: One hundred and eighty seven pts, who initiated AA between Jan-2011 and Jun-2012, were included. Median age at diagnosis and AA start was 65 and 73 years. 73 (39%) pts had M1 disease at diagnosis. ECOG 0/1/2/3 was noted in 17/96/39/8 pts. Median PSA at AA start was 132 with a median PSAdt of 2.8 months. 54 (29%) pts received more than 1 prior course of chemotherapy. Median follow up was 20.5 months. Median survival from start of AA was 9.3 months (95% CI, 7.9-12.6). Regional results were: Alberta 14 months (95% CI, 13-18); BC 8.2 months (95% CI, 5.4-9.6); and Ontario 7.3 months (95% CI, 5.7-8.1). Median overall survival from date of mCRPC was 36 months (95% CI, 29-40); in Alberta this was 39 months (95% CI, 29-47); BC 26 months (95% CI, 18-41); and Ontario 33 months (95% CI, 25-41). AA was well tolerated with toxicities comparable to those seen in the trial population, with anemia and fatigue being the most common reported toxicity. Conclusions: This is one of the largest cohorts of men with mCRPC treated with AA in the non-clinical trial setting. Treatment outcomes corroborate with results reported in clinical trials, supporting the effectiveness of AA in an unselected population. A difference in survival outcomes between the different cancer regions can be attributed to differences in time to AA start. Future analyses to evaluate potential prognostic/predictive factors will be undertaken.

Metastatic non–clear cell renal cell carcinoma (nccRCC) treated with targeted therapy agents: Applying the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic model to predict outcomes

396

Background: The International mRCC Database Consortium (IMDC) Prognostic Model (Heng, et al. model, JCO, 2009) was defined and validated in a patient cohort that was comprised of RCC of all histological-subtypes. Clear-cell RCC (ccRCC) accounts for ~80% of RCC cases, and thus it is unknown if this model is reliable in patients with non-ccRCC (nccRCC). Therefore, we sought to evaluate the reliability of the model separately in ccRCC and nccRCC. Methods: Data on 2,215 (1,963 ccRCC/252 n-ccRCC) patients treated with 1-st line VEGF-and mTOR targeted therapies were collected from the IMDC. nccRCC included papillary, chromophobe, and other histologies. Patients were assigned to favorable, intermediate, and poor prognosis groups according to the ICDM prognostic model. The discrimination ability for overall survival (OS) was evaluated by C-index. Results: The median OS of the entire cohort was 20.9 months. nccRCC patients were of younger age (p < 0.0001), more often presented with low Hb (p = 0.014) and elevated neutrophils (p = 0.0001), but displayed otherwise similar clinicopathological features compared to ccRCC. OS (22.3 vs. 12.8 months; p < 0.0001), and TTF (7.8 vs. 4.2 months; p < 0.0001) were worse in nccRCC compared to ccRCC. The hazard ratio for death (OS) and treatment failure (TTF) when adjusted for the prognostic factors was 1.41 (95%CI 1.19, 1.67, p < 0.0001) and 1.54 (95% CI 1.33, 1.79, p < 0.0001), respectively. The IMDC prognostic model reliably discriminated three risk groups to predict OS and TTF in nccRCC; the median OS and TTF of favorable, intermediate, and poor prognosis groups were 31.4, 16.1, and 5.1 months (p < 0.0001) and 9.6, 4.9, and 2.1 months (p < 0.0001), respectively. The C-indices for OS were 0.66 and 0.64 for the IDCM and MSKCC criteria, respectively. Conclusions: Patients with nccRCC treated with targeted therapies have a significantly worse outcome than ccRCC patients. The IMDC prognostic model reliably predicts OS and TTF in nccRCC and ccRCC.

First-line mTOR inhibition in metastatic renal cell carcinoma (mRCC): An analysis from the International mRCC Database Consortium

430

Background: mTOR inhibitors (mTORi) are an important class of targeted therapies for mRCC that may act through regulation of mTOR as well as hypoxia-inducible factor and its resultant downstream angiogenesis pathways. FDA approval was based on efficacy in poor risk patients in the first-line setting for temsirolimus (T) and in sunitinib- and sorafenib-refractory patients for everolimus (E). Little is known about T’s effectiveness in good and intermediate risk patients and E’s outcomes in the first-line setting. Methods: We evaluated our international mRCC database to evaluate the outcomes of patients who received mTORi as their first-line targeted therapy. Results: Of the 2,370 patients in the database, 49 received a first-line mTORi (7 E, 42 T). Median age was 61 years and median KPS was 80%. 63% had clear cell and 37% had non-clear cell histology. 65% had prior nephrectomy. Of the 38 patients with available Heng prognostic risk criteria, 21%, 21%, and 58% were good, intermediate, and poor risk respectively. Median PFS and OS are detailed below. Objective responses and disease stabilization were achieved in 5% and 58%. Second-line therapy was administered in 21 patients of which 17 received VEGF inhibitors. Conclusions: Outcomes for good and intermediate risk patients treated with first-line mTORi were lower than historically expected for patients treated with VEGF targeted therapies. These results may be due to inclusion of non-clear cell histologies, treatment biases, small sample size, or other undefined confounders that need further exploration. Greater data capture of this important cohort of patients to confirm these results is planned and will be presented. [Table: see text]

Incidence and risk of infections in renal cell cancer (RCC) and non-RCC patients treated with everolimus and temsirolimus: A meta-analysis of randomized control trials

353

Background: Everolimus and temsirolimus are mammalian target of rapamycin (mTOR) inhibitors used in a variety of malignancies including renal cell carcinoma (RCC). These targeted agents have been associated with a unique set of adverse events including infections. We performed an up-to-date meta-analysis of published clinical trials to further characterize the risk of infections in cancer patients treated with mTOR inhibitors. Methods: Pubmed and oncology conference proceedings were searched for studies from January 1966 to June 2012. Eligible studies were limited to phase II and III randomized controlled trials (RCTs) of everolimus or temsirolimus that reported on patients with cancer of any tumor type including RCC and with adequate safety profiles. Summary incidence, RR, and 95% CIs were calculated using random- or fixed-effects models based on the heterogeneity of the included studies. Results: A total of 2,990 patients from 8 RCTs were included. The incidence of all-grade infections due to mTOR inhibitor treatment was 35.7% (95% CI, 28.8-43.3) and that of high-grade infections was 4.2% (95% CI, 2.1-8.4). The relative risk of all-grade infection due to mTOR inhibitors was 1.95 (95% CI, 1.67-2.29, p<.001) and that of high-grade infection was 1.91 (95% CI, 1.09-3.35, p=.024). Subgroup analysis found no difference in the incidence or risks of infections between everolimus and temsirolimus or between different tumor types (RCC vs. non RCC). Infections included respiratory tract (38.0%), urinary tract (17.1%), skin/soft tissue (3.6%), others (2.6%), and infection/not specified (38.7%). No evidence of publication bias was observed. Conclusions: Treatment with mTOR inhibitors, everolimus and temsirolimus, is associated with a significant increase in risk of infection in RCC and non-RCC patients.

Safety of everolimus for women over age 65 with advanced breast cancer (BC): 12.5-month follow-up of BOLERO-2

104

Background: Postmenopausal women with estrogen-receptor–positive (ER+) BC who relapse/progress on a nonsteroidal aromatase inhibitor (NSAI) are usually treated with the steroidal AI exemestane (EXE), but there is no currently approved treatment for this indication. The BOLERO-2 trial showed that adding everolimus (EVE), an oral inhibitor of mammalian target of rapamycin (mTOR), to EXE significantly improved clinical benefit beyond that of EXE alone (Hortobagyi et al, SABCS 2011, Abstract S3-7). As many women with advanced BC are elderly, the tolerability profile of EVE + EXE in this population is of interest. Methods: BOLERO-2 is a phase III, randomized trial comparing EVE (10 mg once daily) vs placebo (PBO), both plus EXE (25 mg once daily), in postmenopausal women with advanced ER+ BC progressing or recurring after NSAIs. Safety data with a focus on elderly patients are reported at 12.5 months’ median follow-up. Results: Baseline disease characteristics, age, and prior cancer therapy were well balanced between treatment arms (N = 724). At 12.5 months’ median follow-up, the addition of EVE to EXE significantly improved progression-free survival in patients <65 (HR, 0.37; p < .05) or ≥65 years of age (HR, 0.56; p < .05). Adverse events (AEs) of special interest (all grades) occurring more frequently with EVE vs PBO (overall study population) included stomatitis (66.6% vs 11.3%), infection (50.4% vs 25.2%), rash (44.0% vs 8.4%), pneumonitis (18.7% vs 0.4%), and hyperglycemia (15.4% vs 2.5%). Elderly EVE-treated patients (≥65 years) had similar or marginally lower incidence of stomatitis (52.1%), rash (32.3%), pneumonitis (14.6%), and hyperglycemia (12.5%) compared with the overall population. Grade 3-4 AEs in patients ≥70 years of age (n = 161) reported only among patients receiving EVE (n = 118) included fatigue (10.2%), anemia (10.2%), hyperglycemia (8.5%), stomatitis (7.6%), dyspnea (6.8%), pneumonitis (5.1%), neutropenia (3.4%), and hypertension (3.4%). Conclusions: Adding EVE to EXE was well tolerated in the overall population and in elderly patients with advanced BC; grade 3-4 AEs were uncommon and manageable. Overall, AEs were consistent with the known safety profile of EVE.

An in-depth multicentered population-based analysis of outcomes of patients with metastatic renal cell carcinoma (mRCC) that do not meet eligibility criteria for clinical trials

4536

Background: Clinical trials have strict eligibility criteria that exclude many patients to whom the trial results are later extrapolated to in clinical practice. Methods: mRCC patients treated with VEGF targeted therapy were retrospectively deemed ineligible for clinical trials (according to commonly used inclusion/exclusion criteria) if they had a Karnofsky Performance Status (KPS) <70%, brain metastases, non-clear cell histology, hemoglobin<=9 g/dL, creatinine >2x the upper limit of normal, platelet count of <100x103/uL, neutrophil count <1500/mm3 or corrected calcium>=12 mg/dL. Results: 894/2076 (43%) patients were deemed ineligible for clinical trials by the above criteria. Between ineligible versus eligible patients, the response rate, median progression free survival (PFS) and median overall survival of first-line targeted therapy were 21% vs 29%, 5.2 vs 8.8 months and 14.5 vs 28.8 months (all p<0.0001), respectively. Second-line PFS (if applicable) was 3.2 months in the trial ineligible vs 4.4 months in the trial eligible patients (p=0.0074). Patients who were excluded due to KPS<70, hemoglobin<=9 g/dL, calcium >=12, brain metastases, and non-clear cell histology, had a hazard ratio (HR) for death of 2.8 (95%CI 2.4-3.4), 1.8 (95%CI 1.4-2.2), 1.8 (95%CI 1.2-2.7), 1.4 (95%CI 1.1-1.8), and 1.4 (95%CI 1.1-1.7), respectively (all p<0.01). When adjusted by the Heng et al prognostic categories, the HR for death between trial ineligible vs trial eligible patients was 1.511 (95%CI=1.335-1.710, p<0.0001). Conclusions: The number of patients that are ineligible for clinical trials is high and their outcomes are inferior. Specific trials addressing the needs of protocol ineligible patients and assessing OS are required. [Table: see text]

Comparison of drug approval between health Canada (HC) and the U.S. Food and Drug Administration (FDA)

6082

Background: Differences in drug approval processes between countries can impact patient access to new therapies. In Canada, patients can freely access a new treatment after regulatory approval by Health Canada (HC) followed by funding approval from the provincial government. The aims of this study were to delineate the Canadian drug approval timeline and to compare the time to drug approval between HC and the US FDA. Methods: Cancer drugs approved by the FDA from 1989 to 2011 were reviewed. For each drug, the following endpoints were determined: publication date of phase I and pivotal phase III trial, date of FDA and HC approval, HC submission date, and funding approval in Alberta (AB). Time intervals between the aforementioned endpoints were calculated. Results: Of 55 FDA-approved drugs, 51 drugs are approved by HC with 40 of these drugs funded in AB. HC approval occurs an average of 14.4 months post FDA approval (95% CI -36.9 to 66.1, sign rank test p<0.0001). However, there was no significant difference between the mean time from Phase I to FDA approval (48.5 months; 95% CI 21.2 to 75.8) and Phase I to HC approval (61.5 months; 95% CI 32.4 to 90.5). Most drugs (74%) were approved by the FDA prior to publication of the phase III trial. There was a trend towards faster drug approval from Phase III to FDA approval compared to HC (-14.97 versus 0.1 months, p = 0.05). HC submission occurs before FDA drug approval 77% of the time (mean 3.0 months prior; 95%CI: -59.1 to 43.4, p = 0.0206). HC approval occurs on average 17 months post HC submission. AB funding approval occurs on average 22 months after HC approval. The time interval from Phase I to AB funding approval was significantly shorter for targeted compared to cytotoxic agents (mean time 58 vs. 120 months; p = 0.039). Conclusions: HC drug approval lags behind FDA approval by about 14 months. Time from Phase III to drug approval tends to be shorter for the FDA compared to HC. This is the first documentation, to our knowledge, of the time required to bring a drug from phase I trial to provincial funding approval.

Quantitative immunohistochemical (IHC) assessment of ataxia-telangiectasia mutated (ATM) in estrogen receptor (ER) negative early breast cancer (BC)

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Background: ATM plays a key role in the cellular response to DNA damage and germline mutations are associated with a predisposition to BC. We evaluated the impact of ATM expression on outcomes in Stage I-III ER negative BC patients (pts). Methods: A tissue microarray was constructed from formalin-fixed paraffin-embedded specimens of ER negative Stage I-III BC pts from the Tom Baker Cancer Centre. ATM expression was assessed by quantitative fluorescence IHC using a rabbit anti-ATM monoclonal antibody (Epitomics) and the HistoRx AQUA platform. ATM expression index (EI) was calculated by the tumor cell to stroma expression ratio. Prognostic ability of ATM EI was explored univariately, and multivariately after adjusting for clinicopathological factors selected using algorithmic methods, with Cox regression methods. Results: Of 126 eligible pts treated from 1999-2004, 44.4% were HER2-neu + and 52.4% were triple negative. ATM EI was normalized using a logarithmic transformation. Univariately, higher ATM EI was associated with worse outcomes (Table). Multivariately, higher ATM EI remained significantly prognostic for recurrence-free survival (RFS) (HR=5.46, p=0.046), local RFS (HR=5.56, p=0.052), distant RFS (HR=4.38, p=0.080), but not overall survival (p=0.48). Conclusions: High ATM EI is associated with worse RFS in ER negative BC in this hypothesis-generating study. Validation of this finding is currently ongoing. [Table: see text]

Characteristics of long-term and short-term survivors of metastatic renal cell carcinoma (mRCC) treated with targeted therapy: Results from the International mRCC Database Consortium

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Background: Patients with mRCC have variable courses in terms of survival and response to targeted therapy. The patients at the two extremes of the survival spectrum need to be characterized. Methods: 2,161 patients with mRCC treated with targeted therapy were examined. 152 patients who survived 4 years or more after the initiation of targeted therapy (long-term) were compared with 218 patients who survived 6 months or less (short-term) over the same time period (2004-2007). Results: Long-term survivors had fewer poor prognostic factors (PFs) such as Karnofsky performance status (KPS) <80%, diagnosis to treatment interval<1 yr, hypercalcemia, anemia, thrombocytosis and neutrophilia (all p<0.0001). Patients with favorable prognosis who responded to targeted therapy were more likely to be long term survivors. For those in the intermediate risk group, patients who were long-term survivors were more likely to have only 1 poor prognostic factor (73% vs. 28%, p<0.0001) and KPS≥80% (88% vs. 69%, p=0.009) compared to those in the short term survivor group. On multivariable analysis adjusting for PFs, response to targeted therapy (PR or better) significantly predicted long term survivor status (odds ratio=6.3, 95% CI: 2.3,17.4, p=0.0004). Conclusions: Long term survivors had a higher response rate to targeted therapy, a longer treatment duration and more use of second-line targeted therapy. Baseline prognostic criteria may be able to discriminate between long- and short- term survivors. [Table: see text]

Predictors of pathologic complete response (pCR) after neoadjuvant chemoradiation (Neo CRT) for rectal cancer: A multicenter population-based study

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Background: pCR to Neo CRT for rectal cancer is associated with better outcomes and used as an early indicator of response. To assess the rate and predictors of pCR, as well as access to care, we performed a retrospective study in two Canadian provinces. Methods: Cancer registries identified consecutive patients with clinical stage I-III rectal cancer from the Tom Baker Cancer Center, Cross Cancer Institute, and Dr. H. Bliss Murphy Cancer Centre who received Neo CRT and had curative intent surgery (Sx) from 2005 to 2011. Patient, tumor and therapy characteristics were correlated with response. Results: 301 patients were included of which 59 (19.6%) had a pCR to Neo CRT. At a median follow-up of 17 months, disease free survival was 96.7% for pCR vs 82.3% for non-pCR (p=0.005). 43 (73%) patients with pCR received adjuvant chemotherapy including bolus FU 27 (63%), capecitabine 10 (23%) and oxaliplatin-based 6 (14%). Median time from diagnosis to consult was 4 weeks (wks), from consult to start of Neo CRT 3.3 wks and start of CRT to Sx 13 wks. On multivariate analysis a low pre-op CEA (p=0.0323) was a significant independent predictor of pCR while statin use at initial consult (p=0.077) and higher pre-op hemoglobin (p=0.0974) trended toward significance when adjusted for clinical stage. Conclusions: Rates of pCR in a population based setting are substantial. A lower pre-op CEA is associated with a pCR to Neo CRT. Statin use and pre-op hemoglobin require further investigation. Our access to care data provides a baseline for future comparisons. [Table: see text]

A multicentered population-based analysis of outcomes of patients with metastatic renal cell carcinoma (mRCC) who do not meet eligibility criteria for clinical trials

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Background: Clinical trials have strict eligibility criteria to maintain internal validity. These criteria exclude many patients to whom the trial results are later applied to in clinical practice. Patients that do not meet eligibility criteria are poorly characterized.

Methods: mRCC patients treated with VEGF targeted therapy were retrospectively deemed ineligible for clinical trials (according to commonly used inclusion/exclusion criteria) if they had a Karnofsky Performance Status (KPS) < 70%, brain metastases, non-clear cell histology, hemoglobin ≤ 9 g/dL, creatinine > 2x the upper limit of normal, platelet count of < 100x103/uL, neutrophil count < 1500/mm3 or corrected calcium ≤ 12 mg/dL.

Results: 894/2076 (43%) patients were deemed ineligible for clinical trials by the above criteria. Between ineligible versus eligible patients, the response rate, median progression free survival (PFS) and median overall survival of first-line targeted therapy were 21% vs 29%, 5.2 vs 8.8 months and 14.5 vs 28.8 months (all p < 0.0001), respectively. Second-line PFS (if applicable) was 3.2 months in the trial ineligible vs 4.4 months in the trial eligible patients (p = 0.0074). When adjusted by the Heng et al prognostic categories, the hazard ratio for death between trial ineligible vs trial eligible patients was 1.621 (95% CI = 1.431–1.836, p < 0.0001). If only KPS, brain metastases and non-clear cell histology were used as exclusion criteria, 672 (32%) patients were excluded and the results were similar.

Conclusions: The number of patients that are ineligible for clinical trials is high and their outcomes are inferior. Designing more inclusive clinical trials for this “ineligible” patient population are needed.

[Table: see text]

Conditional survival (CS) for patients with metastatic renal cell carcinoma (mRCC) treated with vascular endothelial growth factor (VEGF)-targeted therapy (TT): Results from the International mRCC Database Consortium

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Background: Survival estimates for patients with mRCC are traditionally reported from the time of TT initiation. These survival projections, however, may not be applicable to patients who have already survived a period of time after initiating therapy. CS accounts for elapsed time since starting therapy, providing more relevant prognostic information.

Methods: Data on 1673 patients treated with first-line VEGF TT between 4/7/2003 and 10/12/2010 was analyzed. Median follow up for patients still alive is 20.1 months. Conditioned survival was calculated on the set of patients alive or on TT at 3 months and using 3 months increments for up to 18 months.

Results: The 2-year CS probability tends to slightly improve from 44 to 51% when conditioned on having already survived 0 to18 months since initiation of TT, respectively. The Heng et al (JCO 2009) risk criteria (defined at therapy initiation) retains prognostic ability over time independent of previous survival time or previous time on TT up to 18 months (p<0.0001 for all comparisons). In the subgroup analysis stratified by Heng risk groups, 2-year CS minimally changes over time in the favorable (FAV) and in the intermediate (INT) groups, but in the poor risk group, the 2-year CS improves from 11% initially to 33% after 18 months. When conditioned on time on TT, 2-year CS improves from 44% to 68% overall, from 74% to 90% in the FAV risk group, 49% to 57% in the INT risk group and 11% to 73% in the poor-risk group.

Conclusions: Conditional survival may be a more relevant measure of prognosis for those who have already survived or have been on TT for a period of time. The largest improvement was seen in patients in the poor risk group.

[Table: see text]

Vascular endothelial growth factor (VEGF) therapy in metastatic renal cell carcinoma (mRCC): Differences between Asian and non-Asian patients

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Background: Several reports have indicated that VEGF targeted therapy in metastatic renal cell carcinoma (mRCC) may be more toxic in the Asian versus Caucasian populations. Comparative efficacy of these agents with respect to ethnicity is not well characterized.

Methods: Eight centers participating in the International mRCC Database Consortium with available dose reduction data on patients with mRCC treated with VEGF targeted therapy were included in this analysis. Asian patients were derived from centers in Korea and Singapore.

Results: 1024 patients with a median follow-up of 29.4 months were included in this analysis. Baseline characteristics are below. The percentage of dose modifications/reductions between non-Asians and Asians was similar (55% vs 61% p=0.1197) but more patients completely discontinued treatment due to toxicity in the non-Asian vs the Asian group (28% vs 21% p=0.0197). When adjusted for the Heng et al poor prognostic criteria, there was no difference in overall survival (HR 0.887, 95%CI 0.729-1.08, p=0.2322) or progression-free survival (HR 1.069, 95%CI 0.910-1.256, p=0.4184) between non-Asians and Asians. Interestingly, when patients were dose reduced due to toxicity, they had a longer treatment duration and overall survival than those that did not require a dose reduction in both the non-Asian (10.6 vs 5.0 months p<0.0001 and 22.6 vs 16.1 months p=0.0016, respectively) and in the Asian populations (8.9 vs 5.4 months p=0.0028 and 28.0 vs 18.7 months p=0.0069).

Conclusions: After adjusting for risk groups, there appears to be no difference in outcome between Asians vs. non-Asian patients with mRCC treated withVEGF-targeted therapy. Judicious dose reductions may allow for better outcomes in both populations possibly due to longer treatment durations, but direct comparisons are needed.

[Table: see text]

Improving outcomes through the development of quality indicators in renal cell cancer

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Background: Optimal quality of care is necessary for ideal outcomes, and quality indicators (QI) are increasingly being used to measure quality of care. In renal cell carcinoma (RCC), there is a paucity of information defining such optimal care. This is particularly important as care of RCC patients is becoming increasingly complicated with more options and requiring greater expertise. The goal of this study was to identify QI for RCC across the entire disease spectrum from presentation to palliation.

Methods: A multidisciplinary expert panel (13 members) of medical and urologic oncologists from across Canada reviewed potential QI. These potential QI were identified from a systematic review of the literature. In addition, panel members were encouraged to suggest additional potential QI. A modified Delphi technique was utilized to select QI that were both relevant and practical to RCC; this technique incorporated 2 email questionnaires and 1 in-person meeting.

Results: From 250 citations in the systematic review, 34 possible QI were identified; 24 additional potential QI were suggested by panel members. A final set of 23 QI were established by the expert panel. These were distributed across the RCC disease spectrum as follows (number of QI in parentheses): screening (1), diagnosis and prognosis (3), management of localized disease (7), surgical management of locally advanced or metastatic disease (3), systemic therapy (4), and follow-up (3). These 21 QI focused largely on the treatment of RCC. In addition, two QI related to survival outcomes (overall and progression-free) were selected. An example of a QI in localized disease is the proportion of patients undergoing partial nephrectomy for tumors < 4 cm. An example in advanced disease is the proportion of patients who are assessed by members of a multidisciplinary genitourinary cancer team. The final 23 QI selected will be presented in detail.

Conclusions: A systematic, consensus-based approach was used to determine relevant QI in RCC care. These 23 QIs will provide a means of evaluating the quality of RCC care in an effort to improve outcomes for our patients. The next step will be to establish a means of measuring each of these QI based on defined or yet to be defined benchmarks.

A population-based overview of sequences of targeted therapy in metastatic renal cell carcinoma (mRCC)

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Background: There are several types of targeted therapy (TT) available to treat mRCC and data on outcomes and different sequences of therapies are required.

Methods: Consecutive series of patients with mRCC treated with TT were examined. Multivariable analysis was performed when significant differences on univariable analysis were seen.

Results: 2106 patients were included with a median follow-up of 36 months. 907 (43%) and 318 (15%) patients received subsequent second-line and third-line TT, respectively. Baseline characteristics of the groups below were not different except there were more patients with non-clear cell histology in the VEGF to mTOR group compared to the VEGF to VEGF group. When adjusting for the Heng et al poor risk criteria and non-clear cell histology, the hazard ratio of death for the VEGF to mTOR group vs the VEGF to VEGF group was 0.833 (95%CI 0.669-1.037, p=0.1016). When adjusting for poor risk criteria, the hazard ratio of death for the sunitinib to everolimus vs sunitinib to temsirolimus sequences was 0.774 (0.52-1.153, p=0.2086).

Conclusions: The sequence of TT may not have a substantial effect on outcome but results of prospective randomized studies are awaited.

[Table: see text]