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Noepel-Duennebacke S, Juette H, Schulmann K, Graeven U, Porschen R, Stoehlmacher J, Hegewisch-Becker S, Raulf A, Arnold D, Reinacher-Schick A, Tannapfel A. Microsatellite instability (MSI-H) is associated with a high immunoscore but not with PD-L1 expression or increased survival in patients (pts.) with metastatic colorectal cancer (mCRC) treated with oxaliplatin (ox) and fluoropyrimidine (FP) with and without bevacizumab (bev): a pooled analysis of the AIO KRK 0207 and RO91 trials. J Cancer Res Clin Oncol 2021; 147:3063-3072. [PMID: 33675399 PMCID: PMC8397637 DOI: 10.1007/s00432-021-03559-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/06/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION In a retrospective analysis of two randomized phase III trials in mCRC patients treated first line with oxaliplatin, fluoropyrimidine with and without Bevacizumab (the AIO KRK 0207 and R091 trials) we evaluated the association of high microsatellite instability (MSI-H), immunoscore (IS) and PD-L1 expression in relation to overall survival (OS). METHODS In total, 550 samples were analysed. Immunohistochemical analysis of the MMR proteins and additionally fragment length analysis was performed, molecular examinations via allele-discriminating PCR in combination with DNA sequencing. Furthermore PD-L1 and IS were assessed. RESULTS MSI-H tumors were more frequent in right sided tumors (13.66% vs. 4.14%) and were correlated with mutant BRAF (p = 0.0032), but not with KRAS nor NRAS mutations (MT). 3.1% samples were found to be PD-L1 positive, there was no correlation of PDL1 expression with MSI-H status, but in a subgroup analysis of MSI-H tumors the percentage of PD-L1 positive tumors was higher than in MSS tumors (9.75% vs. 2.55%). 8.5% of samples showed a positive IS, MSI-H was associated with a high IS. The mean IS of the pooled population was 0.57 (SD 0.97), while the IS of MSI-H tumors was significantly higher (mean of 2.4; SD 1.4; p =< 0.0001). DISCUSSION Regarding OS in correlation with MSI-H, PD-L1 and IS status we did not find a significant difference. However, PD-L1 positive mCRC tended to exhibit a longer OS compared to PD-L1 negative cancers (28.9 vs. 22.1 months).
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Affiliation(s)
- Stefanie Noepel-Duennebacke
- Department for Hematology, Oncology und Palliative Care, St. Josef-Hospital, Ruhr-University, Bochum, Germany
| | - Hendrik Juette
- Institute of Pathology, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Karsten Schulmann
- Department for Hematology and Oncology, Klinikum Hochsauerland, Meschede, Germany
| | - Ulrich Graeven
- Department for Hematology, Oncology and Gastroenterology, Kliniken Maria-Hilf Mönchengladbach, Mönchengladbach, Germany
| | | | | | | | - Arne Raulf
- Center for Protein Diagnostics, Bioinformatics Group, Faculty of Biology and Biotechnology, Ruhr-University, Bochum, Germany
| | - Dirk Arnold
- Asklepios Cancer Center, Department for Hematology, Oncology and Palliative Care, Asklepios Klinikum Altona Hamburg, Hamburg, Germany
| | - Anke Reinacher-Schick
- Department for Hematology, Oncology und Palliative Care, St. Josef-Hospital, Ruhr-University, Bochum, Germany
| | - Aandrea Tannapfel
- Institute of Pathology, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
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Giuliani J, Mantoan B, Bonetti A. Cost-effectiveness of maintenance therapy after first-line treatment in metastatic colorectal cancer. J Oncol Pharm Pract 2021; 28:194-198. [PMID: 34558365 DOI: 10.1177/10781552211038929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Andrea Bonetti
- 18586Department of Oncology, Az. ULSS 9 Scaligera, Italy
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53
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Adams R, Goey K, Chibaudel B, Koopman M, Punt C, Arnold D, Hinke A, Hegewisch-Becker S, de Gramont A, Labianca R, Diaz Rubio E, Magne Tveit K, Wasan H, Kaplan R, Brown L, Maughan T, Fisher D. Treatment breaks in first line treatment of advanced colorectal cancer: An individual patient data meta-analysis. Cancer Treat Rev 2021; 99:102226. [PMID: 34130171 DOI: 10.1016/j.ctrv.2021.102226] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intermittent systemic anti-cancer therapy in patients with advanced colorectal cancer (aCRC) may improve quality of life without compromising overall survival (OS). We aimed to use individual patient data meta-analysis (IPDMA) from multiple randomised controlled trials evaluating intermittent strategies to inform clinical practice. We also aimed to validate whether thrombocytosis as a predictive biomarker identified patients with significantly reduced OS receiving a complete treatment break. PATIENTS AND METHODS An IPDMA of intermittent strategy impact on survival was undertaken, including all relevant trials in which data were available. Intermittent strategies were classified into two groups: a planned stopping of all therapy ("treatment break strategy"; 6 trials; 2,907 patients) or to the same treatment omitting oxaliplatin ("maintenance strategy"; 3 trials; 1,271 patients). The primary analysis sample was of patients successfully completing induction therapy. Additionally, a pre-planned analysis of the predictive value of thrombocytosis on survival under a continuous versus an intermittent strategy was undertaken. RESULTS All trials had comparable inclusion criteria. The overall IPDMA of intermittent therapy versus continuous therapy demonstrated no detriment in OS (HR = 1.03 [95% CI 0.93-1.14]), whether from complete break (HR 1.04 [95% CI 0.87-1.26]) or maintenance strategies (HR 0.99 [95% CI 0.87-1.13]). Thrombocytosis was confirmed as a marker of poor prognosis in aCRC, but did not predict for OS detriment from treatment break strategies (interaction HR = 0.97 [95% CI 0.66-1.40] compared to continuous therapy). CONCLUSION The highest levels of evidence from this IPDMA indicate no detriment in survival for patients receiving an intermittent therapy strategy, either for maintenance or complete break strategies. Although, thrombocytosis is confirmed as a marker of poor prognosis, it is not predictive of poor outcome for patients treated with intermittent therapy. An intermittent chemotherapy strategy can therefore be applied irrespective of baseline platelet count and does not result in inferior OS compared to continuous chemotherapy.
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Affiliation(s)
- Richard Adams
- Cardiff University and Velindre Cancer Centre, United Kingdom.
| | - Kaitlyn Goey
- University Medical Center, Utrecht, the Netherlands.
| | | | | | - Cornelis Punt
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, the Netherlands.
| | - Dirk Arnold
- Asklepios Tumorzentrum Hamburg, Germany and Instituto CUF de Oncologia, Lisbon, Portugal.
| | | | | | | | | | | | | | | | | | - Louise Brown
- MRC Clinical Trials Unit at UCL, United Kingdom.
| | | | - David Fisher
- MRC Clinical Trials Unit at UCL, United Kingdom.
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Correa E, Lindsay T, Dotan E. Management of Metastatic Colorectal Carcinoma in Older Adults: Balancing Risks and Benefits of Novel Therapies. Drugs Aging 2021; 38:639-654. [PMID: 34143421 PMCID: PMC9951235 DOI: 10.1007/s40266-021-00869-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 11/25/2022]
Abstract
The prevalence of older patients with metastatic colorectal cancer (mCRC) will continue to increase with our aging population. Treatment of mCRC has changed significantly in the last few decades as we have learned how to personalize the treatment of mCRC to the biology of the tumor, utilizing new treatment approaches. With an ever-changing treatment paradigm, managing the population of older adults becomes paramount. This review highlights the pivotal clinical trials that defined the use of systemic therapy, immunotherapy and targeted therapies for mCRC, and how those are applied to the older patient population. In addition, we outline the tools for an in-depth assessment of an older adult in regards to treatment planning and management of therapy-related toxicities. A comprehensive geriatric assessment can assist in the selection of treatment for an older adult with mCRC. While frail older patients can frequently only tolerate single agents or modified regimens, fit older adults remain candidates for a wider range of treatment options. However, since all of these treatments are associated with possible toxicities, each patient's treatment must be personalized to the patient's goals and wishes through a shared decision-making process.
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Affiliation(s)
- Erika Correa
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Timothy Lindsay
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Efrat Dotan
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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55
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Decker T, Seifert R, Bichler M, Birtel A, Fischer G, Nonnenbroich C, Dechow T. Elective Discontinuation of CDK4/6 Inhibitors in Patients with Metastatic Hormone Receptor-Positive, Her-2-Negative Breast Cancer: A Retrospective Single-Center Experience. Oncol Res Treat 2021; 44:443-449. [PMID: 34350900 DOI: 10.1159/000518207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cyclin-dependent 4/6 kinase (CDK4/6) inhibitors given with endocrine therapy until disease progression are standard of care in the treatment of women with advanced HR-positive Her-2-negative breast cancer. No data are available if therapy can be safely de-escalated to endocrine monotherapy in patients with long-lasting disease control. METHODS We performed a retrospective analysis on the clinical course of 22 patients at our center who received CDK4/6 inhibitors with aromatase inhibitors or fulvestrant. All patients had at least stable disease for >6 months and made a joint decision with their provider to electively discontinue CDK4/6 inhibitors. Best objective response (BOR) at treatment discontinuation, progression-free survival, and re-treatment characteristics were recorded. RESULTS Of 138 patients who received CDK4/6 inhibitors as first- or second-line therapy at our center, 22 met the inclusion criteria. Median duration of CDK4/6 treatment was 18 months (range 6-45). BOR was complete response in 1, partial response in 8, and stable disease in 13 patients. After a median duration of endocrine monotherapy of 9.5 months (range 5-44 months), 6 of 22 patients had progressive disease (1 local relapse and 5 systemic progression). All patients with disease progression had at least stable disease to chemotherapy (N = 1) or re-treatment with CDK4/6 inhibitors (N = 4). CONCLUSION Elective discontinuation of CDK4/6 inhibitors is feasible in patients with long-lasting disease stabilization. This strategy should be evaluated in prospective trials.
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Affiliation(s)
| | - Robert Seifert
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | | | | | - Gerhard Fischer
- Onkologie Ravensburg, Ravensburg, Germany.,St. Elisabeth Hospital, Ravensburg, Germany
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Drug Holidays and Overall Survival of Patients with Metastatic Colorectal Cancer. Cancers (Basel) 2021; 13:cancers13143504. [PMID: 34298718 PMCID: PMC8304309 DOI: 10.3390/cancers13143504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 12/24/2022] Open
Abstract
Different de-escalation strategies have been proposed to limit the risk of cumulative toxicity and guarantee quality of life during the treatment trajectory of patients with metastatic colorectal cancer (mCRC). Programmed treatment interruptions, defined as drug holidays (DHs), have been implemented in clinical practice. We evaluated the association between DHs and overall survival (OS). This was a retrospective study, conducted at the University Hospital of Udine and the IRCCS CRO of Aviano. We retrieved records of 608 consecutive patients treated for mCRC from 1 January 2005 to 15 March 2017 and evaluated the impact of different de-escalation strategies (maintenance, DHs, or both) on OS through uni- and multivariate Cox regression analyses. We also looked at attrition rates across treatment lines according to the chosen strategy. In our study, 19.24% of patients received maintenance therapy, 16.12% DHs, and 9.87% both, while 32.07% continued full-intensity first-line treatment up to progression or death. In uni- and multivariate analyses first-line continuous treatment and early discontinuation (treatment for less than 3 months) were associated to worse OS compared to non-continuous strategies (HR, 1.68; 95% CI, 1.22-2.32; p = 0.002 and HR,4.89; 95% CI, 3.33-7.19; p < 0.001, respectively). Attrition rates were 22.8%, 20.61%, and 19.64% for maintenance, DHs, or both, respectively. For continuous therapy and for treatment of less than 3 months it was 21.57% and 49%. De-escalation strategies are safe and effective options. DHs after initial induction chemotherapy may be considered in clinically selected patients with metastatic colorectal cancer.
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57
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Yin G, Zhao L. Risk of hypertension with anti-VEGF monoclonal antibodies in cancer patients: a systematic review and meta-analysis of 105 phase II/III randomized controlled trials. J Chemother 2021; 34:221-234. [PMID: 34229563 DOI: 10.1080/1120009x.2021.1947022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
We performed a meta-analysis to fully investigate the hypertension of anti-VEGF mAbs in cancer patients. Databases were searched for randomized controlled trials (RCTs) treated with anti-VEGF mAbs till January 2021. The relevant RCTs in cancer patients treated with anti-VEGF mAbs were retrieved and the systematic evaluation was conducted. One hundred and five RCTs and 65358 patients were included. Our study suggests that anti-VEGF mAbs significantly increased the risks of all-grade (RR, 3.22; 95%CI, 2.83-3.65; p < 0.00001; I2=71%) and high-grade (RR, 6.15; 95%CI, 5.58-6.78; p < 0.00001; I2=48%) hypertension in cancer patients. Those risks may be dependent on drug type. Icrucumab did not association with an increased risk of hypertension. The RR of hypertension did not vary significantly according to the type of cancer, line of therapy, and treatment duration. The available data suggested that the use of anti-VEGF mAbs were associated with a significantly increased risk of hypertension.
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Affiliation(s)
- Gang Yin
- Central Nervous System Drug Key Laboratory of Sichuan Province, Southwest Medical University, Luzhou, Sichuan, P.R. China.,Engineering Research Center for Pharmaceuticals and Equipments of Sichuan Province, Sichuan Industrial Institute of Antibiotics, School of pharmacy, Chengdu University, Chengdu, Sichuan, P.R. China
| | - Ling Zhao
- Central Nervous System Drug Key Laboratory of Sichuan Province, Southwest Medical University, Luzhou, Sichuan, P.R. China
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Moriwaki T, Gosho M, Sugaya A, Yamada T, Yamamoto Y, Hyodo I. Optimal Maintenance Strategy for First-Line Oxaliplatin-Containing Therapy with or without Bevacizumab in Patients with Metastatic Colorectal Cancer: A Meta-Analysis. Cancer Res Treat 2021; 53:703-713. [PMID: 33285056 PMCID: PMC8291198 DOI: 10.4143/crt.2020.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/30/2020] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Maintenance therapy after oxaliplatin withdrawal is useful in patients with metastatic colorectal cancer (mCRC). This study aimed to investigate the timing of discontinuation or reintroduction of oxaliplatin and the optimal maintenance therapy regimen for survival. MATERIALS AND METHODS PubMed and conference abstracts were searched to select phase II and III trials of first-line oxaliplatin-containing therapy with or without bevacizumab using maintenance therapy for mCRC. Correlations of median overall survival (OS) with induction therapy regimens, induction therapy duration, maintenance therapy regimens (fluoropyrimidine plus bevacizumab [FP+Bev], FP/Bev alone, and no treatment), and oxaliplatin reintroduction were investigated using correlation and weighted multivariate regression analyses. RESULTS Twenty-two treatment arms were analyzed, including 2,581 patients. The maintenance therapy regimen FP+Bev showed the strongest correlation with a prolonged OS (Spearman's partial correlation coefficient=0.42), and the other three variables correlated weakly with the OS. The maintenance therapy regimen significantly interacted with the induction chemotherapy duration (p=0.019). The predicted OS for FP+Bev crossed the lines of FP/Bev alone at 18 weeks of induction therapy, and of no treatment at 23 weeks. The corresponding OS at 12 and 27 weeks of induction therapies were 28.6 and 24.2 months for FP+Bev, 25.9 and 28.8 months for FP/Bev alone, and 20.5 and 27.5 months for no treatment. CONCLUSION The optimal maintenance therapy regimen for the OS is a continuous induction therapy as long as possible followed by FP/Bev alone and switching to FP+Bev within approximately 4 months if induction therapy is discontinued.
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Affiliation(s)
- Toshikazu Moriwaki
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba,
Japan
| | - Masahiko Gosho
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba,
Japan
| | - Akinori Sugaya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba,
Japan
| | - Takeshi Yamada
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba,
Japan
| | - Yoshiyuki Yamamoto
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba,
Japan
| | - Ichinosuke Hyodo
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba,
Japan
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Cainap C, Ungur RA, Bochis OV, Achimas P, Vlad C, Havasi A, Vidrean A, Farcas A, Tat T, Gherman A, Piciu A, Bota M, Constantin AM, Pop LA, Maniu D, Crisan O, Cioban CV, Balacescu O, Coza O, Balacescu L, Marta MM, Dronca E, Cainap S. Partnering bevacizumab with irinotecan as first line-therapy of metastatic colorectal cancer improves progression free survival-A retrospective analysis. PLoS One 2021; 16:e0248922. [PMID: 33909622 PMCID: PMC8081186 DOI: 10.1371/journal.pone.0248922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/08/2021] [Indexed: 12/24/2022] Open
Abstract
Colorectal cancer remains one of the most frequent malignancies (third place at both genders) worldwide in the last decade, owing to significant changes in modern dietary habits. Approximately half of the patients develop metastases during the course of their disease. The available therapeutic armamentarium is constantly evolving, raising questions regarding the best approach for improving survival. Bevacizumab remains one of the most widely used therapies for treating metastatic colorectal cancer and can be used after progression. This study aimed to identify the best chemotherapy partner for bevacizumab after progression. We performed a retrospective analysis of patients with metastatic colorectal cancer who were treated with bevacizumab as first- and second-line chemotherapy. Data were collected for 151 patients, 40 of whom were treated with double-dose bevacizumab after the first progression. The two standard chemotherapy regimens combined with bevacizumab were FOLFIRI/CAPIRI and FOLFOX4/CAPEOX. The initiation of first-line treatment with irinotecan-based chemotherapy improved progression-free survival and time to treatment failure but not overall survival. After the first progression, retreatment with the same regimen as that used in the induction phase was the best approach for improving overall survival (median overall survival: 46.5 vs. 27.0 months for the same vs. switched strategy, respectively). No correlations were observed between the dose intensity of irinotecan, oxaliplatin, 5-fluorouracil, or bevacizumab and the overall survival, progression-free survival in the first-/second-line treatment, and time to treatment failure. Interaction between an irinotecan-based regimen as a second-line treatment and double-dose bevacizumab after progression was associated with an improved overall survival (p = 0.06). Initiating systemic treatment with an irinotecan-based regimen in combination with bevacizumab improved the progression-free survival in the first-line treatment and time to treatment failure. In terms of overall survival, bevacizumab treatment after the first progression is better partnered with the same regimen as that used in the induction phase.
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Affiliation(s)
- Calin Cainap
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
- Department of Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Rodica Ana Ungur
- Department of Medical Specialties, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- * E-mail:
| | | | - Patriciu Achimas
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
- Department of Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Catalin Vlad
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
- Department of Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Havasi
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
| | | | - Anca Farcas
- Department of Medical Specialties, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Tiberiu Tat
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
| | - Alexandra Gherman
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
- Department of Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andra Piciu
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
- Department of Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Madalina Bota
- Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anne-Marie Constantin
- Department of Morphological Sciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Laura Ancuta Pop
- Department of Molecular Sciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana Maniu
- Faculty of Physics, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Ovidiu Crisan
- Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cosmin Vasile Cioban
- Faculty of Dental Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Ovidiu Coza
- Ion Chiricuta Institute of Oncology, Cluj-Napoca, Romania
- Department of Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Monica Mihaela Marta
- Department of Medical Education, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Eleonora Dronca
- Department of Molecular Sciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Simona Cainap
- Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Salvatore L, Bria E, Sperduti I, Hinke A, Hegewisch-Becker S, Aparicio T, Le Malicot K, Boige V, Koeberle D, Baertschi D, Dietrich D, Tortora G, Arnold D. Bevacizumab as maintenance therapy in patients with metastatic colorectal cancer: A meta-analysis of individual patients' data from 3 phase III studies. Cancer Treat Rev 2021; 97:102202. [PMID: 33838596 DOI: 10.1016/j.ctrv.2021.102202] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The real impact of bevacizumab maintenance as single agent in metastatic colorectal cancer (mCRC) remains unclear. SAKK-41/06 and PRODIGE-9 failed to demonstrate the non-inferiority and superiority of bevacizumab versus no maintenance, respectively, while AIO-KRK-0207 showed the non-inferiority of maintenance bevacizumab versus bevacizumab and fluoropyrimidines for time to strategy failure. METHODS Bibliography electronic databases (PubMed, MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were searched for English published clinical trials prospectively randomizing mCRC patients to receive bevacizumab maintenance or not after first-line chemotherapy plus bevacizumab. Individual patients' data (IPD) were provided by investigators for all included trials. Primary end-points were progression-free survival (PFS) and overall survival (OS), both from the start of induction and maintenance. Univariate and multivariate analyses for PFS and OS were performed. RESULTS Three phase III studies - PRODIGE-9, AIO-KRK-0207 and SAKK-41/06 - were included. Considering the different timing of randomization, IPD of patients not progressed during induction and starting maintenance phase entered the analysis. 909 patients were included, 457 (50%) received bevacizumab maintenance. Median PFS from induction start was 9.6 and 8.9 months in bevacizumab group versus no maintenance group, respectively (HR 0.78; 95%CI: 0.68-0.89; p < 0.0001). Subgroups analysis for PFS showed a significant interaction according for RAS status (p = 0.048), with a maintenance benefit limited to RAS wild-type patients. No difference in terms of OS was observed. CONCLUSIONS Despite the statistically significant PFS improvement for bevacizumab maintenance, the absolute benefit appears limited. Subgroup analysis shows a differential effect of bevacizumab maintenance in favor of RAS wild-type patients. Considering these results, maintenance therapy with fluoropyrimidine with or without bevacizumab remains the first option. Single agent bevacizumab maintenance can be considered in selected cases, such as cumulative toxicity or patient's refusal, in particular for RAS wild-type patients.
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Affiliation(s)
- Lisa Salvatore
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy.
| | - Emilio Bria
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Isabella Sperduti
- Biostatistics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | - Thomas Aparicio
- Department of Gastroenterology, Saint Louis Hospital, APHP, Université de Paris, Paris, France
| | - Karine Le Malicot
- Fédération Francophone de Cancérologie Digestive, EPICAD INSERM UMR LNC 1231, Dijon, France
| | - Valérie Boige
- Department of Oncologic Medicine, Gustave Roussy, Villejuif, France
| | | | | | | | - Giampaolo Tortora
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Dirk Arnold
- Asklepios Tumorzentrum Hamburg AK Altona, Hamburg, Germany
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Auber ML, Wen S, Hobbs G, Higa GM. Capecitabine as Maintenance Therapy for High-Risk, Resected Colorectal Cancer. Gastrointest Tumors 2021; 8:81-86. [PMID: 33981686 DOI: 10.1159/000513960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/22/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction In 2020, colorectal cancer will be the fourth most frequently diagnosed malignant neoplasm and the second leading cause of site-specific, cancer-related deaths in the USA. Notably, 80% of the new cases are, by staging criteria, potentially curable even those with completely resected stage 4 disease. If slightly more than half the losses can be attributed to metastatic disease at presentation, then the remaining portion of deaths may be linked to disease relapse after surgery and, if applicable, adjuvant chemotherapy. The inference that these therapies are not curative for a significant number of subjects poses a role for maintenance therapy. Objective To assess event-free survival (EFS) of patients who received capecitabine as maintenance therapy following treatment according to current guidelines. Methods Clinical outcomes data were collected for 35 subjects treated with capecitabine as maintenance therapy. Descriptive statistical analyses were conducted on collective data related to duration of maintenance therapy and disease or clinical status from surgery to initial event. Kaplan-Meier method and log-rank test were used to analyze EFS and overall survival. Results Of the entire cohort, 26 subjects have no evidence of disease (NED), a median of 5.5 years from surgery. Kaplan-Meier analyses indicated a 5-year EFS rate of 74% (95% CI: 60-90%). Eighteen of these 26 patients received capecitabine ≥30 months. Eight of the 17 subjects treated with capecitabine therapy for <30 months developed progressive disease; the majority of the relapses occurred within 20 months of surgery. The difference between the two groups was statistically significant. Six subjects died, only two of who had metastatic disease at the time of death; the other four had NED at least 4 years from surgery. Five patients with resected stage 4 disease who received capecitabine as maintenance therapy were alive >5 years from surgery. Conclusion The findings and analyses of this cohort of patients suggest that maintenance capecitabine therapy reduces the risk of disease progression and cancer-related death.
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Affiliation(s)
- Miklos L Auber
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia, USA
| | - Gerald Hobbs
- Department of Statistics, West Virginia University, Morgantown, West Virginia, USA
| | - Gerald M Higa
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA.,Department of Clinical Pharmacy, West Virginia University, Morgantown, West Virginia, USA
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Dong M, Wang R, Sun P, Zhang D, Zhang Z, Zhang J, Tse G, Zhong L. Clinical significance of hypertension in patients with different types of cancer treated with antiangiogenic drugs. Oncol Lett 2021; 21:315. [PMID: 33692847 PMCID: PMC7933774 DOI: 10.3892/ol.2021.12576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022] Open
Abstract
Hypertension is a common comorbidity in patients receiving antiangiogenic therapy. Prior studies have reported worsening or new-onset hypertension as an adverse event of antiangiogenetic therapy, which can be managed by dose reduction or discontinuation of the culprit medication. By contrast, other studies have found that the occurrence of hypertension is a potential biomarker associated with greater efficacy of antiangiogenic therapy and predicts improved survival. At present, there is no consensus on the effects of hypertension in patients treated with antiangiogenic drugs. The present study reviewed the relationship between antiangiogenic drugs and hypertension in different types of cancer. It was demonstrated that the use of antiangiogenic drugs was associated with an increased risk of hypertension in most types of solid cancers. There was no significant difference in the incidence of hypertension between monoclonal antibody and small-molecule tyrosine kinase inhibitor treatments. Hypertension was more likely to occur in patients younger than 75 years old, female, and those with no history of bevacizumab use. Discontinuation or death caused by hypertension was rare, although previous studies have reported that hypertension was a risk factor for acute and chronic cardiovascular diseases and ischemic stroke. Of note, the early development of hypertension may serve as a potential biomarker associated with greater efficacy of antiangiogenic therapy.
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Affiliation(s)
- Mei Dong
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Rujian Wang
- Department of Oncology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Ping Sun
- Department of Oncology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Dongxia Zhang
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Zhenzhen Zhang
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Jing Zhang
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Lin Zhong
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
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63
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Molecular Genetics and the Role of Molecularly Targeted Agents in Metastatic Colorectal Carcinoma. J Gastrointest Cancer 2021; 51:387-400. [PMID: 31273629 DOI: 10.1007/s12029-019-00272-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the leading causes of mortality and morbidity in the world. It is the third most common malignancy and fourth leading cancer-related deaths worldwide. In the USA, CRC is the third most commonly diagnosed cancer in both men and women. It is caused by genetic components and potential environmental factors such as consumption of processed meat, red meat, animal fats, low fiber intake, and obesity. Despite the utilization of effective screening modalities and guidelines in the USA, a significant number of patients are diagnosed with advanced, metastatic disease at the time of presentation to the physician. Recent advances in the understanding of molecular medicine with subsequent development and incorporation of newer therapeutic agents into current chemotherapeutic regimens have improved outcomes; however, the management of metastatic CRC remains challenging, particularly for the treating oncologists. METHODS We conducted a literature search on CRC mainly related to molecular genetics, targeted biologic agents, and published clinical trials. We also searched and reviewed ongoing clinical trials from Clinicaltrials.gov. RESULTS AND CONCLUSIONS Alterations in several oncogenes are associated with CRC, among those RAS, BRAF, and HER2 are of current clinical importance. Chemotherapy drugs, along with vascular endothelial growth factor or epidermal growth factor receptor monoclonal antibodies, are proven to be efficient with manageable toxicity profiles in metastatic CRC. Additional researches on Her-2-directed therapy, BRAF-targeted agents, immunotherapeutic, and newer molecularly targeted agents are needed for further improvement in outcome.
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Martín-Richard M, Tobeña M. First-Line Maintenance Treatment in Metastatic Colorectal Cancer (mCRC): Quality and Clinical Benefit Overview. J Clin Med 2021; 10:jcm10030470. [PMID: 33530547 PMCID: PMC7865515 DOI: 10.3390/jcm10030470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 01/02/2023] Open
Abstract
Different strategies of maintenance therapy (sequential CT, intermittent CT, intermittent CT and MAbs, or de-escalation MAbs monotherapy) after first-line treatment are undertaken. Many randomized clinical trials (RCT), which evaluated these approaches, suffer from incorrect design, heterogenous primary endpoints, inadequate size, and other methodology flaws. Drawing any conclusions becomes challenging and recommendations are mainly vague. We evaluated those studies from another perspective, focusing on the design quality and the clinical benefit measure with a more objective and accurate methodology. These data allowed a clearer and more exact overview of the statement in maintenance treatment.
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Affiliation(s)
- Marta Martín-Richard
- Medical Oncology Department, Sant Pau Hospital, 08043 Barcelona, Spain
- Correspondence:
| | - Maria Tobeña
- Medical Oncology Department, Quironsalud Hospital, 50006 Zaragoza, Spain;
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Impact of time-varying cumulative bevacizumab exposures on survival: re-analysis of data from randomized clinical trial in patients with metastatic colo-rectal cancer. BMC Med Res Methodol 2021; 21:14. [PMID: 33422006 PMCID: PMC7796644 DOI: 10.1186/s12874-020-01202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/21/2020] [Indexed: 12/24/2022] Open
Abstract
Background As cancer treatment, biotherapies can be as effective as chemotherapy while reducing the risk of secondary effects, so that they can be taken over longer periods than conventional chemotherapy. Thus, some trials aimed at assessing the benefit of maintaining biotherapies during chemotherapy-free intervals (CFI). For example, the recent PRODIGE9 trial assessed the effect of maintaining bevacizumab during CFI in metastatic colorectal cancer (mCRC) patients. However, its analysis was hindered by a small difference of exposure to the treatment between the randomized groups and by a large proportion of early drop outs, leading to a potentially unbalanced distribution of confounding factors among the trial completers. To address these limitations, we re-analyzed the PRODIGE9 data to assess the effects of different exposure metrics on all-cause mortality of patients with mCRC using methods originally developed for observational studies. Methods To account for the actual patterns of drug use by individual patients and for possible cumulative effects, we used five alternative time-varying exposure metrics: (i) cumulative dose, (ii) quantiles of the cumulative dose, (iii) standardized cumulative dose, (iv) Theoretical Blood Concentration (TBC), and (v) Weighted Cumulative Exposure (WCE). The last two metrics account for the timing of drug use. Treatment effects were estimated using adjusted Hazard Ratio from multivariable Cox proportional hazards models. Results After excluding 112 patients who died during the induction period, we analyzed data on 382 patients, among whom 320 (83.8%) died. All time-varying exposures improved substantially the model’s fit to data, relative to using only the time-invariant randomization group. All exposures indicated a protective effect for higher cumulative bevacizumab doses. The best-fitting WCE and TBC models accounted for both the cumulative effects and the different impact of doses taken at different times. Conclusions All time-varying analyses, regardless of the exposure metric used, consistently suggested protective effects of higher cumulative bevacizumab doses. However, the results may partly reflect the presence of a confusion bias. Complementing the main ITT analysis of maintenance trials with an analysis of potential cumulative effects of treatment actually taken can provide new insights, but the results must be interpreted with caution because they do not benefit from the randomization. Trial registration clinicaltrials.gov, NCT00952029. Registered 8 August 2009. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-020-01202-9.
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Geng R, Wang G, Qiu L, Liu B, Yang F, Zhang J, Miao Y. Metronomic capecitabine as maintenance treatment after first line induction with XELOX for metastatic colorectal cancer patients. Medicine (Baltimore) 2020; 99:e23719. [PMID: 33371122 PMCID: PMC7748176 DOI: 10.1097/md.0000000000023719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/16/2020] [Indexed: 01/05/2023] Open
Abstract
Maintenance treatment after first-line chemotherapy for patients with metastatic colorectal cancer (mCRC) is a priority strategy. However, which medicine is chosen is controversial. This study aimed to determine the efficacy and safety of maintenance treatment with metronomic capecitabine vs observation.In this randomized controlled trial, patients who completed 18 weeks of induction chemotherapy with XELOX and achieved disease control were randomly assigned centrally (1:1) to receive maintenance therapy with metronomic chemotherapy or observation until disease progression. The primary endpoint was progression-free survival from randomization; secondary endpoints included overall survival and safety. Analyses were performed by intention to treat.Between January 1st, 2017 and December 31th 2018, 48 patients were enrolled and randomly assigned to receive maintenance treatment with metronomic capecitabine (n = 25) or only observation (n = 23). The median progression-free survival in the metronomic capecitabine group was 5.66 (95% confidence interval [CI] 5.25-6.07) months vs 3.98 (95%CI 3.71-4.24) months in the observation group (hazard ratio 0.11, 95% [CI] 0.04-0.26, P = .000). There was no statistically significant difference in median overall survival: 23.82 (95% CI 22.38-25.25) months in the metronomic capecitabine group vs 21.81 (95% CI 20.23-23.38) months in the observation group (hazard ratio 0.49, 95% CI 0.21-1.11, P = .087). Subgroup analyses were generally consistent with the primary finding. Similar safety profiles were observed in both arms. The most frequent adverse events in metronomic capecitabine group included neutropenia, diarrhea, hand-foot skin reaction, and mucositis.Maintenance therapy with metronomic capecitabine can be considered an alternative option following first-line chemotherapy of XELOX in patients with metastatic colorectal cancer with controlled toxicities.
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Affiliation(s)
- Rui Geng
- School of Public Health, Nanjing Medical University, Nanjing
| | - Gang Wang
- Department of gastrointestinal surgery, the Second People's Hospital of Lianyungang, Lianyungang
| | - Lei Qiu
- Department of gastrointestinal surgery, the Second People's Hospital of Lianyungang, Lianyungang
| | - Bing Liu
- Department of gastrointestinal oncology, the Second People's Hospital of Lianyungang, Lianyungang, China
| | - Fan Yang
- Department of gastrointestinal oncology, the Second People's Hospital of Lianyungang, Lianyungang, China
| | - Jingyu Zhang
- Department of gastrointestinal oncology, the Second People's Hospital of Lianyungang, Lianyungang, China
| | - Yongchang Miao
- Department of gastrointestinal surgery, the Second People's Hospital of Lianyungang, Lianyungang
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67
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Treatments after first progression in metastatic colorectal cancer. A literature review and evidence-based algorithm. Cancer Treat Rev 2020; 92:102135. [PMID: 33307331 DOI: 10.1016/j.ctrv.2020.102135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/23/2022]
Abstract
Prolonging survival, achieving symptoms palliation and preserving quality of life are the primary therapeutic goals of treatments administered after disease progression in mCRC. Even if the impact of these therapies on the prognosis of affected patients is less relevant than the impact of the upfront treatment, tailoring the optimal second-line therapy is increasingly important. Several therapeutic options are available, and different factors including not only patient- and disease-related characteristics, but also the first-line treatment received (i.e., type, timing of disease progression, observed outcome and reported toxicities) may drive this choice. Herein, we describe the current state of the art in the landscape of treatments after progression in mCRC. Based on a critical review of the literature, we built a patient-oriented therapeutic algorithm, aiming to guide clinicians in their daily decision-making.
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68
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Lueong SS, Herbst A, Liffers ST, Bielefeld N, Horn PA, Tannapfel A, Reinacher-Schick A, Hinke A, Hegewisch-Becker S, Kolligs FT, Siveke JT. Serial Circulating Tumor DNA Mutational Status in Patients with KRAS-Mutant Metastatic Colorectal Cancer from the Phase 3 AIO KRK0207 Trial. Clin Chem 2020; 66:1510-1520. [PMID: 33257977 DOI: 10.1093/clinchem/hvaa223] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 08/28/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND We assessed the usefulness of circulating tumor DNA (ctDNA) pre- or post-treatment initiation for outcome prediction and treatment monitoring in metastatic colorectal cancer (mCRC). METHODS Droplet digital PCR was used to measure absolute mutant V-Ki-ras2 Kirsten rat sarcoma viral oncogene ((mut)KRAS) ctDNA concentrations in 214 healthy controls (plasma and sera) and in 151 tissue-based mutKRAS positive patients with mCRC from the prospective multicenter phase 3 trial AIO KRK0207. Serial mutKRAS ctDNA was analyzed prior to and 2-3 weeks after first-line chemotherapy initiation with fluoropyrimidine, oxaliplatin, and bevacizumab in patients with mCRC and correlated with clinical parameters. RESULTS mut KRAS ctDNA was detected in 74.8% (113/151) of patients at baseline and in 59.6% (90/151) at follow-up. mutKRAS ctDNA at baseline and follow-up was associated with poor overall survival (OS) (hazard ratio [HR] =1.88, 95% confidence interval [CI] 1.20-2.95; HR = 2.15, 95% CI 1.47-3.15) and progression-free survival (PFS) (HR = 2.53, 95% CI 1.44-4.46; HR = 1.90, 95% CI 1.23-2.95), respectively. mutKRAS ctDNA clearance at follow-up conferred better disease control (P = 0.0075), better OS (log-rank P = 0.0018), and PFS (log-rank P = 0.0018). Measurable positive mutKRAS ctDNA at follow-up was the strongest and most significant independent prognostic factor on OS in multivariable analysis (HR = 2.31, 95% CI 1.40-3.25). CONCLUSIONS Serial analysis of circulating mutKRAS concentrations in mCRC has prognostic value. Post treatment mutKRAS concentrations 2 weeks after treatment initiation were associated with therapeutic response in multivariable analysis and may be an early response predictor in patients receiving first-line combination chemotherapy. CLINICALTRIALSGOV IDENTIFIER NCT00973609.
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Affiliation(s)
- Smiths S Lueong
- Institute for Developmental Cancer Therapeutics, West German Cancer Center, University Medicine Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Andreas Herbst
- Institute of Laboratory Medicine, University of Munich, Munich, Germany.,German Cancer Consortium (DKTK, Partner Site Munich) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Sven-Thorsten Liffers
- Institute for Developmental Cancer Therapeutics, West German Cancer Center, University Medicine Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Nicola Bielefeld
- Institute for Developmental Cancer Therapeutics, West German Cancer Center, University Medicine Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Peter A Horn
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany.,Institute for Transfusion Medicine, University Hospital Essen, Essen, Germany
| | | | - Anke Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, St. Josef-Hospital, Ruhr-University Bochum
| | - Axel Hinke
- CCRC: Cancer Clinical Research Consulting, Düsseldorf, Germany
| | | | - Frank T Kolligs
- German Cancer Consortium (DKTK, Partner Site Munich) and German Cancer Research Center, DKFZ, Heidelberg, Germany.,Department of Medicine, Division of- Gastroenterology, Hepatology & Infectiology, Helios Clinic Berlin-Buch, Berlin, Germany.,Department of Medicine II, University of Munich, Munich, Germany
| | - Jens T Siveke
- Institute for Developmental Cancer Therapeutics, West German Cancer Center, University Medicine Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
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Manfredi S, Turpin A, Malka D, Barbier E, Laurent-Puig P, Zaanan A, Dahan L, Lièvre A, Phelip JM, Michel P, Hautefeuille V, Legoux JL, Lepage C, Tougeron D, Aparicio T. Maintenance treatment with fluoropyrimidine plus bevacizumab versus fluoropyrimidine alone after induction chemotherapy for metastatic colorectal cancer: The BEVAMAINT - PRODIGE 71 - (FFCD 1710) phase III study. Dig Liver Dis 2020; 52:1143-1147. [PMID: 32747302 DOI: 10.1016/j.dld.2020.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Maintenance treatments with fluoropyrimidine alone or combined with bevacizumab after induction chemotherapy are two standard options in first-line metastatic colorectal cancer (mCRC). However, no trial has compared these two maintenance regimens. METHODS BEVAMAINT is a multicenter, open-label, randomized phase III trial comparing fluoropyrimidine alone or plus bevacizumab as maintenance treatment after induction polychemotherapy in mCRC. The primary endpoint is the time-to-treatment failure (TTF), calculated from date of randomization to first radiological progression, death, start of a new chemotherapy regimen (different from induction or maintenance chemotherapy) or end of maintenance treatment without introduction of further chemotherapy. We expect a 2-month TTF improvement from 6 months in the monotherapy arm to 8 months in the combination arm (hazard ratio [HR], 0.75). Based on a two-sided α risk of 5% and a power of 80%, using Schoenfeld method, 379 events are required (planned enrolment, 400 patients). Patients with mCRC, whose disease is measurable according to RECIST 1.1 criteria and controlled (objective response or stable disease) - but remains unresectable - after 4 to 6 months of induction polychemotherapy (doublet or triplet chemotherapy with or without anti-EGFR or bevacizumab), and who have recovered from limiting adverse events of induction polychemotherapy are eligible for randomization. Randomization is stratified according to center, response to induction chemotherapy (objective response vs stable disease), ECOG performance status (0-1 vs 2), maintenance fluoropyrimidine (5-fluorouracil vs capecitabine) and primary tumor status (resected vs not). Capecitabine or bolus and infusional 5-fluorouracil plus folinic acid (simplified LV5FU2 regimen) are both accepted for maintenance chemotherapy, at investigator's discretion. Clinical evaluation, tumor imaging, carcinoembryonic antigen and circulating tumor DNA dosages are planned at enrolment and every 9 weeks. The maintenance treatment will be discontinued in the event of unbearable toxicity, progression or patient refusal. After maintenance discontinuation, reintroduction of induction polychemotherapy is recommended; otherwise a second-line treatment is started. The enrolment has begun in January 2020.
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Affiliation(s)
- Sylvain Manfredi
- University of Bourgogne Franche-Comté, INSERM U123-1, university hospital Dijon, Gastroenterology unit, 14 rue Paul Gaffarel, 21000 Dijon, France.
| | | | | | - Emilie Barbier
- CRGA FFCD, university of Bourgogne Franche-Comté, INSERM U123-1, Dijon, France
| | - Pierre Laurent-Puig
- Hôpital Européen Georges-Pompidou HEGP, AP-HP, University Paris Descartes, Paris, France
| | - Aziz Zaanan
- Hôpital Européen Georges-Pompidou HEGP, AP-HP, University Paris Descartes, Paris, France
| | | | | | | | | | | | | | - Côme Lepage
- University of Bourgogne Franche-Comté, INSERM U123-1, university hospital Dijon, France
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Vera R, Salgado M, Safont MJ, Gallego J, González E, Élez E, Aranda E. Controversies in the treatment of RAS wild-type metastatic colorectal cancer. Clin Transl Oncol 2020; 23:827-839. [PMID: 32789773 PMCID: PMC7979622 DOI: 10.1007/s12094-020-02475-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/03/2020] [Indexed: 01/05/2023]
Abstract
Objective To provide guidance for the management of RAS wild-type (wt) metastatic colorectal cancer (mCRC) in daily practice. Methods Nominal group and Delphi techniques were used. A steering committee of seven experts analyzed the current management of RAS wt mCRC, through which they identified controversies, critically analyzed the available evidence, and formulated several guiding statements for clinicians. Subsequently, a group of 30 experts (the expert panel) was selected to test agreement with the statements, through two Delphi rounds. The following response categories were established in both rounds: 1 = totally agree, 2 = basically agree, 3 = basically disagree, 4 = totally disagree. Agreement was defined if ≥ 75% of answers were in categories 1 and 2 (consensus with the agreement) or 3 and 4 (consensus with the disagreement). Results Overall, 71 statements were proposed, which incorporated the following areas: (1) overarching principles; (2) tumor location; (3) triplets; (4) maintenance; (5) second-line and beyond treatments; (6) Rechallenge and liquid biopsy. After the two Delphi rounds, only six statements maintained a lack of clear consensus. Conclusions This document aims to describe the expert’s attitude when dealing with several common clinical questions regarding patients with RAS wt mCRC. Electronic supplementary material The online version of this article (10.1007/s12094-020-02475-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R Vera
- Medical Oncology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - M Salgado
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M J Safont
- Medical Oncology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | - J Gallego
- Medical Oncology Department, Hospital General Universitario de Elche, Alicante, Spain
| | - E González
- Medical Oncology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - E Élez
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - E Aranda
- Medical Oncology Department, Maimonides Institute of Biomedical Research (IMIBIC), Hospital Reina Sofía, University of Córdoba, Av. Menendez Pidal, s/n, 14004, Córdoba, Spain.
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Garattini SK, Bonotto M, Porcu L, Ongaro E, Gerratana L, Basile D, Parnofiello A, Pelizzari G, Cortiula F, Corvaja C, Casagrande M, Cardellino GG, Buonadonna A, Aprile G, Puglisi F, Fasola G, Pella N. Determinants of choice in offering drug holidays during first-line therapy for metastatic colorectal cancer. Future Oncol 2020; 16:2645-2660. [PMID: 32776795 DOI: 10.2217/fon-2020-0270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: 'Drug holidays' (DH) for metastatic colorectal cancer (mCRC) were introduced to preserve quality of life. We studied factors associated to a DH offer in first line. Materials & methods: We retrospectively analyzed 754 consecutive patients treated with chemotherapy for mCRC in two Italian institutions between 2005 and 2017. Associations between baseline clinical-pathological factors and DH (56 or more days of treatment interruption) were investigated. Results: In 754 patients, previous metastasectomy, previous thermoablation and previous surgery of primary tumor were independently associated with DH. Excluding procedures or clinical trials: primary rectal cancer and resection of primary tumor were significantly associated to DH. Conclusions: DH was offered to patients with lower burden of disease, but further investigations are needed to safely guide a holiday strategy.
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Affiliation(s)
- Silvio Ken Garattini
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.,Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marta Bonotto
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy
| | - Luca Porcu
- Department of Oncology, Laboratory of Methodology for Clinical Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Elena Ongaro
- Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | - Lorenzo Gerratana
- Department of Medicine, University of Udine, 33100 Udine, Italy.,Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | - Debora Basile
- Department of Medicine, University of Udine, 33100 Udine, Italy.,Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | - Annamaria Parnofiello
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.,Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Giacomo Pelizzari
- Department of Medicine, University of Udine, 33100 Udine, Italy.,Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | - Francesco Cortiula
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.,Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Carla Corvaja
- Department of Medicine, University of Udine, 33100 Udine, Italy.,Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | | | | | - Angela Buonadonna
- Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | - Giuseppe Aprile
- Department of Oncology, Azienda ULSS8 Berica, 36100 Vicenza, Italy
| | - Fabio Puglisi
- Department of Medicine, University of Udine, 33100 Udine, Italy.,Department of Medical Oncology, Unit of Medical Oncology & Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy
| | - Gianpiero Fasola
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy
| | - Nicoletta Pella
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy
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Raimondi A, Di Maio M, Morano F, Corallo S, Lonardi S, Antoniotti C, Rimassa L, Sartore-Bianchi A, Tampellini M, Ritorto G, Murialdo R, Clavarezza M, Zaniboni A, Adamo V, Tomasello G, Petrelli F, Antonuzzo L, Giordano M, Cinieri S, Longarini R, Bergamo F, Niger M, Antista M, Peverelli G, de Braud F, Di Bartolomeo M, Pietrantonio F. Health-related quality of life in patients with RAS wild-type metastatic colorectal cancer treated with panitumumab-based first-line treatment strategy: A pre-specified secondary analysis of the Valentino study. Eur J Cancer 2020; 135:230-239. [PMID: 32623288 DOI: 10.1016/j.ejca.2020.04.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/22/2020] [Accepted: 04/30/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Quality of life (QoL) patient-reported outcomes (PROs) data from pivotal first-line trials in metastatic colorectal cancer (mCRC) are poor. The Valentino study showed that de-escalation to single-agent panitumumab after 4-month induction with panitumumab-FOLFOX is inferior to panitumumab-5-FU/LV in patients with RAS wild-type mCRC, although slightly reducing toxicity. We report QoL, a secondary end-point. METHODS PROs were assessed by European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire - Core 30 (QLQ-C30), EORTC QLQ-CR29, EuroQol EQ-5D questionnaires, at baseline and every 8 weeks until disease progression. First two evaluations correspond to induction treatment (identical in both arms), while subsequent to maintenance. To describe QoL changes over time, mean changes from baseline at each time point were calculated in overall population. To compare maintenance between two arms, mean changes and proportion of improved/stable/worse patients versus baseline were compared for each item. RESULTS In arm A/B, 91.5%/92.0% of enrolled patients completed questionnaires at baseline. No significant differences in the two arms were reported in compliance, baseline scores and mean changes versus baseline for the three questionnaires during maintenance (24/32/40 weeks). Overall, mean changes versus baseline showed an early deterioration during induction with partial recovering during maintenance for global QoL, functional scales and several symptoms/items of QLQ-C30 (fatigue, nausea/vomiting, appetite loss, diarrhoea) and QLQ-CR29 (body image, dry mouth, hair loss, taste, faecal incontinence, sore skin), and EQ-5D Visual Analogue Scale (VAS) score. CONCLUSION In patients with RAS wild-type mCRC, induction with oxaliplatin-containing chemotherapy plus anti-EGFRs induces a transient significant QoL deterioration. After induction phase, treatment deintensification determines an overall recovery of health-related QoL, besides the expected prevention of oxaliplatin-related neurotoxicity.
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Affiliation(s)
- Alessandra Raimondi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Torino, Italy
| | - Federica Morano
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Salvatore Corallo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Sara Lonardi
- Medical Oncology Unit 1, Department of Oncology, Istituto Oncologico Veneto - IRCCS, Padua, Italy
| | - Carlotta Antoniotti
- Unit of Medical Oncology, Azienda Ospedaliero-Universitaria Pisana, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Andrea Sartore-Bianchi
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy; Oncology and Hemato-oncology Department, University of Milan, Milan, Italy
| | - Marco Tampellini
- Department of Oncology, AOU San Luigi di Orbassano, University of Torino, Orbassano, Italy
| | - Giuliana Ritorto
- Colorectal Cancer Unit, Medical Oncology Division 1, Azienda Ospedaliero-Universitaria Città Della Salute e Della Scienza, Torino, Italy
| | - Roberto Murialdo
- Department of Internal Medicine, University of Genoa and IRCCS AOU San Martino-IST, Genoa, Italy
| | - Matteo Clavarezza
- Medical Oncology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | | | - Vincenzo Adamo
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Fausto Petrelli
- Medical Oncology Unit, Oncology Department, ASST Bergamo Ovest, Treviglio, Italy
| | - Lorenzo Antonuzzo
- Department of Medical Oncology, Oncology Unit, AOU Careggi, Florence, Italy
| | - Monica Giordano
- Medical Oncology Unit, Azienda Socio Sanitaria Territoriale Lariana, Como, Italy
| | - Saverio Cinieri
- Medical Oncology Unit, Ospedale Antonio Perrino, Brindisi, Italy
| | | | - Francesca Bergamo
- Medical Oncology Unit 1, Department of Oncology, Istituto Oncologico Veneto - IRCCS, Padua, Italy
| | - Monica Niger
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Maria Antista
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Giorgia Peverelli
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Filippo de Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy; Oncology and Hemato-oncology Department, University of Milan, Milan, Italy
| | - Maria Di Bartolomeo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Filippo Pietrantonio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy; Oncology and Hemato-oncology Department, University of Milan, Milan, Italy.
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Wang L, Liu Y, Yin X, Fang W, Xiong J, Zhao B, Zhang M, Zou Y, Qiu H, Yuan X. Effect of Reduced-Dose Capecitabine Plus Cetuximab as Maintenance Therapy for RAS Wild-Type Metastatic Colorectal Cancer: A Phase 2 Clinical Trial. JAMA Netw Open 2020; 3:e2011036. [PMID: 32687588 PMCID: PMC7372324 DOI: 10.1001/jamanetworkopen.2020.11036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Fluorouracil-based chemotherapy combined with anti-epidermal growth factor receptor/vascular endothelial growth factor therapy is the standard first-line treatment for metastatic colorectal cancer followed by low-intensity maintenance therapy to balance the clinical efficacy and adverse effects (AEs). However, there have been concerns about the AEs of capecitabine plus cetuximab as a maintenance therapy in patients with RAS wild-type metastatic colorectal cancer. OBJECTIVE To evaluate the biological activity and safety of capecitabine plus cetuximab as a novel maintenance therapy for RAS wild-type metastatic colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This phase 2 prospective clinical trial was conducted from April 29, 2016, to April 29, 2019, at 5 centers in China. Patients diagnosed as having RAS wild-type metastatic colorectal cancer were recruited to receive fluorouracil-based cytotoxic agents combined with cetuximab followed by capecitabine plus cetuximab for maintenance therapy. Forty-seven patients with histologically confirmed metastatic colorectal cancer and genetic test results showing a wild-type RAS were enrolled in maintenance therapy. INTERVENTIONS Induction therapy for patients with RAS wild-type metastatic colorectal cancer was 8 to 12 cycles of fluorouracil-based chemotherapy combined with cetuximab. After stable disease status or better was achieved, reduced-dose capecitabine plus cetuximab was administered for maintenance therapy. MAIN OUTCOMES AND MEASURES The primary end point was progression-free survival during maintenance therapy. The secondary end points were total progression-free survival, overall survival, quality of life, safety, and toxic effects of treatment. RESULTS Forty-seven patients were enrolled in maintenance therapy, with a median age of 52 years (range, 25-81 years) and 32 (68%) of them being men. The median maintenance progression-free survival was 7.2 (95% CI, 5.8-8.6) months. The median progression-free survival was 12.7 (95% CI, 11.8-15.4) months. The median overall survival was 27.4 (95% CI, 21.4-35.5) months. Grade 3 to 4 AEs during induction therapy included neutropenia (4 patients [9%]), diarrhea (4 patients [9%]), nausea or vomiting (3 patients [6%]), rash acneiform (10 patients [21%]), and hand-foot syndrome (8 patients [17%]). Grade 3 to 4 AEs during maintenance therapy included diarrhea (2 patients [4%]), rash acneiform (8 patients [17%]), and hand-foot syndrome (5 patients [11%]). CONCLUSIONS AND RELEVANCE Reduced-dose capecitabine plus cetuximab after initial chemotherapy is a novel maintenance therapy for patients with RAS wild-type metastatic colorectal cancer that achieved good outcomes and tolerable nonserious AEs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02717923.
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Affiliation(s)
- Lu Wang
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ying Liu
- Department of Medical Oncology of Zhengzhou University Affiliated Cancer Hospital, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Xianli Yin
- Gastroenterology and Urology Department, Hunan Cancer Hospital & The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Weijia Fang
- Department of Medical Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianping Xiong
- Department of Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ben Zhao
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Mingsheng Zhang
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yanmei Zou
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hong Qiu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xianglin Yuan
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Stahler A, Heinemann V, Ricard I, von Einem JC, Giessen-Jung C, Westphalen CB, Michl M, Heinrich K, Miller-Phillips L, Jelas I, Stintzing S, Modest DP. Current treatment options in RAS mutant metastatic colorectal cancer patients: a meta-analysis of 14 randomized phase III trials. J Cancer Res Clin Oncol 2020; 146:2077-2087. [PMID: 32561975 PMCID: PMC7324435 DOI: 10.1007/s00432-020-03290-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/10/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Although biomarkers for patients with metastatic colorectal cancer exist, the benefit patients with RAS mutated tumors derive from established regimens is unclear. METHODS Efficacy of therapeutic strategies available for RAS mutated patients (addition of chemotherapeutic agents and/or anti angiogenic agents) were investigated in fourteen randomized controlled phase III trials at trial level by meta-analysing individual study hazard ratios and 95% confidence intervals (95% CI) for overall survival (OS) and progression free survival (PFS). RESULTS 6810 of 10,748 patients (63.3%) were available (48.5% RAS wildtype, 51.5% RAS mutated). Across all treatment lines, additional treatment efficacy (chemotherapy and/or anti angiogenic agents) was significantly smaller in RAS mutated compared to wildtype tumors for OS and PFS. In detail, patients with RAS mutated metastatic colorectal cancer derived significant benefit in PFS but not in OS by the addition of either chemotherapy or anti angiogenic agents to the respective comparator. In patients with RAS wildtype metastatic colorectal cancer, PFS and OS were improved by the addition of chemotherapy or anti angiogenic agent. CONCLUSION The therapeutic benefit of additional substances is less distinct in patients with RAS mutated as compared to RAS wildtype metastatic colorectal cancer, especially with regard to OS.
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Affiliation(s)
- Arndt Stahler
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Volker Heinemann
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany.,DKTK, German Cancer Consortium, German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Ingrid Ricard
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Jobst C von Einem
- Department of Hematology, Oncology, and Tumor Immunology (CCM), Charité-Universtiaetsmedizin, Berlin, Germany
| | - Clemens Giessen-Jung
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christoph Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Marlies Michl
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Kathrin Heinrich
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Lisa Miller-Phillips
- Department of Medicine III and Comprehensive Cancer Centre, University Hospital Grosshadern, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ivan Jelas
- Department of Hematology, Oncology, and Tumor Immunology (CCM), Charité-Universtiaetsmedizin, Berlin, Germany
| | - Sebastian Stintzing
- Department of Hematology, Oncology, and Tumor Immunology (CCM), Charité-Universtiaetsmedizin, Berlin, Germany
| | - Dominik Paul Modest
- Department of Hematology, Oncology, and Tumor Immunology (CVK), Charité-Universtiaetsmedizin, Berlin, Germany
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Abstract
This article deals with the treatment of metastatic colorectal cancer (stage IV). The treatment goals and approaches are determined by the resectability status of the metastases: resectable liver and lung metastases are primarily resected and perioperative chemotherapy appears to be dispensable. In potentially resectable metastases, a conversion therapy is attempted to enable a potentially curative resection. In the case of nonresectability the treatment goal is palliative. Induction and maintenance therapy as well as drug holidays are suggested in an attempt to achieve extended survival while maintaining the quality of life, beginning with the best possible individual treatment. For some patients with stage IV, molecular targeted therapies are available. The study situation and approval status are dealt with in detail. With improved molecular characterization of tumors the treatment can be further individualized.
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Niogret J, Limagne E, Thibaudin M, Blanc J, Bertaut A, Le Malicot K, Rinaldi Y, Caroli-Bosc FX, Audemar F, Nguyen S, Sarda C, Lombard-Bohas C, Locher C, Carreiro M, Legoux JL, Etienne PL, Baconnier M, Porneuf M, Aparicio T, Ghiringhelli F. Baseline Splenic Volume as a Prognostic Biomarker of FOLFIRI Efficacy and a Surrogate Marker of MDSC Accumulation in Metastatic Colorectal Carcinoma. Cancers (Basel) 2020; 12:cancers12061429. [PMID: 32486421 PMCID: PMC7352427 DOI: 10.3390/cancers12061429] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background: Predictive biomarkers of response to chemotherapy plus antiangiogenic for metastatic colorectal cancer (mCRC) are lacking. The objective of this study was to test the prognostic role of splenomegaly on baseline CT scan. Methods: This study is a sub-study of PRODIGE-9 study, which included 488 mCRC patients treated by 5-fluorouracil, leucovorin and irinotecan (FOLFIRI) and bevacizumab in first line. The association between splenic volume, and PFS and OS was evaluated by univariate and multivariable Cox analyses. The relation between circulating monocytic Myeloid derived suppressor cells (mMDSC) and splenomegaly was also determined. Results: Baseline splenic volume > 180 mL was associated with poor PFS (median PFS = 9.2 versus 11.1 months; log-rank p = 0.0125), but was not statistically associated with OS (median OS = 22.6 versus 28.5 months; log-rank p = 0.1643). The increase in splenic volume at 3 months had no impact on PFS (HR 0.928; log-rank p = 0.56) or on OS (HR 0.843; log-rank p = 0.21). Baseline splenic volume was positively correlated with the level of baseline circulating mMDSC (r = 0.48, p-value = 0.031). Conclusion: Baseline splenomegaly is a prognostic biomarker in patients with mCRC treated with FOLFIRI and bevacizumab, and a surrogate marker of MDSC accumulation.
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Affiliation(s)
- Julie Niogret
- Department of Medical Oncology, Georges François Leclerc Cancer Center-UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France;
- Department of Medical Oncology, University of Burgundy-Franche-Comté, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France;
- INSERM U1231, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France; (E.L.); (M.T.)
| | - Emeric Limagne
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France; (E.L.); (M.T.)
| | - Marion Thibaudin
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France; (E.L.); (M.T.)
| | - Julie Blanc
- Methodology, Data-Management, and Biostatistics Unit, Georges François Leclerc Cancer Center—UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France; (J.B.); (A.B.)
| | - Aurelie Bertaut
- Methodology, Data-Management, and Biostatistics Unit, Georges François Leclerc Cancer Center—UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France; (J.B.); (A.B.)
| | - Karine Le Malicot
- Department of Medical Oncology, University of Burgundy-Franche-Comté, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France;
- Fédération Francophone de Cancérologie Digestive, EPICAD INSERM U1231, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France
| | - Yves Rinaldi
- Department of Hepato-Gastroenterology, European Hospital, 6 Rue Désirée Clary, 13003 Marseille, France;
| | | | - Franck Audemar
- Department of Gastroenterology, Côte Basque Hospital Center, 13 Avenue de l’Interne Jacques Loeb, 64100 Bayonne, France;
| | - Suzanne Nguyen
- Department of Medical Oncology, Hospital Center, 4 Boulevard Hauterive, 64000 Pau, France;
| | - Corinne Sarda
- Department of Medical Oncology, Saintonge Hospital Center, 11 Boulevard Ambroise Paré, 17100 Saintes, France;
| | - Catherine Lombard-Bohas
- Department of Medical Oncology, Edouard Herriot Hospital, HCL, 5 Place d’Arsonval, 69003 Lyon, France;
| | - Christophe Locher
- Department of Gastroenterology, Est-Francilien Great Hospital, 6-8 Rue Saint-Fiacre, 77100 Meaux, France;
| | - Miguel Carreiro
- Department of Medical Oncology and Internal medicine, Hospital Center, 100 Rue Léon Cladel, 82000 Montauban, France;
| | - Jean-Louis Legoux
- Department of Hepato-Gastroenterology and Digestive Oncology, Regional Hospital Center, 14 Avenue de l’Hôpital, 45100 Orléans, France;
| | - Pierre-Luc Etienne
- Department of Medical Oncology, CARIO, Côtes d’Armor Private Hospital, 10 Rue François Jacob, 22190 Plerin, France;
| | - Mathieu Baconnier
- Department of Hepato-Gastroenterology, Annecy Genevois Hospital Center, 1 Avenue de l’Hôpital, 74374 Pringy, France;
| | - Marc Porneuf
- Department of Medical Oncology and Hematology, Yves Le Foll Hospital Center, 10 Rue Marcel Proust, 22000 Saint-Brieuc, France;
| | - Thomas Aparicio
- Department of Gastroenterology, University Hospital Center Saint Louis, APHP, 1 Avenue Claude Vellefaux, 75010 Paris, France;
| | - Francois Ghiringhelli
- Department of Medical Oncology, Georges François Leclerc Cancer Center-UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France;
- Department of Medical Oncology, University of Burgundy-Franche-Comté, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France;
- INSERM U1231, 7 Boulevard Jeanne d’Arc, 21000 Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center—UNICANCER, 1 rue Professeur Marion, 21000 Dijon, France; (E.L.); (M.T.)
- Correspondence:
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Hu H, Liu X, Cai W, Wu D, Xu J, Yuan Y. A Retrospective Exploration of Targeted Maintenance Therapy in Advanced Colorectal Cancer: Based on the Background of Chinese Patient Assistance Program. Front Oncol 2020; 10:522. [PMID: 32391263 PMCID: PMC7190810 DOI: 10.3389/fonc.2020.00522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/23/2020] [Indexed: 01/04/2023] Open
Abstract
Background: Maintenance therapy with bevacizumab (Bev) in patients with colorectal cancer (CRC) provides progression-free survival (PFS) benefits. However, the role of maintenance therapy with an anti-EGFR monoclonal antibody has not been established. Methods: Eligible CRC patients were assigned to maintenance therapy with cetuximab (Cet; Cet group) or Bev (Bev group). PFS, the duration of maintenance therapy, and safety were analyzed. Cox multivariate regression analyses were performed to determine independent prognostic factors. Results: A total of 143 eligible patients were assigned to the Cet (n = 79) or Bev (n = 64) groups. In the Cet group, all patients had KRAS wild-type. The baseline characteristics were well-balanced between the two groups, except for a higher percentage of patients with a left-sided primary tumor in the Cet group than in the Bev group (86.1 vs. 62.5%, P < 0.0001). The median PFS was not significantly different between the Cet group and the Bev group: 5.9 months (95% CI 2.30–9.50) vs. 7.0 months (95% CI 3.69–10.31) (HR 1.17, 95% CI 0.77–1.79, P = 0.45). The median duration of maintenance therapy in the Cet group was shorter than that in the Bev group: 4.0 months (95% CI 1.94–5.99) vs. 4.8 months (95% CI 2.68–6.98) (HR 0.90, 95% CI 0.61–1.33; P = 0.59). The subgroup analyses showed that the median PFS for the first maintenance therapy and the second maintenance therapy were 3.2 months (95% CI 1.69–4.78) and 5.2 months (95% CI 1.58–8.83), respectively (HR 0.89, 95% CI 0.44–1.81; P = 0.75). Conclusions: This study suggests that maintenance therapy with Cet or Bev can be considered an appropriate option following induction chemotherapy for selected patients with advanced CRC. Multiple maintenance therapy seems to confer survival benefits in advanced CRC. Maintenance therapy with Cet after first-line induction chemotherapy seems to be associated with greater survival benefits.
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Affiliation(s)
- Hanguang Hu
- Departments of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xue Liu
- Departments of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Cai
- Departments of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dehao Wu
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junxi Xu
- Departments of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Yuan
- Departments of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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78
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Lau DK, Burge M, Roy A, Chau I, Haller DG, Shapiro JD, Peeters M, Pavlakis N, Karapetis CS, Tebbutt NC, Segelov E, Price TJ. Update on optimal treatment for metastatic colorectal cancer from the AGITG expert meeting: ESMO congress 2019. Expert Rev Anticancer Ther 2020; 20:251-270. [PMID: 32186929 DOI: 10.1080/14737140.2020.1744439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Outcomes in metastatic colorectal cancer are improving, due to the tailoring of therapy enabled by better understanding of clinical behavior according to molecular subtype.Areas covered: A review of the literature and recent conference presentations was undertaken on the topic of systemic treatment of metastatic colorectal cancer. This review summarizes expert discussion of the current evidence for therapies in metastatic colorectal cancer (mCRC) based on molecular subgrouping.Expert opinion: EGFR-targeted and VEGF-targeted antibodies are now routinely incorporated into treatment strategies for mCRC. EGFR-targeted antibodies are restricted to patients with extended RAS wild-type profiles, with evidence that they should be further restricted to patients with left-sided tumors. Clinically distinct treatment pathways based on tumor RAS, BRAF, HER2 and MMR status, are now clinically applicable. Evidence suggests therapy for additional subgroups will soon be defined; the most advanced being for patients with KRAS G12 C mutation and gene TRK fusion defects.
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Affiliation(s)
- David K Lau
- GI and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Matthew Burge
- Medical Oncology, Royal Brisbane Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Amitesh Roy
- Medical Oncology, Flinders Centre for Innovation in Cancer, Bedford Park, Australia
| | - Ian Chau
- GI and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London and Surrey, UK
| | - Daniel G Haller
- Abramson Cancer Center at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy D Shapiro
- Monash University, Melbourne, Australia.,Medical Oncology, Cabrini Medical Centre, Melbourne, Australia
| | - Marc Peeters
- Medical Oncology, University Hospital Antwerp, Edegem, Belgium
| | - Nick Pavlakis
- Medical Oncology, Royal North Shore Hospital, St Leonards, Australia.,Sydney University, Camperdown, Sydney, Australia
| | | | - Niall C Tebbutt
- Medical Oncology, Austin Health, Heidelberg, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Eva Segelov
- Monash University, Melbourne, Australia.,Medical Oncology, Monash Medical Centre, Clayton, Australia
| | - Timothy J Price
- Medical Oncology, The Queen Elizabeth Hospital, Woodville, Australia
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Cremolini C, Antoniotti C, Rossini D, Lonardi S, Loupakis F, Pietrantonio F, Bordonaro R, Latiano TP, Tamburini E, Santini D, Passardi A, Marmorino F, Grande R, Aprile G, Zaniboni A, Murgioni S, Granetto C, Buonadonna A, Moretto R, Corallo S, Cordio S, Antonuzzo L, Tomasello G, Masi G, Ronzoni M, Di Donato S, Carlomagno C, Clavarezza M, Ritorto G, Mambrini A, Roselli M, Cupini S, Mammoliti S, Fenocchio E, Corgna E, Zagonel V, Fontanini G, Ugolini C, Boni L, Falcone A, Falcone A, Lonardi S, De Braud FGM, Bordonaro R, Maiello E, Tamburini E, Santini D, Frassineti GL, Gamucci T, Aprile G, Zaniboni A, Granetto C, Buonadonna A, Di Costanzo F, Tomasello G, Gianni L, Di Donato S, Carlomagno C, Clavarezza M, Racca P, Mambrini A, Roselli M, Allegrini G, Sobrero A, Aglietta M, Corgna E, Cortesi E, Corsi DC, Ballestrero A, Bonetti A, Di Clemente F, Ruggeri E, Ciardiello F, Benasso M, Vitello S, Cinieri S, Mosconi S, Silvestris N, Frassoldati A, Cupini S, Bertolini A, Tortora G, Bengala C, Ferrari D, Ardizzoia A, Milandri C, Chiara S, Romano G, Miraglia S, Scaltriti L, Pucci F, Blasi L, Brugnatelli S, Fioretto L, Ribecco AS, Longarini R, Frisinghelli M, Banzi M. Upfront FOLFOXIRI plus bevacizumab and reintroduction after progression versus mFOLFOX6 plus bevacizumab followed by FOLFIRI plus bevacizumab in the treatment of patients with metastatic colorectal cancer (TRIBE2): a multicentre, open-label, phase 3, randomised, controlled trial. Lancet Oncol 2020; 21:497-507. [DOI: 10.1016/s1470-2045(19)30862-9] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 01/07/2023]
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80
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Xie YH, Chen YX, Fang JY. Comprehensive review of targeted therapy for colorectal cancer. Signal Transduct Target Ther 2020; 5:22. [PMID: 32296018 PMCID: PMC7082344 DOI: 10.1038/s41392-020-0116-z] [Citation(s) in RCA: 804] [Impact Index Per Article: 201.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 12/24/2022] Open
Abstract
Colorectal cancer (CRC) is among the most lethal and prevalent malignancies in the world and was responsible for nearly 881,000 cancer-related deaths in 2018. Surgery and chemotherapy have long been the first choices for cancer patients. However, the prognosis of CRC has never been satisfying, especially for patients with metastatic lesions. Targeted therapy is a new optional approach that has successfully prolonged overall survival for CRC patients. Following successes with the anti-EGFR (epidermal growth factor receptor) agent cetuximab and the anti-angiogenesis agent bevacizumab, new agents blocking different critical pathways as well as immune checkpoints are emerging at an unprecedented rate. Guidelines worldwide are currently updating the recommended targeted drugs on the basis of the increasing number of high-quality clinical trials. This review provides an overview of existing CRC-targeted agents and their underlying mechanisms, as well as a discussion of their limitations and future trends.
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Affiliation(s)
- Yuan-Hong Xie
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, 200001, Shanghai, China
| | - Ying-Xuan Chen
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, 200001, Shanghai, China.
| | - Jing-Yuan Fang
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, 200001, Shanghai, China.
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81
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Modest DP, Heinemann V, Folprecht G, Denecke T, Pratschke J, Lang H, Bemelmans M, Becker T, Rentsch M, Seehofer D, Bruns CJ, Gebauer B, Held S, Stahler A, Heinrich K, von Einem JC, Stintzing S, Neumann UP, Ricard I. Factors That Influence Conversion to Resectability and Survival After Resection of Metastases in RAS WT Metastatic Colorectal Cancer (mCRC): Analysis of FIRE-3- AIOKRK0306. Ann Surg Oncol 2020; 27:2389-2401. [PMID: 32172334 PMCID: PMC7311511 DOI: 10.1245/s10434-020-08219-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Tumor assessments after first-line therapy of RAS wild-type mCRC with cetuximab (cet) versus bevacizumab (bev) in combination with FOLFIRI were evaluated for factors influencing resectability, conversion to resectability, and survival after best response. METHODS Conversion to resectability was defined as conversion of initially unresectable to resectable disease at best response as determined by retrospective assessment. Univariate and multivariate logistic models were fitted with resectability at best response as response variable. A Cox model comparing the survival from best response was used to measure the influence of treatment, resectability at best response, and resection. Interaction of resection and treatment arm on survival was tested by likelihood ratio test. RESULTS Overall, 270 patients were evaluable (127 cet-arm, 143 bev-arm). Lung metastases (odds ratio [OR] 0.35, 95% confidence response [CI] 0.19-0.63), BRAF mutation (OR 0.33, 95% CI 0.12-0.82), and elevated alkaline phosphatase (OR 0.42, 95% CI 0.18-0.9) before randomization were associated with less chance of successful conversion and were integrated into a nomogram. Early tumor shrinkage (OR 1.86, 95% CI 1.06-3.3; p 0.034) and depth of response (OR 1.02, 95% CI 1.01-1.03; p < 0.001) were associated with successful conversion therapy. Resection of metastases improved post-best-response survival (hazard ratio 0.53, 95% CI 0.29-0.97; p = 0.039), predominantely in cet-treated patients (interaction test, p = 0.02). CONCLUSIONS Conversion to resectability is significantly associated with baseline characteristics that can be used in a nomogram to predict conversion. Moreover, early efficacy parameters (ETS and DpR) are associated with successful conversion therapy. In FIRE-3, resection of metastases was associated with improved post-best response survival, this effect originated predominantly from the cetuximab-based study arm.
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Affiliation(s)
- Dominik Paul Modest
- Department of Hematology, Oncology and Tumor Immunology, CVK, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Volker Heinemann
- Medical Department III and Comprehensive Cancer Center, Hospital of the University, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Gunnar Folprecht
- University Cancer Center/Medical Department I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Timm Denecke
- Institute of Radiology, Charité, Berlin, Germany
| | - Johann Pratschke
- General, Visceral, and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Hauke Lang
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Mainz, Germany
| | - Marc Bemelmans
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thomas Becker
- Klinik für Allgemeine-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Markus Rentsch
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
| | - Daniel Seehofer
- Klinik und Poliklinik für Visceral-, Transplantations-, Thorax- und Gefäßchirurgie Universitätsklinikum Leipzig, Leipzig, Germany
| | - Christiane J Bruns
- Klinik und Poliklinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Cologne, Germany
| | | | | | - Arndt Stahler
- Medical Department III and Comprehensive Cancer Center, Hospital of the University, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Kathrin Heinrich
- Medical Department III and Comprehensive Cancer Center, Hospital of the University, Ludwig-Maximilian-University (LMU), Munich, Germany
| | - Jobst C von Einem
- Department of Hematology, Oncology and Tumor Immunology, CVK, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Stintzing
- Department of Hematology, Oncology and Tumor Immunology, CVK, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, Aachen, Germany
| | - Ingrid Ricard
- Comprehensive Cancer Center, Hospital of the University, Ludwig-Maximilian-University (LMU), Munich, Germany
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82
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Sonbol MB, Mountjoy LJ, Firwana B, Liu AJ, Almader-Douglas D, Mody K, Hubbard J, Borad M, Ahn DH, Murad MH, Bekaii-Saab T. The Role of Maintenance Strategies in Metastatic Colorectal Cancer: A Systematic Review and Network Meta-analysis of Randomized Clinical Trials. JAMA Oncol 2020; 6:e194489. [PMID: 31855256 DOI: 10.1001/jamaoncol.2019.4489] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance In metastatic colorectal cancer, induction combination chemotherapy with a targeted agent is considered the mainstay of treatment. Multiple randomized clinical trials have examined different strategies of continuing cytotoxic therapy until progression compared with a period of either observation or the use of various maintenance agents. However, those randomized clinical trials have shown inconsistent efficacy results that make it challenging to draw any conclusion on which strategy is preferred. Therefore, a network meta-analysis is helpful to compare different agents across randomized clinical trials. Objective To evaluate the comparative effectiveness of different treatment strategies for patients with metastatic colorectal cancer. Evidence Review MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for randomized clinical trials evaluating different strategies for patients with previously untreated metastatic colorectal cancer. Trials of interest included those including patients with metastatic colorectal cancer who were treated with an initial period of cytotoxic chemotherapy (with or without a biologic) and then switched to one of the following strategies: observation; maintenance with bevacizumab (Bev), fluoropyrimidine (FP), or both (FP + Bev); or continuing the induction regimen until progression. Outcomes of interest included overall survival (OS) and progression-free survival (PFS). The overall effect was pooled using the DerSimonian and Laird random-effects model. Network meta-analysis was conducted using a random-effects consistency model to pool evidence from direct and indirect comparisons. Agents were ranked using surface under the cumulative ranking (SUCRA) probabilities. Higher SUCRA scores correspond to greater efficacy. Initial analysis was performed on December 18, 2018. An updated search was performed in April 2019, and no additional studies were added. Findings Twelve trials at low risk of bias (5540 patients; age range, 23-85 years; 64.4 % male) were included. Network meta-analysis showed no benefit of continuing full cytotoxic chemotherapy until progression vs observation in terms of PFS (hazard ratio, 0.71; 95% CI, 0.46-1.09) and OS (hazard ratio, 0.95; 95% CI, 0.85-1.07). Compared with observation, maintenance therapy showed a PFS benefit (hazard ratio, 0.58; 95% CI, 0.43-0.77) but not an OS benefit (hazard ratio, 0.91; 95% CI, 0.83-1.01). All maintenance strategies (FP, FP + Bev, and Bev) showed significant improvement in PFS vs observation. On SUCRA analysis, maintenance treatment (FP or FP + Bev) had the highest likelihood of achieving improved PFS (67.1% for FP, 99.8% for FP + Bev, and 36.5% for Bev) and OS (81.3% for FP, 73.2% for FP + Bev, and 32.6% for Bev). Conclusions and Relevance For patients with metastatic colorectal cancer, there is no benefit to continuing the full induction regimen until progression, without a period of either observation or maintenance treatment. A maintenance strategy with a fluoropyrimidine, with or without the addition of bevacizumab, is preferred. However, given the lack of a clear OS benefit, shared decision-making should include observation as an acceptable alternative.
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Affiliation(s)
| | - Luke J Mountjoy
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Belal Firwana
- Heartland Cancer Research NCI Community Oncology Research Program, Missouri Baptist Medical Center, St Louis
| | - Alex J Liu
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Kabir Mody
- Mayo Clinic Cancer Center, Mayo Clinic, Jacksonville, Florida
| | - Joleen Hubbard
- Mayo Clinic Cancer Center, Mayo Clinic, Rochester, Minnesota
| | - Mitesh Borad
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Daniel H Ahn
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota
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83
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Haslam A, Herrera-Perez D, Gill J, Prasad V. Patient Experience Captured by Quality-of-Life Measurement in Oncology Clinical Trials. JAMA Netw Open 2020; 3:e200363. [PMID: 32129865 PMCID: PMC7057133 DOI: 10.1001/jamanetworkopen.2020.0363] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Quality of life (QoL) is an important consideration in cancer medicine, especially because drugs are becoming more costly and may only result in modest gains in overall survival. However, there has been no descriptive analysis for the points at which QoL is measured in cancer trials. OBJECTIVE To estimate the prevalence of studies that measure QoL at different points and see how many studies measure QoL for the entirety of a patient's life. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis includes all articles on oncology clinical trials in the 3 highest-impact oncology journals, published between July 2015 and June 2018, that reported QoL outcomes. MAIN OUTCOMES AND MEASURES Data were abstracted on when QoL was assessed and the characteristics of these studies. RESULTS For all 149 studies that met inclusion criteria, QoL assessment was high during treatment (104 articles [69.8%]), during follow-up (81 articles [54.4%]), and after the end of the intervention (68 articles [45.6%]). In 5 of the 149 studies (3.4%), QoL was assessed until death, including in only 1 of the 74 studies on metastatic or incurable cancers. Among these 5 studies, only 1 (20%) used a drug intervention, 1 (20%) used a behavioral intervention, and 2 (40%) used a radiation intervention; only 1 of 5 was in the metastatic setting. The number of studies that reported a positive QoL outcome (ie, QoL outcome was more favorable in the intervention group than in the control group) was between 42 of 81 articles (51.9%) and 16 of 28 articles (57.1%) for most QoL assessment points but only 1 of 5 articles (20%) for studies measuring QoL until death. CONCLUSIONS AND RELEVANCE This study found that most clinical trials assessed QoL during the treatment or intervention and often during a given amount of follow-up but infrequently assessed QoL on disease progression and rarely followed QoL until the end of the patient's life. Most studies reporting QoL until the end of life reported worse QoL outcomes for the intervention group than the control group. Future research and policy recommendations should consider not just short-term QoL outcomes but QoL outcomes throughout the patient's cancer care.
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Affiliation(s)
- Alyson Haslam
- Knight Cancer Institute, Oregon Health & Science University, Portland
| | | | - Jennifer Gill
- Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Vinay Prasad
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland
- Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland
- Center for Health Care Ethics, Oregon Health & Science University, Portland
- Division of General Medicine, Department of Medicine, Oregon Health & Science University, Portland
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84
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Predictive factors for early progression during induction chemotherapy and chemotherapy-free interval: analysis from PRODIGE 9 trial. Br J Cancer 2020; 122:957-962. [PMID: 32015513 PMCID: PMC7109054 DOI: 10.1038/s41416-020-0735-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/26/2019] [Accepted: 01/17/2020] [Indexed: 01/09/2023] Open
Abstract
Background Identifying patients with metastatic colorectal cancer who will have an early disease progression during induction chemotherapy (IC) and identifying patients who may have a chemotherapy-free interval (CFI) after IC are two major challenges. Methods A logistic model was used to identify factors associated with early progression during IC and with short duration of the first CFI in 488 patients enrolled in the PRODIGE 9 trial. Independent factors were defined with a threshold 0.10. Results In multivariate analysis, baseline leukocytes >10 × 109/L (OR = 1.98 [1.02–3.8], p = 0.04), and stable or increasing CEA at 2 months (OR = 3.61 [1.68–7.75], p = 0.01) were independent factors associated with progression during IC. Male gender (OR = 1.725 [0.92–3.325], p = 0.09) and no tumour response at first evaluation (OR = 1.90 [0.96–3.76], p = 0.07) were significantly associated with a short CFI. The presence of BRAF V600E mutation was also associated with short CFI (OR = 4.59 [0.95; 22.3], p = 0.058). Conclusion High baseline leukocyte count and the lack of CEA decrease level at first evaluation were associated with early progression, and could be in favour of early chemotherapy intensification. Male gender, no tumour response at first evaluation and BRAF mutation are associated with a short CFI, and may be considered for maintenance chemotherapy after IC. Clinical trial number NCT00952029.
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85
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Yeom SS, Lee SY, Kwak HD, Kim CH, Kim YJ, Kim HR. The outcome of primary tumor resection in the unresectable stage IV colorectal cancer patients who received the bevacizumab-containing chemotherapy. Medicine (Baltimore) 2020; 99:e19258. [PMID: 32049866 PMCID: PMC7035101 DOI: 10.1097/md.0000000000019258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Primary tumor resection (PTR) for unresectable metastatic colorectal cancer (mCRC) patients has been documented to be associated with postoperative hyper-neovascularization and enhanced growth of metastases, which may be prevented by bevacizumab. This study aimed to investigate the survival outcome of PTR in patients who received palliative bevacizumab-containing chemotherapy (BCT).From January 2006 to December 2018, medical records of 240 mCRC patients who received palliative BCT at a single tertiary colorectal cancer center were retrospectively reviewed. Patients were classified into three groups: PTR-a (PTR before BCT, n = 60), PTR-b (PTR during BCT, n = 17), and BCT-only group (n = 163). Resectable mCRCs or recurrent diseases were excluded, and the end-point was overall survival (OS) rate.Three groups had similar age, cell differentiation, location of the primary tumor, and the number of metastatic organs. More than two-thirds of patients who received PTR experienced disease-progressions (PD) during their postoperative chemotherapy-free time (PTR-a vs PTR-b; 66.7% vs 76.5%, P = .170), but OS was not inferior to the BCT-only group (PTR-a vs BCT-only; HR 0.477 [95% CI 0.302-0.754], P = .002/PTR-b vs BCT-only; HR 0.77 [95% CI 0.406-1.462], P = .425). The postoperative chemotherapy-free time was similar between PTR-a and PTR-b (median 32.0 [14-98] days vs 41.0 [18-71] days, P = .142), but non-obstructive indications (perforation, bleeding, pain) were the more frequent in the PTR-b than PTR-a. Young age, the number of BCT, and PTR-a were the independent factors for OS.The efficacy of the PTR for unresectable mCRC has been controversial, but this study demonstrated that PTR should be considered for the unresectable mCRC patients regardless before and during BCT.
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86
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Lombardi P, Marandino L, De Luca E, Zichi C, Reale ML, Pignataro D, Di Stefano RF, Ghisoni E, Mariniello A, Trevisi E, Leone G, Muratori L, La Salvia A, Sonetto C, Leone F, Aglietta M, Novello S, Scagliotti GV, Perrone F, Di Maio M. Quality of life assessment and reporting in colorectal cancer: A systematic review of phase III trials published between 2012 and 2018. Crit Rev Oncol Hematol 2020; 146:102877. [PMID: 31981880 DOI: 10.1016/j.critrevonc.2020.102877] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 12/09/2019] [Accepted: 01/17/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In this study, our aim was to describe quality of life (QoL) prevalence and heterogeneity in QoL reporting in colorectal cancer phase III trials. METHODS We included all phase III trials evaluating anticancer drugs in colorectal cancer patients published between 2012 and 2018 by 11 major journals. RESULTS Out of the 67 publications identified, in 41 (61.2 %) QoL was not listed among endpoints. Out of 26 primary publications of trials including QoL among endpoints, QoL results were not reported in 10 (38.5 %). Overall, no QoL data were available in 51/67 (76.1 %) primary publications. In particular, in the metastatic setting, QoL data were not available in 12/18 (66.7 %) trials with primary endpoint overall survival, and in 20/29 (69.0 %) trials with other primary endpoints. CONCLUSIONS QoL was absent in a high proportion of recently published phase III trials in colorectal cancer, even in trials of second or further lines, where attention to QoL should be particularly high.
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Affiliation(s)
- Pasquale Lombardi
- Department of Oncology, University of Turin, Candiolo Cancer Institute - FPO- IRCCS, Candiolo, TO, Italy
| | - Laura Marandino
- Department of Oncology, University of Turin, Candiolo Cancer Institute - FPO- IRCCS, Candiolo, TO, Italy
| | - Emmanuele De Luca
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Torino, Italy
| | - Clizia Zichi
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Torino, Italy
| | - Maria Lucia Reale
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Daniele Pignataro
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Rosario F Di Stefano
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Eleonora Ghisoni
- Department of Oncology, University of Turin, Candiolo Cancer Institute - FPO- IRCCS, Candiolo, TO, Italy
| | - Annapaola Mariniello
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Elena Trevisi
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Gianmarco Leone
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Leonardo Muratori
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Anna La Salvia
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Cristina Sonetto
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Francesco Leone
- Department of Oncology, University of Turin, Candiolo Cancer Institute - FPO- IRCCS, Candiolo, TO, Italy
| | - Massimo Aglietta
- Department of Oncology, University of Turin, Candiolo Cancer Institute - FPO- IRCCS, Candiolo, TO, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Giorgio V Scagliotti
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, TO, Italy
| | - Francesco Perrone
- Clinical Trials Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale"-IRCCS, Napoli, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Torino, Italy.
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87
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Maintenance treatment in metastatic colorectal cancer: in search of the best strategy. Clin Transl Oncol 2020; 22:1205-1215. [PMID: 31898053 DOI: 10.1007/s12094-019-02267-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/08/2019] [Indexed: 12/22/2022]
Abstract
Over the last 2 decades, the standard fluoropyrimidine-based chemotherapy backbone for metastatic colorectal cancer has been complemented by the addition of novel biological agents, achieving impressive increases in 5-year survival rates. Nonetheless, these new combinations have also entailed increases in toxicity, leading to evaluation of de-escalated chemotherapy regimens and "drug holiday" periods in attempts to reduce side effects and optimise quality of life without impairing efficacy. Here, we review the current and emerging evidence for maintenance schedules with chemotherapy and targeted agents, versus continuous treatment after induction treatment, in metastatic colorectal cancer patients.
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88
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Quan R, Zhang H, Li Z, Li X. Survival analysis of patients with glioblastoma treated by long-term administration of temozolomide. Medicine (Baltimore) 2020; 99:e18591. [PMID: 31914038 PMCID: PMC6959873 DOI: 10.1097/md.0000000000018591] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This analysis aimed to investigate whether the long-term administration of temozolomide (TMZ) claimed a survival advantage for patients with glioblastoma in China.A total of 75 patients with newly diagnosed glioblastoma at the Department of Radiation Oncology, Shenzhen People's Hospital between August 2008 and August 2016 were retrospectively evaluated during analysis. A propensity-matched analysis was performed to balance the basic characteristics of patients between compared groups. Kaplan-Meier method and Cox proportional hazards model were used to assess progression-free survival (PFS) and overall survival (OS) of patients receiving 6 adjuvant TMZ cycles compared with patients treated with more than 6 cycles.Twenty of 75 patients received more than 6 cycles of TMZ, and the other 55 patients were treated with a median of 6 cycles ranging from 1 to 6. The patients with long-term administration of TMZ had better OS (47.0 months, 95% CI 20.0-73.9 vs 20.6 months, 95% CI 17.9-23.2, P = .014) but not PFS (17.0 months, 95% CI 10.1-24.5 vs 14.2 months, 95% CI 11.8-16.6, P = .133). Balancing the clinical factors with a propensity-matched analysis also showed the significant advantage of prolonged TMZ application in terms of OS but not PFS.Prolonged administration of TMZ beyond 6 cycles did demonstrate survival benefits for patients with initially diagnosed glioblastoma.
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Affiliation(s)
- Rencui Quan
- Department of Radiation Oncology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital
| | - Huaqing Zhang
- Department of Endocrinology, Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Zihuang Li
- Department of Radiation Oncology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital
| | - Xianming Li
- Department of Radiation Oncology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital
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89
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Modest DP, Martens UM, Riera-Knorrenschild J, Greeve J, Florschütz A, Wessendorf S, Ettrich T, Kanzler S, Nörenberg D, Ricke J, Seidensticker M, Held S, Buechner-Steudel P, Atzpodien J, Heinemann V, Seufferlein T, Tannapfel A, Reinacher-Schick AC, Geissler M. FOLFOXIRI Plus Panitumumab As First-Line Treatment of RAS Wild-Type Metastatic Colorectal Cancer: The Randomized, Open-Label, Phase II VOLFI Study (AIO KRK0109). J Clin Oncol 2019; 37:3401-3411. [DOI: 10.1200/jco.19.01340] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This trial investigated the addition of panitumumab to triplet chemotherapy with fluorouracil/folinic acid, oxaliplatin, and irinotecan (FOLFOXIRI) in a two-to-one randomized, controlled, open-label, phase II trial in patients with untreated RAS wild-type (WT) metastatic colorectal cancer. PATIENTS AND METHODS The primary end point was objective response rate (ORR) according to RECIST (version 1.1). The experimental arm (modified FOLFOXIRI [mFOLFOXIRI] plus panitumumab) was considered active if the ORR was ≥ 75%. The experimental ORR was compared with an estimated ORR of 60% based on historical data, verified by a randomized control group (FOLFOXIRI). The power of the trial was 80%, with a potential type I error of 0.05. Secondary end points included secondary resection rate, toxicity, progression-free survival, and overall survival. RESULTS A total of 63 patients were randomly assigned to the experimental arm and 33 patients to the control arm. The ORR of the mFOLFOXIRI plus panitumumab arm exceeded 75% and was higher when compared with that of FOLFOXIRI (87.3% v 60.6%; odds ratio, 4.469; 95% CI, 1.61 to 12.38; P = .004). The secondary resection rate was improved with the addition of panitumumab (33.3% v 12.1%; P = .02). Progression-free survival was similar in the study arms, whereas overall survival showed a trend in favor of the panitumumab-containing arm (hazard ratio for death, 0.67; 95% CI, 0.41 to 1.11; P = .12). CONCLUSION The addition of panitumumab to mFOLFOXIRI in patients with RAS WT metastatic colorectal cancer improved the ORR and rate of secondary resection of metastases and represents a treatment option in selected and fit patients in need of highly active first-line therapy. Future studies should determine whether the addition of panitumumab to mFOLFOXIRI prolongs survival.
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Affiliation(s)
- Dominik P. Modest
- Hospital of the University of Munich, Munich, Germany
- German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Uwe M. Martens
- Klinik für Innere Medizin III, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | | | - Jobst Greeve
- St Vincenz-Krankenhaus Paderborn, Paderborn, Germany
| | | | | | | | | | | | - Jens Ricke
- Hospital of the University of Munich, Munich, Germany
| | | | | | | | - Jens Atzpodien
- Franziskus-Hospital Harderberg, Georgsmarienhütte, Germany
| | - Volker Heinemann
- Hospital of the University of Munich, Munich, Germany
- German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
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90
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Ma H, Wu X, Tao M, Tang N, Li Y, Zhang X, Zhou Q. Efficacy and safety of bevacizumab-based maintenance therapy in metastatic colorectal cancer: A meta-analysis. Medicine (Baltimore) 2019; 98:e18227. [PMID: 31852082 PMCID: PMC6922481 DOI: 10.1097/md.0000000000018227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To identify the optimal treatment strategy after first-line induction chemotherapy for metastatic colorectal cancer (mCRC). METHODS We conducted a meta-analysis of randomized controlled trials comparing bevacizumab-based maintenance therapy, observation, and continuous chemotherapy.We searched the PubMed, Embase, and Cochrane databases for relevant articles published through March 2018. All randomized phase-III trials evaluating bevacizumab-based maintenance treatment after bevacizumab-based induction treatment were eligible for inclusion. The primary and secondary endpoints were progression-free survival (PFS) and overall survival (OS), respectively. Hazard ratios (HRs) with 95% confidence intervals (CIs) or data for calculating HRs with 95% CIs were extracted. The RevMan v5.3 (Copenhagen, Denmark) software was used for data analysis. RESULTS Nine trials (3121 patients) were included in this meta-analysis. Compared with observation alone, bevacizumab-based maintenance therapy significantly improved PFS (HR: 0.62, 95% CI: 0.47-0.82) and showed a trend toward prolonged OS (HR: 0.93, 95% CI: 0.83-1.05). The incidence of grade 3/4 toxicity, including hypertension and fatigue, was higher after maintenance therapy than after observation alone. PFS (HR: 0.91, 95% CI: 0.70-1.18) and OS (HR: 0.88, 95% CI: 0.74-1.04) did not differ between the maintenance treatment and continuous chemotherapy groups. Grade 3/4 toxicity, including diarrhea and sensory neuropathy, was less common after maintenance therapy than after continuous chemotherapy. CONCLUSION Bevacizumab-based maintenance therapy significantly improved PFS, showed a trend toward prolonged OS, and reduced cumulative grade 3/4 toxicity relative to continuous chemotherapy with comparable efficacy. Although maintenance therapy was beneficial, the optimal strategy should be individualized.
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Affiliation(s)
- Hongbo Ma
- The Fuling Center Hospital of Chongqing City
| | - Xiaoli Wu
- The Fuling Center Hospital of Chongqing City
| | | | - Nan Tang
- The Fuling Center Hospital of Chongqing City
| | - Yanyan Li
- The Fuling Center Hospital of Chongqing City
| | - Xianquan Zhang
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Zhou
- The Fuling Center Hospital of Chongqing City
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91
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Baek SK, Lee KT, Bae SB, Lee SC. Evaluating the recent developments in palliative chemotherapy for metastatic colorectal cancer. Korean J Intern Med 2019; 34:1188-1196. [PMID: 31346151 PMCID: PMC6823574 DOI: 10.3904/kjim.2019.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/21/2019] [Indexed: 12/17/2022] Open
Abstract
The incidence of colorectal cancer (CRC) has increased. CRC is the third most common cancer and the fourth most common cause of cancer-related deaths in Korea. Palliative chemotherapy can be used to shrink tumors and ease symptoms caused by the cancer when cure is not possible. It is important to identify chemotherapeutic agents that can be used to effectively treat metastatic CRC (mCRC) and thus improve the survival and quality of life of patients with mCRC. This review aimed to evaluate the recent developments in palliative chemotherapy for mCRC and the biological or targeted agents used based on genetic alterations.
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Affiliation(s)
- Sun Kyung Baek
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Kyu Taek Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Sang Byung Bae
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Sang-Cheol Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
- Correspondence to Sang-Cheol Lee, M.D. Division of Hematology & Oncology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnamgu, Cheonan 31151, Korea Tel: +82-41-570-3803 Fax: +82-41-574-5762 E-mail:
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92
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A prospective observational study on the optimal maintenance strategy in HER2-positive advanced gastric cancer treated with trastuzumab-based therapy. J Cancer Res Clin Oncol 2019; 146:287-295. [DOI: 10.1007/s00432-019-03060-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 10/16/2019] [Indexed: 02/07/2023]
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93
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Guler I, Askan G, Klostergaard J, Sahin IH. Precision medicine for metastatic colorectal cancer: an evolving era. Expert Rev Gastroenterol Hepatol 2019; 13:919-931. [PMID: 31475851 DOI: 10.1080/17474124.2019.1663174] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Metastatic colorectal cancer (CRC) remains a dilemma for cancer researchers with an increasing incidence in the younger patient population. Until the last decade, limited therapeutic options were available for metastatic CRC patients leading to relatively poor clinical outcomes.Areas covered: With advances in genome sequencing technology and reductions in the cost of next-generation sequencing, molecular profiling has become more accessible for cancer researchers and clinical investigators, which has furthered our understanding of the molecular behavior of CRC. This progress has recently translated into significant advances in molecular-based therapeutics and led to the development of new target-specific agents in metastatic CRC patients. In this review article, we extensively elaborate on genomic alterations seen in CRC patients including, but not limited to, EGFR, MMR, BRAF, HER2, NTRKs, FGFR, BRCA1/2, PALB2, POLE, and POLD1 genes, all of which are potentially actionable by either an FDA-approved agent or in a clinical trial setting.Expert opinion: We strongly recommend molecular profiling in metastatic CRC patients during the early course of their disease, as this may provide therapeutic and prognostic information that can guide clinicians to practice precision medicine. Patients with potentially actionable genes should be considered for targeting agents based on molecular alterations.
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Affiliation(s)
- Irem Guler
- Department of Medicine, Baskent University School of Medicine, Ankara, Turkey
| | - Gokce Askan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jim Klostergaard
- Department of Molecular and Cellular Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Ibrahim Halil Sahin
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
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94
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Ji X, Pang C, Tang Y, Teng Y, Li D, Ma H, Yang D, Wang D. Maintenance Versus Intermittent Strategies in the Treatment of Metastatic Colorectal Cancer: A Meta-Analysis from Another Angle. Adv Ther 2019; 36:2838-2848. [PMID: 31432462 DOI: 10.1007/s12325-019-01059-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Considering the differences in overall survival (OS) and progression-free survival (PFS), treatment options for metastatic colorectal cancer (mCRC) are still inconclusive. We carried out a meta-analysis of maintenance and intermittent strategies for the treatment of mCRC aiming at providing an accurate estimation of different treatments in increasing the chance and duration of survival. METHODS PubMed, Embase and CNKI were systematically searched. The pooled hazard ratio (HR) and 95% confidence interval (CI) were counted. We used STATA 12.0 and RevMan 5.2 for statistical analyses. RESULTS A total of six publications with a population of 1975 mCRC patients were included in our meta-analysis. Analysis of OS revealed a statistically significant benefit associated with maintenance therapy (HR: 0.86, 95% CI 0.75-0.98, P = 0.02). Comparing maintenance therapy with an intermittent strategy, the first progression-free survival (PFS1) showed no significant difference (HR, 0.77; 95% CI 0.48-1.24, P = 0.29), but maintenance therapy improved the second progression-free survival (PFS2) significantly (HR, 0.66; 95% CI 0.54-0.81, P < 0.001). Sensitivity analysis was carried out to assess the stability of results. No publication bias was detected during analysis. CONCLUSION Compared with the maintenance strategy, first-line chemotherapy that was completely stopped until disease progression did not benefit mCRC patients in terms of OS and PFS2. Therefore, a maintenance strategy is a good option for individualized mCRC patients.
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Affiliation(s)
- Xiaohui Ji
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China.
| | - Caishuang Pang
- Graduate School of Chongqing Medical University, NO. 1, Medical School Road, Chongqing, 400016, China
| | - Ying Tang
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China
| | - Yan Teng
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China
| | - Dairong Li
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China
| | - Huiwen Ma
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China
| | - Dan Yang
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China
| | - Donglin Wang
- Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital and Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing, 400030, China
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95
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Cremolini C, Antoniotti C, Lonardi S, Aprile G, Bergamo F, Masi G, Grande R, Tonini G, Mescoli C, Cardellino GG, Coltelli L, Salvatore L, Corsi DC, Lupi C, Gemma D, Ronzoni M, Dell'Aquila E, Marmorino F, Di Fabio F, Mancini ML, Marcucci L, Fontanini G, Zagonel V, Boni L, Falcone A. Activity and Safety of Cetuximab Plus Modified FOLFOXIRI Followed by Maintenance With Cetuximab or Bevacizumab for RAS and BRAF Wild-type Metastatic Colorectal Cancer: A Randomized Phase 2 Clinical Trial. JAMA Oncol 2019; 4:529-536. [PMID: 29450468 DOI: 10.1001/jamaoncol.2017.5314] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance The combination of a triple-drug chemotherapy regimen with an anti-epidermal growth factor receptor (EGFR) agent as a first-line treatment of metastatic colorectal cancer (mCRC) showed promising activity along with safety concerns in single-arm phase 2 trials. The role of maintenance following chemotherapy and anti-EGFR and the optimal regimen to be adopted are not established. Objectives To evaluate the activity and safety of cetuximab plus modified FOLFOXIRI (mFOLFOXIRI) and explore the role of maintenance with cetuximab or bevacizumab in RAS and BRAF wild-type mCRC. Design, Setting, and Participants In a prospective, noncomparative, open-label, multicenter, randomized phase 2 trial, patients aged 18 to 75 years with unresectable, previously untreated RAS and BRAF wild-type (before amendment, KRAS wild-type) mCRC were recruited from 21 oncology units in Italy from October 19, 2011, to March 1, 2015 (followed up through May 31, 2017). In total, 323 patients were screened and 143 were randomized to 2 treatment arms to receive as a first-line induction a regimen of mFOLFOXIRI plus cetuximab followed by cetuximab (arm A) or bevacizumab (arm B) until disease progression. Primary analyses were conducted in a modified intention-to-treat population. Interventions mFOLFOXIRI plus cetuximab repeated every 2 weeks for up to 8 cycles, followed by maintenance with cetuximab or bevacizumab until disease progression. Main Outcomes and Measures The primary end point was the 10-month progression-free rate (PFR); secondary end points included progression-free and overall survival, response rate, rate of metastases resection, and adverse events. Results Of 143 patients randomized, 116 (81.1%) (median [interquartile range (IQR)] age, 59.5 [53-67] years; 34 [29.3%] women) had RAS and BRAF wild-type mCRC. At a median (IQR) follow-up of 44.0 (30.5-52.1) months, 10-month PFRs were 50.8% (90% CI, 39.5%-62.2%) in arm A and 40.4% (90% CI, 29.4%-52.1%) in arm B. The overall response rate was 71.6% (95% CI, 62.4%-79.5%). Main grade 3/4 adverse events were neutropenia (occurring in 36 patients [31%]), diarrhea (in 21 patients [18%]), skin toxic effects (in 18 patients [16%]), asthenia (in 11 patients [9%]), stomatitis (in 7 patients [6%]), and febrile neutropenia (in 3 patients [3%]). Conclusions and Relevance Although neither of the 2 arms met the primary end point, the findings indicate that a 4-month induction regimen of mFOLFOXIRI plus cetuximab is feasible and provides relevant activity results, leading to a high surgical resection rate. Trial Registration clinicaltrials.gov Identifier: NCT02295930.
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Affiliation(s)
- Chiara Cremolini
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Carlotta Antoniotti
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara Lonardi
- Medical Oncology Unit 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Giuseppe Aprile
- Department of Oncology, University and General Hospital, Udine, Italy.,Department of Oncology, San Bortolo General Hospital, ULSS8 Berica, East District, Vicenza, Italy
| | - Francesca Bergamo
- Medical Oncology Unit 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Gianluca Masi
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Roberta Grande
- Department of Medical Oncology, Hospital of Frosinone, Frosinone, Italy
| | - Giuseppe Tonini
- Dipartimento di Oncologia Università Campus Bio-Medico di Roma, Rome, Italy
| | - Claudia Mescoli
- Surgical Pathology and Cytopathology Unit, Department of Medicine, University of Padua, Padova, Italy
| | | | - Luigi Coltelli
- Unit of Medical Oncology, Hospital Felice Lotti, Azienda Toscana Nord Ovest, Pontedera, Italy
| | - Lisa Salvatore
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy.,Unit of Medical Oncology, Policlinico G. B. Rossi, Azienda Ospedaliera Integrata di Verona, Verona, Italy
| | | | - Cristiana Lupi
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Donatello Gemma
- Department of Medical Oncology, Hospital of Frosinone, Frosinone, Italy
| | - Monica Ronzoni
- Department of Oncology, Hospital San Raffaele IRCSS, Milan, Italy
| | | | - Federica Marmorino
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesca Di Fabio
- Unit of Medical Oncology, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Maria Laura Mancini
- Department of Medical Oncology, Policlinico Umberto I Sapienza, University of Rome, Rome, Italy
| | - Lorenzo Marcucci
- Unit of Medical Oncology, Hospital Felice Lotti, Azienda Toscana Nord Ovest, Pontedera, Italy
| | - Gabriella Fontanini
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Vittorina Zagonel
- Medical Oncology Unit 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Luca Boni
- Clinical Trials Coordinating Center, Toscano Cancer Institute, University Hospital Careggi, Florence, Italy
| | - Alfredo Falcone
- Unit of Medical Oncology 2, Department of Translational Research and New Technologies in Medicine and Surgery, Azienda Ospedaliera-Universitaria Pisana, University of Pisa, Pisa, Italy
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96
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Anandappa G, Cunningham D. Panitumumab Alone for Maintenance Treatment in Advanced Colorectal Cancer. JAMA Oncol 2019; 5:1262-1264. [PMID: 31268483 DOI: 10.1001/jamaoncol.2019.1447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Gayathri Anandappa
- Gastrointestinal and Lymphoma Unit, Royal Marsden Hospital, London and Surrey, England
| | - David Cunningham
- Gastrointestinal and Lymphoma Unit, Royal Marsden Hospital, London and Surrey, England
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97
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Pietrantonio F, Morano F, Corallo S, Miceli R, Lonardi S, Raimondi A, Cremolini C, Rimassa L, Bergamo F, Sartore-Bianchi A, Tampellini M, Racca P, Clavarezza M, Berenato R, Caporale M, Antista M, Niger M, Smiroldo V, Murialdo R, Zaniboni A, Adamo V, Tomasello G, Giordano M, Petrelli F, Longarini R, Cinieri S, Falcone A, Zagonel V, Di Bartolomeo M, de Braud F. Maintenance Therapy With Panitumumab Alone vs Panitumumab Plus Fluorouracil-Leucovorin in Patients With RAS Wild-Type Metastatic Colorectal Cancer: A Phase 2 Randomized Clinical Trial. JAMA Oncol 2019; 5:1268-1275. [PMID: 31268481 DOI: 10.1001/jamaoncol.2019.1467] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Few studies are available on the role of maintenance strategies after induction treatment regimens based on anti-epidermal growth factor receptors, and the optimal regimen for an anti-epidermal growth factor receptors-based maintenance treatment in patients with RAS wild-type metastatic colorectal cancer is still to be defined. Objective To determine whether maintenance therapy with single-agent panitumumab was noninferior to panitumumab plus fluorouracil and leucovorin after a 4-month induction treatment regimen. Design, Setting, and Participants This open-label, randomized phase 2 noninferiority trial was conducted from July 7, 2015, through October 27, 2017, at multiple Italian centers. Patients with RAS wild-type, unresectable metastatic colorectal adenocarcinoma who had not received previous treatment for metastatic disease were eligible. Induction therapy consisted of panitumumab plus FOLFOX-4 (panitumumab, 6 mg/kg, oxaliplatin, 85 mg/m2 at day 1, leucovorin calcium, 200 mg/m2, and fluorouracil, 400-mg/m2 bolus, followed by 600-mg/m2 continuous 24-hour infusion at days 1 and 2, every 2 weeks). Cutoff date for analyses was July 30, 2018. Interventions Patients were randomized (1:1) to first-line panitumumab plus FOLFOX-4 for 8 cycles followed by maintenance therapy with panitumumab plus fluorouracil-leucovorin (arm A) or panitumumab (arm B) until progressive disease, unacceptable toxic effects, or consent withdrawal. The minimization method was used to stratify randomization by previous adjuvant treatment and number of metastatic sites. Main Outcomes and Measures The prespecified primary end point was 10-month progression-free survival (PFS) analyzed on an intention-to-treat basis with a noninferiority margin of 1.515 for the upper limit of the 1-sided 90% CI of the hazard ratio (HR) of arm B vs A. Results Overall, 229 patients (153 male [66.8%]; median age, 64 years [interquartile range (IQR), 56-70 years]) were randomly assigned to arm A (n = 117) or arm B (n = 112). At a median follow-up of 18.0 months (IQR, 13.1-23.3 months]), a total of 169 disease progression or death events occurred. Arm B was inferior (upper limit of 1-sided 90% CI of the HR, 1.857). Ten-month PFS was 59.9% (95% CI, 51.5%-69.8%) in arm A vs 49.0% (95% CI, 40.5%-59.4%) in arm B (HR, 1.51; 95% CI, 1.11-2.07; P = .01). During maintenance, arm A had a higher incidence of grade 3 or greater treatment-related adverse events (36 [42.4%] vs 16 [20.3%]) and panitumumab-related adverse events (27 [31.8%] vs 13 [16.4%]), compared with arm B. Conclusions and Relevance In patients with RAS wild-type metastatic colorectal cancer, maintenance therapy with single-agent panitumumab was inferior in terms of PFS compared with panitumumab plus fluorouracil-leucovorin, which slightly increased the treatment toxic effects. Trial Registration ClinicalTrials.gov identifier: NCT02476045.
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Affiliation(s)
- Filippo Pietrantonio
- Oncology and Hemato-oncology Department, University of Milan, Milan, Italy.,Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Morano
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Salvatore Corallo
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Rosalba Miceli
- Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Lonardi
- Unit of Medical Oncology 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto, IRCCS, Padua, Italy
| | - Alessandra Raimondi
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Chiara Cremolini
- Unit of Medical Oncology, Azienda Ospedaliero-Universitaria (AOU) Pisana, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Francesca Bergamo
- Unit of Medical Oncology 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto, IRCCS, Padua, Italy
| | - Andrea Sartore-Bianchi
- Oncology and Hemato-oncology Department, University of Milan, Milan, Italy.,Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Tampellini
- Department of Oncology, AOU San Luigi di Orbassano, University of Torino, Orbassano, Italy
| | - Patrizia Racca
- Colorectal Cancer Unit, Medical Oncology Division 1, AOU Città della Salute e della Scienza, Torino, Italy
| | - Matteo Clavarezza
- Medical Oncology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - Rosa Berenato
- Medical Oncology Unit A.O. Papardo and Department of Human Pathology, University of Messina, Messina, Italy
| | - Marta Caporale
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Antista
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Niger
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Valeria Smiroldo
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Roberto Murialdo
- Department of Internal Medicine, University of Genoa and IRCCS AOU San Martino-IST, Genoa, Italy
| | | | - Vincenzo Adamo
- Medical Oncology Unit A.O. Papardo and Department of Human Pathology, University of Messina, Messina, Italy
| | - Gianluca Tomasello
- Medical Oncology Unit, Azienda Socio-Sanitaria Territoriale (ASST) Ospedale di Cremona, Cremona, Italy
| | - Monica Giordano
- Medical Oncology Unit, Azienda Socio Sanitaria Territoriale Lariana, Como, Italy
| | - Fausto Petrelli
- Medical Oncology Unit, Oncology Department, ASST Bergamo Ovest, Treviglio, Italy
| | | | - Saverio Cinieri
- Medical Oncology Unit, Ospedale Antonio Perrino, Brindisi, Italy
| | - Alfredo Falcone
- Unit of Medical Oncology, Azienda Ospedaliero-Universitaria (AOU) Pisana, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Vittorina Zagonel
- Unit of Medical Oncology 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto, IRCCS, Padua, Italy
| | - Maria Di Bartolomeo
- Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo de Braud
- Oncology and Hemato-oncology Department, University of Milan, Milan, Italy.,Department of Medical Oncology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Nazionale dei Tumori, Milan, Italy
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Hess LM, Brnabic A, Mason O, Lee P, Barker S. Relationship between Progression-free Survival and Overall Survival in Randomized Clinical Trials of Targeted and Biologic Agents in Oncology. J Cancer 2019; 10:3717-3727. [PMID: 31333789 PMCID: PMC6636299 DOI: 10.7150/jca.32205] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/15/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction: With a gap in a full understanding of the mechanisms by which survival is extended for patients with cancer who are treated with novel biologic and targeted agents, there is the risk that discordant progression-free and overall survival outcomes are observed due to poor clinical trial design or biases in the interpretation of data. This study was designed to examine the role of study quality and design on the outcomes observed with biologic and targeted agents. Methods: A review of studies in clinicaltrials.gov supplemented with a literature review in OVID Medline was conducted to identify all randomized trials of a biologic/targeted agent versus a non-biologic/targeted comparator in oncology that report both median overall and progression-free survival outcomes. Details of the study, design, population, drugs, and outcomes were extracted. Study quality was evaluated using the PEDro scale. Data were summarized using SPSS 22.0.0.0. Results: A total of 192 unique studies of 206 pairwise comparisons between a biologic/targeted and comparator were identified. The average absolute magnitude of post-progression survival (difference between OS and PFS) was 9.7 months for biologic/targeted therapy and 9.8 for the comparator. A total of 64 comparisons (31.1%) showed an increase in OS and decrease in PFS, or vice versa, and 25 (12.1%) showed a magnitude of more than 4 months difference between the delta of OS and delta of PFS between the biologic/targeted and comparator arms. Average study quality was high overall (7.7/10), and was comparable for studies with directional differences (7.2/10) as well as for those with the greatest magnitude in post-progression survival (7.4/10). Conclusion: This review and analysis specifically examined small PFS benefit with large OS benefit as well as small OS benefit with large PFS benefit, including differences in direction of PFS and OS outcomes. No evidence was identified that these are the result of poor study design, but may rather be due to the mechanism of action, specific disease, and population under study. Further work is needed to understand the mechanism of action of novel biologic/targeted agents to better understand their interaction with the tumor microenvironment.
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Affiliation(s)
| | | | | | - Pablo Lee
- Eli Lilly and Company, Indianapolis USA
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Abstract
Colorectal carcinoma is the third most common cancer worldwide. Approximately 20% of patients with colorectal cancer will have metastatic disease at the time of initial diagnosis, and approximately 30% to 50% of patients with primary colon cancer will relapse and die of metastatic cancer. The 5-year survival rate of metastatic colorectal cancer remains disappointing at approximately 10%.Angiogenesis plays a significant role in tumor growth and metastasis in colorectal carcinoma. There are currently 4 US Food and Drug Administration-approved antiangiogenic agents for metastatic colorectal cancer. Bevacizumab is the only antiangiogenic agent approved by the US Food and Drug Administration for first-line treatment of metastatic colorectal cancer. Other antiangiogenic agents include ramucirumab, ziv-aflibercept, and regorafenib. We review the data supporting the use of antiangiogenics in this disease.
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