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Landscape of Immunotherapy Options for Colorectal Cancer: Current Knowledge and Future Perspectives beyond Immune Checkpoint Blockade. Life (Basel) 2022; 12:life12020229. [PMID: 35207516 PMCID: PMC8878674 DOI: 10.3390/life12020229] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/21/2022] [Accepted: 01/31/2022] [Indexed: 11/24/2022] Open
Abstract
Colorectal cancer is the third most prevalent malignancy in Western countries and a major cause of death despite recent improvements in screening programs and early detection methods. In the last decade, a growing effort has been put into better understanding how the immune system interacts with cancer cells. Even if treatments with immune checkpoint inhibitors (anti-PD1, anti-PD-L1, anti-CTLA4) were proven effective for several cancer types, the benefit for colorectal cancer patients is still limited. However, a subset of patients with deficient mismatch repair (dMMR)/microsatellite-instability-high (MSI-H) metastatic colorectal cancer has been observed to have a prolonged benefit to immune checkpoint inhibitors. As a result, pembrolizumab and nivolumab +/− ipilimumab recently obtained the Food and Drug Administration approval. This review aims to highlight the body of knowledge on immunotherapy in the colorectal cancer setting, discussing the potential mechanisms of resistance and future strategies to extend its use.
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Vogel JD, Felder SI, Bhama AR, Hawkins AT, Langenfeld SJ, Shaffer VO, Thorsen AJ, Weiser MR, Chang GJ, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colon Cancer. Dis Colon Rectum 2022; 65:148-177. [PMID: 34775402 DOI: 10.1097/dcr.0000000000002323] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | | | | | | | | | | | - Amy J Thorsen
- Colon and Rectal Surgery Associates, Minneapolis, Minnesota
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Jayaprakasam VS, Paroder V, Gibbs P, Bajwa R, Gangai N, Sosa RE, Petkovska I, Golia Pernicka JS, Fuqua JL, Bates DDB, Weiser MR, Cercek A, Gollub MJ. MRI radiomics features of mesorectal fat can predict response to neoadjuvant chemoradiation therapy and tumor recurrence in patients with locally advanced rectal cancer. Eur Radiol 2022; 32:971-980. [PMID: 34327580 PMCID: PMC9018044 DOI: 10.1007/s00330-021-08144-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/11/2021] [Accepted: 06/02/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To interrogate the mesorectal fat using MRI radiomics feature analysis in order to predict clinical outcomes in patients with locally advanced rectal cancer. METHODS This retrospective study included patients who underwent neoadjuvant chemoradiotherapy for locally advanced rectal cancer from 2009 to 2015. Three radiologists independently segmented mesorectal fat on baseline T2-weighted axial MRI. Radiomics features were extracted from segmented volumes and calculated using CERR software, with adaptive synthetic sampling being employed to combat large class imbalances. Outcome variables included pathologic complete response (pCR), local recurrence, distant recurrence, clinical T-category (cT), post-treatment T category (ypT), and post-treatment N category (ypN). A maximum of eight most important features were selected for model development using support vector machines and fivefold cross-validation to predict each outcome parameter via elastic net regularization. Diagnostic metrics of the final models were calculated, including sensitivity, specificity, PPV, NPV, accuracy, and AUC. RESULTS The study included 236 patients (54 ± 12 years, 135 men). The AUC, sensitivity, specificity, PPV, NPV, and accuracy for each clinical outcome were as follows: for pCR, 0.89, 78.0%, 85.1%, 52.5%, 94.9%, 83.9%; for local recurrence, 0.79, 68.3%, 80.7%, 46.7%, 91.2%, 78.3%; for distant recurrence, 0.87, 80.0%, 88.4%, 58.3%, 95.6%, 87.0%; for cT, 0.80, 85.8%, 56.5%, 89.1%, 49.1%, 80.1%; for ypN, 0.74, 65.0%, 80.1%, 52.7%, 87.0%, 76.3%; and for ypT, 0.86, 81.3%, 84.2%, 96.4%, 46.4%, 81.8%. CONCLUSION Radiomics features of mesorectal fat can predict pathological complete response and local and distant recurrence, as well as post-treatment T and N categories. KEY POINTS • Mesorectal fat contains important prognostic information in patients with locally advanced rectal cancer (LARC). • Radiomics features of mesorectal fat were significantly different between those who achieved complete vs incomplete pathologic response (accuracy 83.9%, 95% CI: 78.6-88.4%). • Radiomics features of mesorectal fat were significantly different between those who did vs did not develop local or distant recurrence (accuracy 78.3%, 95% CI: 72.0-83.7% and 87.0%, 95% CI: 81.6-91.2% respectively).
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Affiliation(s)
- Vetri Sudar Jayaprakasam
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA.
| | - Peter Gibbs
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Raazi Bajwa
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Natalie Gangai
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Ramon E Sosa
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Jennifer S Golia Pernicka
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - James Louis Fuqua
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - David D B Bates
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 29, New York, NY, 10065, USA
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54
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Saude Conde R, Bregni G, Saad E, Hendlisz A, Sclafani F. JCOG0603: Are We Really Sure This Was a Negative Trial? J Clin Oncol 2022; 40:803-805. [PMID: 35025615 DOI: 10.1200/jco.21.02299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rita Saude Conde
- Rita Saude Conde, MD, Institut Jules Bordet, Brussels, Belgium; Giacomo Bregni, MD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium; Everardo Saad, MD, International Drug Development Institute, Louvain-la-Neuve, Belgium, Dendrix Research, Sao Paulo, Brazil; and Alain Hendlisz, MD, PhD, and Francesco Sclafani, MD, PhD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Giacomo Bregni
- Rita Saude Conde, MD, Institut Jules Bordet, Brussels, Belgium; Giacomo Bregni, MD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium; Everardo Saad, MD, International Drug Development Institute, Louvain-la-Neuve, Belgium, Dendrix Research, Sao Paulo, Brazil; and Alain Hendlisz, MD, PhD, and Francesco Sclafani, MD, PhD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Everardo Saad
- Rita Saude Conde, MD, Institut Jules Bordet, Brussels, Belgium; Giacomo Bregni, MD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium; Everardo Saad, MD, International Drug Development Institute, Louvain-la-Neuve, Belgium, Dendrix Research, Sao Paulo, Brazil; and Alain Hendlisz, MD, PhD, and Francesco Sclafani, MD, PhD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alain Hendlisz
- Rita Saude Conde, MD, Institut Jules Bordet, Brussels, Belgium; Giacomo Bregni, MD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium; Everardo Saad, MD, International Drug Development Institute, Louvain-la-Neuve, Belgium, Dendrix Research, Sao Paulo, Brazil; and Alain Hendlisz, MD, PhD, and Francesco Sclafani, MD, PhD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Francesco Sclafani
- Rita Saude Conde, MD, Institut Jules Bordet, Brussels, Belgium; Giacomo Bregni, MD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium; Everardo Saad, MD, International Drug Development Institute, Louvain-la-Neuve, Belgium, Dendrix Research, Sao Paulo, Brazil; and Alain Hendlisz, MD, PhD, and Francesco Sclafani, MD, PhD, Institut Jules Bordet, Brussels, Belgium, Université Libre de Bruxelles (ULB), Brussels, Belgium
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55
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Oki E, Ando K, Taniguchi H, Yoshino T, Mori M. Sustainable Clinical Development of Adjuvant Chemotherapy for Colon Cancer. Ann Gastroenterol Surg 2022; 6:37-45. [PMID: 35106413 PMCID: PMC8786685 DOI: 10.1002/ags3.12503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/28/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023] Open
Abstract
Numerous clinical studies in an adjuvant setting have been conducted and the combination therapy of 5-fluorouracil and oxaliplatin has been established as the standard treatment for Stage III and as an option for high-risk Stage II patients. Biologics such as bevacizumab and antiepidermal growth factor receptor antibodies have failed to show additional survival benefits. The indication of adjuvant chemotherapy has been determined according to the pathological stage. Nevertheless, a pathological diagnosis does not necessarily result in selection of the optimal treatment. To improve treatment decisions, many trials have aimed to stratify patients into treatment groups using genomic testing. Recently, gene signature, Immunoscore, and circulating tumor DNA (ctDNA) assays have been reported and among them, ctDNA was shown to be a promising accurate predictive marker for recurrence. Treatment of ctDNA-positive patients with aggressive chemotherapy may reduce recurrence rates. The ultimate goal is to accurately predict the risk of recurrence and to prevent recurrence in colon cancer patients. In this review we focus on the clinical development of adjuvant chemotherapy and stratification of patients according to risk of recurrence and the future direction of adjuvant chemotherapy.
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Affiliation(s)
- Eiji Oki
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Koji Ando
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | | | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Masaki Mori
- Tokai University School of MedicineIseharaJapan
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56
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Wada Y, Shimada M, Morine Y, Ikemoto T, Saito Y, Zhu Z, Wang X, Etxart A, Park Y, Bujanda L, Park IJ, Goel A. Circulating miRNA Signature Predicts Response to Preoperative Chemoradiotherapy in Locally Advanced Rectal Cancer. JCO Precis Oncol 2021; 5:PO.21.00015. [PMID: 34913022 DOI: 10.1200/po.21.00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 08/22/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
Patients with locally advanced rectal cancer (LARC) are recommended to receive preoperative chemoradiotherapy (PCRT) followed by surgery. Response to PCRT varies widely: 60%-70% of patients with LARC do not derive therapeutic benefit from PCRT, whereas 15%-20% of patients achieve pathologic complete response (pCR). We sought to develop a liquid biopsy assay for identifying response to PCRT in patients with LARC. MATERIALS AND METHODS We analyzed two genome-wide microRNA (miRNA) expression profiling data sets from tumor tissue samples for in silico discovery (GSE68204) and validation (GSE29298). We prioritized biomarkers in pretreatment plasma specimens from clinical training (n = 41; 15 responders and 26 nonresponders) and validation (n = 65; 29 responders and 36 nonresponders) cohorts of patients with LARC. We developed an integrated miRNA panel and established a risk assessment model, which was combined with the miRNA panel and carcinoembryonic antigen levels. RESULTS Our comprehensive discovery effort identified an 8-miRNA panel that robustly predicted response to PCRT, with an excellent accuracy in the discovery (area under the curve [AUC] = 0.95) and validation (AUC = 0.92) cohorts. We successfully established a circulating miRNA panel with remarkable diagnostic accuracy in the clinical training (AUC = 0.82) and validation (AUC = 0.81) cohorts. Moreover, the predictive accuracy of the panel was significantly superior to conventional clinical factors in both cohorts (P < .01) and the risk assessment model was superior (AUC = 0.83). Finally, we applied our model to detect patients with pathologic complete response and showed that it was dramatically superior to currently used pathologic features (AUC = 0.92). CONCLUSION Our novel risk assessment signature for predicting response to PCRT has a potential for clinical translation as a liquid biopsy assay in patients with LARC.
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Affiliation(s)
- Yuma Wada
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Monrovia, CA.,Department of Surgery, Tokushima University, Tokushima, Japan.,Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX
| | - Mitsuo Shimada
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Yuji Morine
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Tetsuya Ikemoto
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Yu Saito
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Zhongxu Zhu
- Department of Biomedical Sciences, City University of Hong Kong, Hong Kong, China
| | - Xin Wang
- Department of Biomedical Sciences, City University of Hong Kong, Hong Kong, China
| | - Ane Etxart
- Department of Surgery, Donostia Hospital University, Instituto Biodonostia, San Sebastián, Spain
| | - Yangsoon Park
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Luis Bujanda
- Gastroenterology Department, Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ajay Goel
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Monrovia, CA.,Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX.,City of Hope Comprehensive Cancer Center, Duarte, CA
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Oneda E, Zaniboni A. Adjuvant treatment of colon cancer with microsatellite instability - the state of the art. Crit Rev Oncol Hematol 2021; 169:103537. [PMID: 34801698 DOI: 10.1016/j.critrevonc.2021.103537] [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: 04/20/2021] [Revised: 10/15/2021] [Accepted: 11/15/2021] [Indexed: 12/19/2022] Open
Abstract
Adjuvant chemotherapy with fluoropyrimidine (FP) plus oxaliplatin in stage III resected colorecatal cancer (RCRC) resulted in a 30% relative reduction of disease recurrence risk and mortality. The presence of altered mismatch repair genes identify tumors with microsatellite instability (MSI) that have a better prognosis than stable tumors, but data about adjuvant chemotherapy benefit in this subgroup are compelling. We investigate the role of adjuvant therapy in resected MSI RCRC. The standard treatment is the association of FP plus oxaliplatin, while it can avoided in low risk stage II, thanks to its good prognosis. We propose a practice strategy to approach MSI RCRC in line with the current knowledge. In consideration of the dramatic results in chemorefractory MSI metastatic CRC, there are assumptions that immunotherapy can become a potential alternative to classical systemic therapies also in the adjuvant setting. We await the results of ongoing studies to draw further conclusions."
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Affiliation(s)
- Ester Oneda
- Department of Clinical Oncology, Fondazione Poliambulanza, Bissolati street, 25124, Brescia, Italy.
| | - Alberto Zaniboni
- Department of Clinical Oncology, Fondazione Poliambulanza, Bissolati street, 25124, Brescia, Italy.
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58
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Hao S, Parikh AA, Snyder RA. Racial Disparities in the Management of Locoregional Colorectal Cancer. Surg Oncol Clin N Am 2021; 31:65-79. [PMID: 34776065 DOI: 10.1016/j.soc.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA.
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59
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Heinemann V, Stintzing S. [Neoadjuvant and adjuvant therapy of resectable colon cancer - Current standards and developments]. Dtsch Med Wochenschr 2021; 146:1457-1467. [PMID: 34741291 DOI: 10.1055/a-1391-5124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The present review focusses on perioperative diagnosis and treatment of resectable colon cancer. In UICC stages associated with a higher risk of recurrence, adjuvant chemotherapy after resection of the primary tumor is an established standard. While initial data also indicate the benefit of Neoadjuvant, pre-operative chemotherapy, a final evaluation is still pending. The main focus of molecular testing in the perioperative setting is the analysis of microsatellite instability, which should routinely be performed in defined subgroups. In UICC stage II without risk factors, adjuvant therapy has a limited benefit and therefore is not a preferred option. In UICC stage II with risk factors, adjuvant therapy can be performed. The approach here is based on the recommendations applicable to stage III. In UICC stage III with low risk, adjuvant chemotherapy with CAPOX for 3 months is preferentially recommended. In UICC stage III with high risk, adjuvant chemotherapy over 6 months is recommended, preferentially with FOLFOX. Microsatellite instability (MSI) is clearly associated with favorable prognosis in non-metastatic colon cancer. However, it cannot be considered a predictive factor for the efficacy of adjuvant chemotherapy. Specifically, recent data of the IDEA study have opened the arena for shared decision making between physicians and patients allowing to define individual treatment approaches based on common assessment of risks and benefits. After completion of perioperative treatment, structured follow-up is of great importance and should be carried out according to the recommendations of the S3 guideline.
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60
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Naidoo M, Piercey O, Tie J. Circulating Tumour DNA and Colorectal Cancer: the Next Revolutionary Biomarker? Curr Oncol Rep 2021; 23:140. [PMID: 34735665 DOI: 10.1007/s11912-021-01137-4] [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] [Accepted: 03/30/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Improving outcomes for patients with colorectal cancer in both the adjuvant and metastatic setting has been challenging. Here, we review the current and future directions for using ctDNA in clinical practice. RECENT FINDINGS Circulating tumour DNA (ctDNA) with its ability to detect minimal residual disease is beginning to refine the way we assess recurrence risk in the adjuvant setting. We can potentially tailor treatments to reduce recurrence risk and minimize treatment toxicity. In the metastatic setting, ctDNA can provide a less invasive method of detecting clinically important genetic changes to guide molecularly targeted treatment and to identify mechanisms of molecular resistance. ctDNA can be a surrogate marker for treatment response and help guide the timing of anti-EGFR rechallenge. We await the results of the randomized clinical trials assessing clinical utility of ctDNA in both the adjuvant and metastatic setting before incorporating ctDNA into clinical practice.
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Affiliation(s)
- Mahendra Naidoo
- Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Parkville Melbourne, VIC 3000, Australia.
| | - Oliver Piercey
- Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Parkville Melbourne, VIC 3000, Australia
| | - Jeanne Tie
- Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Parkville Melbourne, VIC 3000, Australia.,Division of Personalised Oncology, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, 3052, Australia.,Department of Medical Oncology, Western Health, Melbourne, VIC, 3021, Australia.,Sir Peter MacCallum, Department of Oncology, The University of Melbourne, Melbourne, VIC, 3010, Australia
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61
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Yin J, Salem ME, Dixon JG, Jin Z, Cohen R, DeGramont A, Van Cutsem E, Taieb J, Alberts SR, Wolmark N, Schmoll HJ, Saltz LB, George TJ, Goldberg RRM, Kerr R, Lonardi S, Yoshino T, Yothers G, Grothey A, Andre T, Shi Q. Reevaluating Disease-Free Survival as an Endpoint vs Overall Survival in Stage III Adjuvant Colon Cancer Trials. J Natl Cancer Inst 2021; 114:60-67. [PMID: 34505880 PMCID: PMC8755492 DOI: 10.1093/jnci/djab187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/17/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Disease-free survival (DFS) with a 3-year median follow-up (3-year DFS) was validated as a surrogate for overall survival (OS) with a 5-year median follow-up (5-year OS) in adjuvant chemotherapy colon cancer (CC) trials. Recent data show further improvements in OS and survival after recurrence in patients who received adjuvant FOLFOX. Hence, reevaluation of the association between DFS and OS and determination of the optimal follow-up duration of OS to aid its utility in future adjuvant trials are needed. METHODS Individual patient data from 9 randomized studies conducted between 1998 and 2009 were included; 3 trials tested biologics. Trial-level surrogacy examining the correlation of treatment effect estimates of 3-year DFS with 5 to 6.5-year OS was evaluated using both linear regression (RWLS2) and Copula bivariate (RCopula2) models and reported with 95% confidence intervals (CIs). For R2, a value closer to 1 indicates a stronger correlation. RESULTS Data from a total of 18 396 patients were analyzed (median age = 59 years; 54.0% male), with 54.1% having low-risk tumors (T1-3 and N1), 31.6% KRAS mutated, 12.3% BRAF mutated, and 12.4% microsatellite instability high or deficient mismatch repair tumors. Trial-level correlation between 3-year DFS and 5-year OS remained strong (RWLS2 = 0.82, 95% CI = 0.67 to 0.98; RCopula2 = 0.92, 95% CI = 0.83 to 1.00) and increased as the median follow-up of OS extended. Analyses limited to trials that tested biologics showed consistent results. CONCLUSIONS Three-year DFS remains a validated surrogate endpoint for 5-year OS in adjuvant CC trials. The correlation was likely strengthened with 6 years of follow-up for OS.
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Affiliation(s)
- Jun Yin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - Jesse G Dixon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Zhaohui Jin
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Romain Cohen
- Department of Medical Oncology, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - Aimery DeGramont
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - Eric Van Cutsem
- Digestive Oncology, University Hospitals Gasthuisberg Leuven and University of Leuven, Leuven, Belgium
| | - Julien Taieb
- Sorbonne Paris Cité, Paris Descartes University Georges Pompidou European Hospital, Paris, France
| | | | - Norman Wolmark
- Department of Clinical Trials, Alleghany Health Network, Pittsburgh, PA, USA
| | | | | | - Thomas J George
- University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Richard R M Goldberg
- West Virginia University Cancer Institute, the Mary Babb Randolph Cancer Center, Morgantown, WV, USA
| | - Rachel Kerr
- Adjuvant Colorectal Cancer Group, University of Oxford, Oxford, UK
| | - Sara Lonardi
- Department of Oncology, Veneto Institute of Oncology IRCCS, Padova PD, Italy
| | - Takayuki Yoshino
- Department of Gastrointestinal Oncology, National Cancer Center, Tokyo, Japan
| | - Greg Yothers
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Thierry Andre
- Department of Medical Oncology, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA,Correspondence to: Qian Shi, PhD, Department of Quantitative Health Sciences, Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA (e-mail: )
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62
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Hanna CR, Robles-Zurita JA, Briggs A, Harkin A, Kelly C, McQueen J, Allan K, Pearson S, Hollander H, Glimelius B, Salazar R, Segelov E, Saunders M, Iveson T, Jones RJ, Boyd KA. Three Versus Six Months of Adjuvant Doublet Chemotherapy for Patients With Colorectal Cancer: A Multi-Country Cost-Effectiveness and Budget Impact Analysis. Clin Colorectal Cancer 2021; 20:236-244. [PMID: 33992542 DOI: 10.1016/j.clcc.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Short Course Oncology Treatment (SCOT) trial demonstrated non-inferiority, less toxicity, and cost-effectiveness from a UK perspective of 3 versus 6 months of oxaliplatin-based chemotherapy for patients with colorectal cancer. This study assessed the cost-effectiveness of shorter treatment and the budget impact of implementing trial findings from the perspectives of all countries recruited to SCOT: Australia, Denmark, New Zealand, Spain, Sweden, and the United Kingdom. PATIENTS AND METHODS Individual cost-utility analyses were performed from the perspective of each country. Resource, quality of life, and survival estimates from the SCOT trial (N = 6065) were used. Probabilistic sensitivity analysis and subgroup analyses were undertaken. Using undiscounted costs from these cost-utility analyses, the impact on country-specific healthcare budgets of implementing the SCOT trial findings was calculated over a 5-year period. The currency used was US dollars (US$), and 2019 was the base year. One-way and scenario sensitivity analysis addressed uncertainty within the budget impact analysis. RESULTS Three months of treatment were cost saving and cost-effective compared to 6 months from the perspective of all countries. The incremental net monetary benefit per patient ranged from US$8972 (Spain) to US$13,884 (Denmark). The healthcare budget impact over 5 years for the base-case scenario ranged from US$3.6 million (New Zealand) to US$61.4 million (UK) and totaled over US$150 million across all countries. CONCLUSION This study has widened the transferability of results from the SCOT trial, showing that shorter treatment is cost-effective from a multi-country perspective. The vast savings from implementation could fully justify the investment in conducting the SCOT trial.
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Affiliation(s)
- Catherine R Hanna
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland.
| | - Jose A Robles-Zurita
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Andrew Briggs
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrea Harkin
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland
| | - Caroline Kelly
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland
| | - John McQueen
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland
| | - Karen Allan
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland
| | - Sarah Pearson
- Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Henrik Hollander
- Department of Oncology, Zealand University Hospital, Naestved, Denmark
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Ramon Salazar
- Departament of Medical Oncology, Catalon Institute of Oncology, Oncobell Program, Bellvitge Biomedical Research Institute (IDIBELL)-CIBERONC, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eva Segelov
- Monash Health and Monash University, Clayton, Victoria, Australia
| | - Mark Saunders
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Tim Iveson
- Southampton General Hospital, University Hospital Southampton, Southampton, United Kingdom
| | - Robert J Jones
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland
| | - Kathleen A Boyd
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
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Prasanna T, Yip D. Adjuvant Therapies in Colon Cancer. COLORECTAL CANCER 2021. [DOI: 10.5772/intechopen.93874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Most of the patients with localized colon cancer undergo curative resection. However, significant number of patients will recur with metastatic disease, especially those with node positive cancer. Adjuvant chemotherapy has shown to improve cure rate and survival by eradicating micrometastases. The benefit of adjuvant therapy is well established in node-positive cancers, while their role in stage II cancer is not well defined. A number of molecular markers have been identified that are prognostic and/or predictive in colon cancer. Such molecular markers, and other clinicopathological features play an important role in selection of appropriate therapy and duration of treatment. Emerging evidence for the utility of genomic profiling or detection of circulating tumor DNA (ctDNA) are promising which may further facilitate decision making in the future. This chapter reviews the evolution of adjuvant therapy for resected colon cancer, the current evidence and the factors influence the choice of therapy.
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Huang WK, Hsu HC, Chang SH, Chou WC, Chang PH, Chiang SF, Chang JWC, Chen JS, Yang TS, See LC. Real-World Effectiveness of Adjuvant Oxaliplatin Chemotherapy in Stage III Colon Cancer: A Controlled Interrupted Time Series Analysis. Front Pharmacol 2021; 12:693009. [PMID: 34267662 PMCID: PMC8276019 DOI: 10.3389/fphar.2021.693009] [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: 04/09/2021] [Accepted: 05/28/2021] [Indexed: 12/09/2022] Open
Abstract
Background: The real-world effectiveness of oxaliplatin in stage III colon cancer has not been determined in a large-scale population. We aimed to assess the real-world impact of adjuvant oxaliplatin treatment on the survival of these patients. Methods: Based on Taiwan cancer registry, we evaluated 17,801 patients with resected stage III colon cancer, including 14,168 patients receiving adjuvant chemotherapy and 3,633 not receiving adjuvant chemotherapy as the control group between 2004 and 2014. We used the controlled interrupted time-series analysis to assess the three-year disease-free survival and five-year overall survival rates before (2004–2008) and after (2009–2014) the addition of oxaliplatin. Results: The introduction of oxaliplatin was associated with no significant improvement in the slopes (per half-year) of the three-year disease-free survival rate (0.2%, 95% CI: −1.7∼2.2%) and five-year overall survival rate (0.6%, 95% CI: −1.8∼3%). The patients receiving oxaliplatin-based chemotherapy also showed no significant increase in the slopes (per half-year) of the three-year disease-free survival rate (0.6%, 95% CI: −1.4∼2.6%) and five-year overall survival rate (1%, 95% CI: −1.5∼3.5%). The nonsignificant results were consistent across subgroup analyses of age (<70 vs. ≥70 years), recurrence risk (T1-3 or N1 vs. T4 or N2), and cycle of oxaliplatin use (≤6 vs. >6). However, oxaliplatin-based chemotherapy significantly increased the slope (per half-year) of the five-year OS (2%, 95% CI: 0.2∼3.8%) for patients in the high-risk group (T4 or N2). The present results were robust in several sensitivity analyses. Conclusion: Among real-world patients with stage III colon cancer, the introduction of oxaliplatin does not yield a significant improvement in survival. Future work should identify the subpopulation(s) of patients who benefit significantly from the addition of oxaliplatin.
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Affiliation(s)
- Wen-Kuan Huang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Hung-Chih Hsu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Hao Chang
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Hung Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Sum-Fu Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - John Wen-Cheng Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tsai-Sheng Yang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
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Hiramatsu K, Shindoh J, Hanaoka Y, Toda S, Ueno M, Matoba S, Kuroyanagi H. Postoperative Nutritional Status is Predictive of the Survival Outcomes in Patients Undergoing Resection of Stage III Colorectal Cancer. World J Surg 2021; 45:3198-3205. [PMID: 34143267 DOI: 10.1007/s00268-021-06202-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Preoperative nutritional status is reportedly associated with the clinical outcomes in patients with colorectal cancer (CRC), although it remains inconclusive whether the preoperative nutritional status that may improve after surgery is truly predictive of the survival outcomes of patients with CRC. METHODS Clinical records of patients with stage III CRC (n = 821) in whom curative resection had been achieved were retrospectively reviewed and the prognostic impact of nutritional status, determined by the controlling nutritional status (CONUT) score, was analyzed. RESULTS The CONUT undernutrition grade was significantly associated with the overall survival rate (OS) in the original population (P < 0.0001). By adopting a cut-off value of CONUT score of ≥ 2 and adjustment for clinical variables using the inverse probability treatment weighting methods, the group with a preoperative CONUT score of ≥ 2 showed a worse OS as compared to the groups with a preoperative CONUT score of < 2 (P = 0.037). However, sub-analysis based on the dynamic changes in the CONUT score revealed that sustained malnutrition in the postoperative period was more frequent among patients with preoperative CONUT score of ≥ 2, and that the OS and recurrence-free survival rate (RFS) were significantly correlated with the "postoperative" nutritional status, irrespective of the preoperative nutritional status. Patients who showed improvements of the nutritional status after surgery showed a significantly longer OS and RFS. CONCLUSIONS Sustained undernutrition or worsening of the nutritional status after colectomy may be associated with a worse OS and RFS after curative resection in patients with stage III CRC.
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Affiliation(s)
- Kosuke Hiramatsu
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Junichi Shindoh
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan. .,Okinaka Memorial Institute for Medical Disease, Tokyo, Japan.
| | - Yutaka Hanaoka
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Shigeo Toda
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Masashi Ueno
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Shuichiro Matoba
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Hiroya Kuroyanagi
- Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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Yan SH, Feng S, Xu Y, Yan YZ, He B, Sun LY, Pang B, Liu WJ, Xu YY, Zhao N, Tang M, Chen Y, Yu MK, Yang YF. Effectiveness of Herbal Medicine for Leukopenia/Neutropenia Induced by Chemotherapy in Adults with Colorectal Cancer: A Systematic Review and Meta-analysis. Integr Cancer Ther 2021; 20:15347354211021654. [PMID: 34116595 PMCID: PMC8202260 DOI: 10.1177/15347354211021654] [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] [Indexed: 12/24/2022] Open
Abstract
Objective: To evaluate the effectiveness of Chinese Herbal Medicine (CHM) on leukopenia/neutropenia induced by chemotherapy in adults with colorectal cancer (CRC). Methods: Eight electronic databases were searched from their inception to June 2020. Randomized controlled trials with clarified sequence generation were qualified. Two reviewers independently conducted the screening and data extraction. Methodological quality was assessed using the Risk of Bias tool. RevMan 5.4 was applied to the meta-analysis. Results: Twenty-seven studies involving 1867 participants were qualified, of which 26 were included in the quantitative synthesis. Meta-analysis showed that CHM significantly reduced the incidence of leukopenia induced by chemotherapy (RR = 0.69; 95% CI 0.59-0.82), as well as the grade 3/4 leukopenia (RR = 0.71; 95% CI 0.55-0.90). Meanwhile,CHM decreased the occurrence of neutropenia (RR = 0.52, 95% CI 0.35-0.77), especially for the grades 3/4 neutropenia (RR = 0.42, 95% CI 0.27-0.64). Twenty-six of the included studies focused on the adverse events related to CHM. Conclusion: CHM may relieve neutropenia/leukopenia induced by chemotherapy in adults with colorectal cancer.
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Affiliation(s)
- Shao-Hua Yan
- Xiyuan Hospital,China Academy of Chinese Medical Sciences, Beijing, China
| | - Shuo Feng
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Yun Xu
- Xiyuan Hospital,China Academy of Chinese Medical Sciences, Beijing, China
| | - Yun-Zi Yan
- Beijing University of Chinese Medicine, Beijing, China
| | - Bin He
- Xiyuan Hospital,China Academy of Chinese Medical Sciences, Beijing, China
| | - Ling-Yun Sun
- Xiyuan Hospital,China Academy of Chinese Medical Sciences, Beijing, China
| | - Bing Pang
- Guang'anmen Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Wen-Jia Liu
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yu-Ying Xu
- Beijing University of Chinese Medicine, Beijing, China
| | - Na Zhao
- Beijing University of Chinese Medicine, Beijing, China
| | - Mo Tang
- Xiyuan Hospital,China Academy of Chinese Medical Sciences, Beijing, China
| | - Yue Chen
- Beijing University of Chinese Medicine, Beijing, China
| | - Ming-Kun Yu
- Beijing University of Chinese Medicine, Beijing, China
| | - Yu-Fei Yang
- Xiyuan Hospital,China Academy of Chinese Medical Sciences, Beijing, China
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Treasure M, Thomas A, Ganocy S, Hong A, Krishnamurthi SS, Bajor DL, Berger NA, Meropol NJ. A pilot study of a low glycemic load diet in patients with stage I-III colorectal cancer. J Gastrointest Oncol 2021; 12:910-920. [PMID: 34295544 DOI: 10.21037/jgo-20-330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/28/2021] [Indexed: 01/05/2023] Open
Abstract
Background Consumption of a diet with high glycemic indices has been associated with inferior cancer-specific outcomes in patients with early-stage colorectal cancer, but there is limited prospective evidence that alterations in dietary habits improves cancer outcomes. This study aimed to determine the feasibility and acceptability of following a low glycemic load (GL) diet in patients with stage I-III colorectal cancer. Methods Patients with stage I-III colorectal cancer, who completed definitive therapy, and consumed an average daily GL >150 participated in a 12-week tailored face-to-face dietary intervention with a target GL. This study followed a 2-stage design, with 4 planned cohorts, each with an assigned GL target and dietary intervention intensity. The primary endpoint of feasibility was determined by participant compliance, defined as an individual following the assigned GL ≥75% of the time. Compliance was determined using 24-hour telephone recalls. A cohort was deemed feasible if at least 67% of participants were compliant. Secondary endpoints included acceptability of the diet, nutritional support resources necessary to follow the diet, and evaluation of the effect of the diet on physical measures and correlative laboratories. Results Only cohort 1 was required as the primary endpoint of feasibility was met (stringent GL target, low intensity dietary support). The majority of participants experienced a decrease in body mass index (BMI) and waist circumference, 29% experiencing meaningful weight loss (≥5%). The dietitian spent an average of 6.97 hours (SD 2.18) face-to-face time and 1.58 hours (SD 0.68) by phone with each participant. Significant decreases were seen in total cholesterol, very-low-density lipoprotein (VLDL) and triglycerides (all P<0.05). All participants liked the foods and were satisfied with the diet. All participants felt the in-person meetings were helpful, and 62% did not feel a virtual meeting (e.g., Skype, etc.) could replace in-person meetings. Conclusions Patients with stage I-III colorectal cancer can follow a low GL diet with a 12-week in-person dietary intervention. Significant changes in physical and laboratory measures suggest relevant biologic effects of the dietary intervention. This study establishes feasibility, and warrants a larger scale prospective intervention trial to evaluate the impact of a low GL diet on cancer outcomes.
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Affiliation(s)
- Michelle Treasure
- Department of Medicine, Division of Hematology and Oncology, Cleveland Clinic Foundation, Case Comprehensive Cancer Center, Cleveland Clinic Learner College of Medicine, Cleveland, OH, USA
| | - Alicia Thomas
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stephen Ganocy
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Augustine Hong
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Smitha S Krishnamurthi
- Department of Medicine, Division of Hematology and Oncology, Cleveland Clinic Foundation, Case Comprehensive Cancer Center, Cleveland Clinic Learner College of Medicine, Cleveland, OH, USA
| | - David L Bajor
- Department of Medicine, Division of Hematology and Oncology, University Hospitals Cleveland Medical Center, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nathan A Berger
- Department of Medicine, Division of Hematology and Oncology, University Hospitals Cleveland Medical Center, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Neal J Meropol
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Flatiron Health, Inc., New York, NY, USA
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Okamoto K, Nozawa H, Hongo K, Iida Y, Kawai K, Sasaki K, Murono K, Kita Y, Ishihara Y, Takabayashi N, Kobayashi R, Hiramatsu T, Ishihara S. Risk factors of mFOLFOX6-induced hyperammonemia in patients with colorectal cancer: an observational study. Int J Clin Oncol 2021; 26:1477-1484. [PMID: 33991268 DOI: 10.1007/s10147-021-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 05/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND FOLFOX therapy, a standard treatment for colorectal cancer (CRC), causes a rare, but serious adverse event, hyperammonemia. However, the risk factors of hyperammonemia remain unknown. METHODS We examined 74 patients who received mFOLFOX6 therapy with or without biologics for CRC between April 2013 and March 2018 in Yaizu City Hospital. Clinicopathological factors were retrospectively reviewed in association with hyperammonemia, and risk factors of hyperammonemia during mFOLFOX6 therapy were analyzed in 32 patients with the available data. RESULTS Seven patients developed hyperammonemia, with onset exclusively on day 2 or 3 in the first cycle of therapy. They were treated with branched chain amino acid administration and hydration; however, one patient with stage G4 chronic kidney disease (CKD) died. By multivariate analysis, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 was independently associated with hyperammonemia during FOLFOX therapy (odds ratio: 9.0, p = 0.040). CONCLUSIONS Reduced eGFR is considered a risk factor of developing hyperammonemia during FOLFOX therapy. Serum ammonia levels should be monitored especially during the first cycle of FOLFOX therapy in patients with CKD stage G3 or higher.
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Affiliation(s)
- Kazuaki Okamoto
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kumiko Hongo
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan.,Department of Surgery, Hiratsuka City Hospital, 1-19-1, Minamihara, Hiratsuka-shi, Kanagawa, 254-0065, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.,Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yusuke Kita
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Yukio Ishihara
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Naoki Takabayashi
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Ryo Kobayashi
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Takeyuki Hiramatsu
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Oki E, Watanabe J, Sato T, Kagawa Y, Kuboki Y, Ikeda M, Ueno H, Kato T, Kusumoto T, Masuishi T, Yamaguchi K, Kanazawa A, Nishina T, Uetake H, Yamanaka T, Yoshino T. Impact of the 12-gene recurrence score assay on deciding adjuvant chemotherapy for stage II and IIIA/B colon cancer: the SUNRISE-DI study. ESMO Open 2021; 6:100146. [PMID: 33984677 PMCID: PMC8134704 DOI: 10.1016/j.esmoop.2021.100146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recent advances in adjuvant chemotherapy for early colon cancer have widened physicians' recommendations on the regimen and duration (3 or 6 months) of the treatment. We conducted this prospective study to evaluate whether the 12-gene recurrence score (12-RS) assay affected physicians' recommendations on adjuvant treatment selection. PATIENTS AND METHODS Patients with stage IIIA/IIIB or stage II colon cancer were enrolled. After the patients discussed adjuvant treatment with their treating physicians, the physicians filled in the questionnaire before assay indicating the treatment recommendation. When the 12-RS assay results were available, the physicians again filled in the questionnaire after assay. The primary endpoint was the rate of change in treatment recommendations from before to after the assay, with a threshold rate of change being 20%. Patients with stage IIIA/B to II were enrolled in a ratio of 2 : 1. RESULTS Overall, the treatment recommendations changed in 40% of cases after obtaining 12-RS assay results. Recommendations were changed in 45% (80/178; 95% confidence interval, 37% to 53%; P < 0.001) and 30% (29/97; 95% confidence interval, 21% to 40%; P < 0.001) of patients with stage IIIA/B and II colon cancer, respectively. Patients with stage IIIA/B cancer had significantly more change than those with stage II cancer (P = 0.0148). From before to after the 12-RS assay, the percentage of patients whose physicians reported being confident in their treatment recommendations significantly increased from 54% to 81% in stage IIIA/B (P < 0.001) and from 65% to 83% in stage II (P < 0.001). CONCLUSION Our study confirmed the usefulness of the 12-RS assay in aiding the physician-patient decision-making process for tailoring adjuvant chemotherapy for stage IIIA/B colon cancer.
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Affiliation(s)
- E Oki
- Department of Surgery and Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - J Watanabe
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - T Sato
- Department of Colorectal Surgery, Kitasato University Hospital, Kanagawa, Japan
| | - Y Kagawa
- Department of Surgery, Kansai Rosa Hospital, Hyogo, Japan
| | - Y Kuboki
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - M Ikeda
- Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - H Ueno
- Department of Surgery, National Defense Medical College, Saitama, Japan
| | - T Kato
- Department of Surgery, NHO Osaka National Hospital, Osaka, Japan
| | - T Kusumoto
- Department of Gastroenterological Surgery, NHO National Kyushu Medical Center, Fukuoka, Japan
| | - T Masuishi
- Department of Clinical Oncology, Aichi Cancer Center Hospital, Aichi, Japan
| | - K Yamaguchi
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - A Kanazawa
- Department of Gastroenterological Surgery, Shimane Prefectural Central Hospital, Shimane, Japan
| | - T Nishina
- Department of Gastrointestinal Medical Oncology, NHO Shikoku Cancer Center, Ehime, Japan
| | - H Uetake
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo, Japan
| | - T Yamanaka
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan.
| | - T Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
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Żok J, Bieńkowski M, Radecka B, Korniluk J, Adamowicz K, Duchnowska R. Impact of relative dose intensity of oxaliplatin in adjuvant therapy among stage III colon cancer patients on early recurrence: a retrospective cohort study. BMC Cancer 2021; 21:529. [PMID: 33971834 PMCID: PMC8112028 DOI: 10.1186/s12885-021-08183-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 04/13/2021] [Indexed: 02/04/2023] Open
Abstract
Background Oxaliplatin-based therapy with FOLFOX-4 or CAPOX administered over 6 months remains the standard adjuvant treatment for stage III colon cancer (CC) patients. However, many patients experience dose reduction or early termination of chemotherapy due to oxaliplatin toxicity, which may increase the risk of early recurrence. The objective of this study was to analyze the relationship between the relative dose intensity of oxaliplatin (RDI-O) and early recurrence among stage III CC patients. Methods The study included 365 patients treated at five oncology centers in Poland between 2000 and 2014. Survival analysis was performed using the Kaplan-Meier method. Univariate analysis was performed using the Cox proportional hazard model; multivariate analysis was performed with the stepwise forward approach. For all analyses the α level of 0.05 was employed. Results The median follow-up was 51.8 months (range 8.2–115.1). Early recurrence < 36 months after surgery occurred in 130 patients (37.8%). In this group 51 (39.2%) and 87 (66.9%) of patients were low and high-risk, respectively. Receipt < 60% of RDI-O was associated with early recurrence within 18 months after surgery (OR = 2.05; 95%CI: 1.18–3.51; p = 0.010), especially in low-risk group (HR = 1.56 (95%CI: 0.96–2.53), p = 0.07). In the multivariate analysis early recurrence was correlated with grade (OR = 2.47; 95% CI: 1.25–4.8; p = 0.008), pN (OR = 2.63; 95% CI: 1.55–4.54; p < 0.001), the number of lymph nodes harvested (OR = 0.51; 95% CI: 0.29–0.86; p = 0.013) and RDI-O (OR = 1.91; 95%CI: 1.06–3.39; p = 0.028). The early vs. late recurrence negatively correlated with OS regardless of the RDI-O (HR = 22.9 (95%CI: 13.9–37.6; p < 0.001). Conclusions RDI-O < 60% in adjuvant therapy among stage III CC (especially in low-risk group) increases the risk of early recurrence within 18 months of surgery. Patients with early recurrence showed worse overall survival regardless of the RDI-O.
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Affiliation(s)
- Jolanta Żok
- Department of Chemotherapy, Center of Pulmonology and Chemotherapy, 58-580, Szklarska Poręba, Poland
| | - Michał Bieńkowski
- Department of Pathomorphology, Medical University of Gdańsk, 80-214, Gdańsk, Poland
| | - Barbara Radecka
- Department of Oncology, Institute of Medical Science, University of Opole, 46-020, Opole, Poland
| | - Jan Korniluk
- Department of Oncology, Military Institute of Medicine, 04-141, Warsaw, Poland
| | | | - Renata Duchnowska
- Department of Oncology, Military Institute of Medicine, 04-141, Warsaw, Poland.
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Otegbeye EE, Mitchem JB, Park H, Chaudhuri AA, Kim H, Mutch MG, Ciorba MA. Immunity, immunotherapy, and rectal cancer: A clinical and translational science review. Transl Res 2021; 231:124-138. [PMID: 33307273 PMCID: PMC8016725 DOI: 10.1016/j.trsl.2020.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/28/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023]
Abstract
Rectal cancer remains a challenging disease to treat. Therapy for locally advanced rectal cancer (LARC), the most frequent presentation, has evolved to include a multimodal approach of radiation, chemotherapy, and surgery. While this approach improves local disease control, the distant recurrence rate is nearly 30% and treatment-related morbidity is substantial, thus underscoring the need for new therapeutic approaches with better efficacy and lower side effects. Immunotherapy could potentially fill this need, but its promise is not yet realized in rectal cancer. In this translational science review, we address what is known about how cytotoxic therapies shape rectal cancer immunity and potentially prime the tumor microenvironment for response to immune checkpoint inhibitors and other immunotherapies. We also address the role of current immunotherapies in colorectal cancer and highlight where novel immunotherapy approaches are currently being evaluated in LARC. Finally, we address important future directions in LARC immunotherapy including the need to define optimal therapeutic sequencing, predictive biomarkers, strategies to limit treatment-related side effects and the potential of gut microbiome manipulation to improve outcomes. In summary, this review provides a framework to guide future research and inform immunotherapy trial design so as to advance rectal cancer care.
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Affiliation(s)
- Ebunoluwa E Otegbeye
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jonathan B Mitchem
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri; Surgical Service, Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri
| | - Haeseong Park
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Aadel A Chaudhuri
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri; Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri; Department of Genetics, Washington University School of Medicine, St. Louis, Missouri; Department of Computer Science & Engineering, Washington University, St. Louis, Missouri
| | - Hyun Kim
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri; Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew G Mutch
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri; Department of Surgery, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Ciorba
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri; Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri.
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72
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Boakye D, Jansen L, Halama N, Chang-Claude J, Hoffmeister M, Brenner H. Early discontinuation and dose reduction of adjuvant chemotherapy in stage III colon cancer patients. Ther Adv Med Oncol 2021; 13:17588359211006348. [PMID: 33995589 PMCID: PMC8072866 DOI: 10.1177/17588359211006348] [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: 02/04/2021] [Accepted: 03/11/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The benefit of chemotherapy in colon cancer patients is well documented but depends largely on whether patients complete the planned treatment regimen. We evaluated predictors of early discontinuation (EDChemo) and dose reduction of chemotherapy, especially the role of adverse treatment effects, in stage III patients who received adjuvant chemotherapy. METHODS Stage III colon cancer patients who were diagnosed in 2003-2014 and recruited into a population-based study in Germany and received FOLFOX [5-fluorouracil (5-FU), leucovorin (LV), and oxaliplatin], capecitabine monotherapy (CapMono), or 5-FU/LV were included. We assessed determinants of EDChemo and dose reduction using multivariable logistic regression. Also, we estimated proportions of EDChemo and dose reduction that are attributable to adverse effects using attributable fractions. RESULTS EDChemo and dose reduction rates were 52% and 17% for FOLFOX, 28% and 9% for CapMono, and 45% and 6% for 5-FU/LV, respectively. Predictors of EDChemo were low-grade tumor and treatment in a medium-volume hospital (for FOLFOX), obesity (for CapMono), and increasing age, T4 stage, and treatment in a medium-volume hospital (for 5-FU/LV). Adverse effects were particularly strongly associated with EDChemo and contributed to about 63%, 51%, and 32% of EDChemo of FOLFOX, CapMono, and 5-FU/LV, respectively. Of the various adverse effects, gastrointestinal events showed the strongest associations with EDChemo and accounted for about 7%, 26%, and 20% of EDChemo of FOLFOX, CapMono, and 5-FU/LV, respectively. Adverse effects were, moreover, a strong determinant of dose reduction and accounted for about 82% of all cases. CONCLUSIONS EDChemo is common in stage III colon cancer patients receiving chemotherapy and more than half of the cases of EDChemo and dose reduction are due to adverse treatment effects. Further research should address the potential for reducing EDChemo and dose reduction rates by close monitoring of patients for early signs and enhanced management of adverse effects, especially gastrointestinal events.
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Affiliation(s)
- Daniel Boakye
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Niels Halama
- Division of Translational Immunotherapy, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jenny Chang-Claude
- Unit of Genetic Epidemiology, Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Cancer Epidemiology Group, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, Heidelberg, 69120, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
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73
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Lin X, Wang G, Liu P, Han L, Wang T, Chen K, Gao Y. Gallic acid suppresses colon cancer proliferation by inhibiting SRC and EGFR phosphorylation. Exp Ther Med 2021; 21:638. [PMID: 33968169 PMCID: PMC8097205 DOI: 10.3892/etm.2021.10070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/10/2021] [Indexed: 02/06/2023] Open
Abstract
The aim of the present study was to investigate the effects of gallic acid (GA) on the proliferation and apoptosis of colon cancer cells and to further clarify the mechanism of GA function associated with SRC and EGFR phosphorylation. HCT116 and HT29 cells were treated with different concentrations of GA for 24 h. Cell proliferation and apoptosis were analyzed using plate clone formation and flow cytometry assays, respectively. In addition, the expression of apoptosis-related proteins was examined by western blotting. Furthermore, the level of STAT3, AKT, SRC and EGFR phosphorylation was analyzed by western blotting and immunofluorescence. Subsequently, the SRC inhibitor PP2 and the EGFR inhibitor gefitinib were used to analyze the GA-associated mechanisms. In addition, a xenograft tumor model was established to confirm the effects of GA in vivo. The results indicated that GA inhibited cell proliferation and promoted cell apoptosis by upregulating the ratio of cleaved caspase-3/pro-caspase-3 and cleaved caspase-9/pro-caspase-9. Concurrently, GA decreased the level of phosphorylated (p)-SRC, p-EGFR, p-AKT and p-STAT3. Following treatment with PP2 and gefitinib in both cancer cell lines and animal model, GA was demonstrated to inhibit EGFR and SRC phosphorylation to downregulate STAT3 and AKT phosphorylation. In vivo, GA prevented tumor growth, promoted tumor apoptosis and decreased the level of p-SRC, p-EGFR, p-STAT3 and p-AKT. In conclusion, GA was indicated to suppress colon cancer proliferation by inhibiting SRC and EGFR phosphorylation.
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Affiliation(s)
- Xiaoming Lin
- Luye Pharma Group Ltd., Yantai, Shandong 264000, P.R. China
| | - Guangfei Wang
- School of Life Sciences, Yantai University, Yantai, Shandong 264005, P.R. China
| | - Ping Liu
- School of Life Sciences, Yantai University, Yantai, Shandong 264005, P.R. China
| | - Lei Han
- School of Life Sciences, Yantai University, Yantai, Shandong 264005, P.R. China
| | - Tong Wang
- School of Life Sciences, Yantai University, Yantai, Shandong 264005, P.R. China
| | - Kaili Chen
- School of Life Sciences, Yantai University, Yantai, Shandong 264005, P.R. China
| | - Yonglin Gao
- School of Life Sciences, Yantai University, Yantai, Shandong 264005, P.R. China
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Boerner T, Zambirinis C, Gagnière J, Chou JF, Gonen M, Kemeny NE, Cercek A, Connell LC, Kingham TP, Allen PJ, Balachandran VP, Drebin J, Jarnagin WR, D’Angelica MI. Early liver metastases after "failure" of adjuvant chemotherapy for stage III colorectal cancer: is there a role for additional adjuvant therapy? HPB (Oxford) 2021; 23:601-608. [PMID: 32943326 PMCID: PMC8385642 DOI: 10.1016/j.hpb.2020.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The utility of adjuvant chemotherapy after resection of colorectal liver metastasis (CLM) in patients with rapid recurrence after adjuvant chemotherapy for their primary tumor is unclear. The aim of this study was to evaluate the oncologic benefit of adjuvant hepatic arterial plus systemic chemotherapy (HAIC + Sys) in patients with early CLM. METHODS A retrospective analysis of patients with early CLM (≤12 months of adjuvant chemotherapy for primary tumor) who received either HAIC + Sys, adjuvant systemic chemotherapy alone (Sys), or active surveillance (Surgery alone) following resection of CLM was performed. Recurrence and survival were compared between treatment groups using Kaplan-Meier methods and Cox proportional hazards models. RESULTS Of 239 patients undergoing resection of early CLM, 79 (33.1%) received HAIC + Sys, 77 (32.2%) received Sys, and 83 (34.7%) had Surgery alone. HAIC + Sys was independently associated with reduced risk of RFS events (adjusted hazard ratio [HRadj]: 0.64, 95%CI:0.44-0.94, p = 0.022) and all-cause mortality (HRadj: 0.54, 95%CI:0.36-0.81, p = 0.003) compared to Surgery alone patients. Largest tumor >5 cm (HRadj: 2.03, 95%CI: 1.41-2.93, p < 0.001) and right-sided colon tumors (HRadj: 1.93, 95%CI: 1.29-2.89, p = 0.002) were independently associated with worse OS. CONCLUSION Adjuvant HAIC + Sys after resection of early CLM that occur after chemotherapy for node-positive primary is associated with improved outcomes.
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Affiliation(s)
- Thomas Boerner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Johan Gagnière
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Current affiliations: Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France, U1071 Inserm / Clermont-Auvergne University, Clermont-Ferrand, France
| | - Joanne F. Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy E. Kemeny
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Louise C. Connell
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Current affiliation: Department of Surgery, Duke University, Durham, NC
| | | | - Jeffrey Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Huang H, Park S, Zhang H, Park S, Kwon W, Kim E, Zhang X, Jang S, Yoon D, Choi SK, Yi JK, Kim SH, Dong Z, Lee MH, Ryoo Z, Kim MO. Targeting AKT with costunolide suppresses the growth of colorectal cancer cells and induces apoptosis in vitro and in vivo. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2021; 40:114. [PMID: 33785035 PMCID: PMC8010944 DOI: 10.1186/s13046-021-01895-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is a clinically challenging malignant tumor worldwide. As a natural product and sesquiterpene lactone, Costunolide (CTD) has been reported to possess anticancer activities. However, the regulation mechanism and precise target of this substance remain undiscovered in CRC. In this study, we found that CTD inhibited CRC cell proliferation in vitro and in vivo by targeting AKT. METHODS Effects of CTD on colon cancer cell growth in vitro were evaluated in cell proliferation assays, migration and invasion, propidium iodide, and annexin V-staining analyses. Targets of CTD were identified utilizing phosphoprotein-specific antibody array; Costunolide-sepharose conjugated bead pull-down analysis and knockdown techniques. We investigated the underlying mechanisms of CTD by ubiquitination, immunofluorescence staining, and western blot assays. Cell-derived tumour xenografts (CDX) in nude mice and immunohistochemistry were used to assess anti-tumour effects of CTD in vivo. RESULTS CTD suppressed the proliferation, anchorage-independent colony growth and epithelial-mesenchymal transformation (EMT) of CRC cells including HCT-15, HCT-116 and DLD1. Besides, the CTD also triggered cell apoptosis and cell cycle arrest at the G2/M phase. The CTD activates and induces p53 stability by inhibiting MDM2 ubiquitination via the suppression of AKT's phosphorylation in vitro. The CTD suppresses cell growth in a p53-independent fashion manner; p53 activation may contribute to the anticancer activity of CTD via target AKT. Finally, the CTD decreased the volume of CDX tumors without of the body weight loss and reduced the expression of AKT-MDM2-p53 signaling pathway in xenograft tumors. CONCLUSIONS Our project has uncovered the mechanism underlying the biological activity of CTD in colon cancer and confirmed the AKT is a directly target of CTD. All of which These results revealed that CTD might be a new AKT inhibitor in colon cancer treatment, and CTD is worthy of further exploration in preclinical and clinical trials.
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Affiliation(s)
- Hai Huang
- Department of Animal Science and Biotechnology, ITRD, Kyungpook National University, Sangju, 37224, Republic of Korea
| | - Song Park
- Core Protein Resources Center, DGIST, Daegu, Republic of Korea.,Department of Brain and Cognitive Sciences, DGIST, Daegu, Republic of Korea
| | - Haibo Zhang
- Department of Animal Science and Biotechnology, ITRD, Kyungpook National University, Sangju, 37224, Republic of Korea
| | - Sijun Park
- School of Life Science, Kyungpook National University, Daegu, Republic of Korea
| | - Wookbong Kwon
- Division of Biotechnology, DGIST, Daegu, Republic of Korea
| | - Enugyung Kim
- Department of Animal Science and Biotechnology, ITRD, Kyungpook National University, Sangju, 37224, Republic of Korea
| | - Xiujuan Zhang
- Department of Pulmonary and Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Soyoung Jang
- School of Life Science, Kyungpook National University, Daegu, Republic of Korea
| | - Duhak Yoon
- Department of Animal Science and Biotechnology, ITRD, Kyungpook National University, Sangju, 37224, Republic of Korea
| | - Seong-Kyoon Choi
- Core Protein Resources Center, DGIST, Daegu, Republic of Korea.,Division of Biotechnology, DGIST, Daegu, Republic of Korea
| | - Jun-Koo Yi
- Gyeongsangbuk-do Livestock Research Institute, Yeongju, South Korea
| | - Sung-Hyun Kim
- Department of Bio-Medical Analysis, Korea Polytechnic College, Chungnam, Korea
| | - Zigang Dong
- China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Mee-Hyun Lee
- College of Korean Medicine, Dongshin University, Naju, Jeollanamdo, 58245, Republic of Korea.
| | - Zaeyoung Ryoo
- School of Life Science, Kyungpook National University, Daegu, Republic of Korea.
| | - Myoung Ok Kim
- Department of Animal Science and Biotechnology, ITRD, Kyungpook National University, Sangju, 37224, Republic of Korea.
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76
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Jia R, Liu N, Cai G, Zhang Y, Xiao H, Zhou L, Ji Q, Zhao L, Zeng P, Liu H, Huo J, Yue X, Zhang Y, Wu C, Sun X, Feng Y, Liu H, Liu H, Han Z, Lai Y, Zhang Y, Han G, Gong H, Wang Y, Li Q. Effect of PRM1201 Combined With Adjuvant Chemotherapy on Preventing Recurrence and Metastasis of Stage III Colon Cancer: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Front Oncol 2021; 11:618793. [PMID: 33747930 PMCID: PMC7968418 DOI: 10.3389/fonc.2021.618793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background Chemotherapy is the standard adjuvant treatment for colon cancer. Chinese herbal formula PRM1201 improves the efficacy of chemotherapy when used in combination with Cetuximab or Bevacizumab in patients with metastatic colorectal cancer. This study aims to explore the benefits of treatment with chemotherapy plus PRM1201 in the postoperative adjuvant setting. Methods In this parallel-group study, patients who had undergone curative resection for stage III colon cancer were randomly assigned to receive adjuvant chemotherapy (FOLFOX q2w for 6 months, or CapeOx q3w for 6 months) plus PRM1201 (chemo+PRM1201 group) or adjuvant chemotherapy plus placebo (chemo+placebo group). The primary endpoint was disease-free survival (DFS), and the secondary endpoints were quality of life (QOL) and toxicity. Results A total of 370 patients were randomly assigned to chemotherapy plus PRM1201 group (n = 184) and chemotherapy plus placebo group (n = 186). Up to October 30, 2019, 96 events of recurrence, metastasis, or death had been reported, of which 38 events were in the group of chemotherapy plus PRM1201 and 58 events in the chemo+placebo group. The 3-year DFS rate was 77.1 and 68.6% in the chemo+PRM1201 and chemo+placebo group, respectively (hazard ratio [HR], 0.63; 95% CI, 0.42 to 0.94). The QOL of patients in the chemo+PRM1201 group were significantly improved in terms of global quality of life, physical functioning, role functioning, emotional functioning, fatigue, and appetite loss. The incidence of grade 3 or 4 treatment-related adverse event (TRAEs) were similar between the two arms. Conclusions Chemotherapy in combination with PRM1201 improved the adjuvant treatment of colon cancer. PRM1201 can be recommended as an effective option in clinical practice. Clinical Trial Registration Chinese Clinical Trials Registry, identifier ChiCTR-IOR-16007719.
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Affiliation(s)
- Ru Jia
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ningning Liu
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guoxiang Cai
- Department of Colorectal Cancer Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yun Zhang
- Department of Gastrointestinal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Haijuan Xiao
- Department of Oncology, Hospital Affiliated to Shaanxi University of Chinese Medicine, Xianyang, China
| | - Lihong Zhou
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qing Ji
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ling Zhao
- Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Puhua Zeng
- Department of Medical Oncology, Hunan University of Chinese Medicine Integrated Chinese and Western Medicine Affiliated Hospital, Changsha, China
| | - Huaimin Liu
- Department of Integrated Chinese and Western Medicine, Henan Cancer Hospital, Zhengzhou, China
| | - Jiege Huo
- Department of Oncology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaoqiang Yue
- Department of Traditional Chinese Medicine, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yi Zhang
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chaojun Wu
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaoting Sun
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuanyuan Feng
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongjie Liu
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hui Liu
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhifen Han
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Youying Lai
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yanbo Zhang
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Gang Han
- Department of Gastrointestinal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hangjun Gong
- Department of Gastrointestinal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yan Wang
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qi Li
- Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Iveson TJ, Sobrero AF, Yoshino T, Souglakos I, Ou FS, Meyers JP, Shi Q, Grothey A, Saunders MP, Labianca R, Yamanaka T, Boukovinas I, Hollander NH, Galli F, Yamazaki K, Georgoulias V, Kerr R, Oki E, Lonardi S, Harkin A, Rosati G, Paul J. Duration of Adjuvant Doublet Chemotherapy (3 or 6 months) in Patients With High-Risk Stage II Colorectal Cancer. J Clin Oncol 2021; 39:631-641. [PMID: 33439695 PMCID: PMC8078416 DOI: 10.1200/jco.20.01330] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/17/2020] [Accepted: 10/23/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE As oxaliplatin results in cumulative neurotoxicity, reducing treatment duration without loss of efficacy would benefit patients and healthcare providers. PATIENTS AND METHODS Four of the six studies in the International Duration of Adjuvant Chemotherapy (IDEA) collaboration included patients with high-risk stage II colon and rectal cancers. Patients were treated (clinician and/or patient choice) with either fluorouracil, leucovorin, and oxaliplatin (FOLFOX) or capecitabine and oxaliplatin (CAPOX) and randomly assigned to receive 3- or 6-month treatment. The primary end point is disease-free survival (DFS), and noninferiority of 3-month treatment was defined as a hazard ratio (HR) of < 1.2- v 6-month arm. To detect this with 80% power at a one-sided type one error rate of 0.10, a total of 542 DFS events were required. RESULTS 3,273 eligible patients were randomly assigned to either 3- or 6-month treatment with 62% receiving CAPOX and 38% FOLFOX. There were 553 DFS events. Five-year DFS was 80.7% and 83.9% for 3-month and 6-month treatment, respectively (HR, 1.17; 80% CI, 1.05 to 1.31; P [for noninferiority] .39). This crossed the noninferiority limit of 1.2. As in the IDEA stage III analysis, the duration effect appeared dependent on the chemotherapy regimen although a test of interaction was negative. HR for CAPOX was 1.02 (80% CI, 0.88 to 1.17), and HR for FOLFOX was 1.41 (80% CI, 1.18 to 1.68). CONCLUSION Although noninferiority has not been demonstrated in the overall population, the convenience, reduced toxicity, and cost of 3-month adjuvant CAPOX suggest it as a potential option for high-risk stage II colon cancer if oxaliplatin-based chemotherapy is suitable. The relative contribution of the factors used to define high-risk stage II disease needs better understanding.
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Affiliation(s)
| | | | | | - Ioannis Souglakos
- Department of Medical Oncology, University Hospital of Heraklion, Iraklio, Greece
| | | | | | | | - Axel Grothey
- West Cancer Center and Research Institute, Germantown, TN
| | | | - Roberto Labianca
- Cancer Center, Ospedale Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Takeharu Yamanaka
- Department of Biostatistics, Yokohama City University School of Medicine, Kanagawa, Japan
| | | | | | - Fabio Galli
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | | | | | - Rachel Kerr
- University of Oxford, Oxford, United Kingdom
| | - Eiji Oki
- Kyushu University, Fukuoka, Japan
| | - Sara Lonardi
- Veneto Institute of Oncology IRCCS, Padua, Italy
| | - Andrea Harkin
- University of Glasgow, Institute of Cancer Sciences, Scotland, United Kingdom
| | | | - James Paul
- University of Glasgow, Institute of Cancer Sciences, Scotland, United Kingdom
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78
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Takeshita E, Ishibashi K, Koda K, Oda N, Yoshimatsu K, Sato Y, Oya M, Yamaguchi S, Nakajima H, Momma T, Maekawa H, Tsubaki M, Yamada T, Kobayashi M, Tanakaya K, Ishida H. The updated five-year overall survival and long-term oxaliplatin-related neurotoxicity assessment of the FACOS study. Surg Today 2021; 51:1309-1319. [PMID: 33586034 DOI: 10.1007/s00595-021-02230-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/10/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE We previously reported the first evidence of oncological benefits from a Japanese phase II trial of oxaliplatin-based adjuvant chemotherapy in patients with stage III colon cancer (the FACOS study). We herein report the long-term survival and persistent oxaliplatin-related peripheral sensory neuropathy (PSN) for patients enrolled in this trial. METHODS Patients were scheduled to receive the mFOLFOX6 or CAPOX regimen in the adjuvant setting. The five-year overall survival (OS) rate and persistent PSN were evaluated. RESULTS A total of 130 patients (mFOLFOX6, n = 73; CAPOX, n = 57) were eligible. The 5-year OS rate was 91.4%. No significant difference in the OS rate was observed between regimens (mFOLFOX6, 94.4%; CAPOX, 87.4%; P = 0.25). The incidence of PSN during adjuvant treatment was 55.4% in grade 1 (G1), 30.0% in G2, and 4.6% in G3. No patients showed G3 PSN at 12 months, but G1 or G2 residual PSN after 5 years was observed in 21.8% (G1, 20%; G2, 1.8%). CONCLUSIONS Updated results from the FACOS study support the benefits of oxaliplatin-based adjuvant chemotherapy in terms of the long-term survival among Japanese patients with stage III colon cancer. However, long-term persistent PSN occurs in about 20% of survivors, counterbalancing the favorable OS.
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Affiliation(s)
- Emiko Takeshita
- Department of Surgery, Saitama Medical Center, Dokkyo University, Kosihgaya, Japan
| | - Keiichiro Ishibashi
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Noritaka Oda
- Colo-Proctological Institute, Matsuda Hospital, Hamamatsu, Japan
| | - Kazuhiko Yoshimatsu
- Department of Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yu Sato
- Department of Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Masatoshi Oya
- Department of Surgery, Saitama Medical Center, Dokkyo University, Kosihgaya, Japan
| | - Satoru Yamaguchi
- First Department of Surgery, Dokkyo Medical University, Mibu, Japan
| | - Hideo Nakajima
- Department of Oncology, Ageo Central General Hospital, Ageo, Japan
| | - Tomoyuki Momma
- Department of Gastrointestinal Tract Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Maekawa
- Department of Surgery, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | | | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Michiya Kobayashi
- Cancer Treatment Center, Kochi Medical School Hospital, Nankoku, Japan
| | - Kohji Tanakaya
- Department of Surgery, Iwakuni Clinical Center, Iwakuni, Japan
| | - Hideyuki Ishida
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan.
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Shimizu H, Kuriu Y, Arita T, Kiuchi J, Yamamoto Y, Konishi H, Morimura R, Shiozaki A, Ikoma H, Kubota T, Fujiwara H, Okamoto K, Otsuji E. Staging Paradox and Discrepancy in Adjuvant Chemotherapy in Patients with T4N0, T1-2N1, and T3N1 Colon Cancer. World J Surg 2021; 45:1561-1568. [PMID: 33538878 DOI: 10.1007/s00268-021-05973-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND A survival paradox between T4N0 (stage IIB/C) and T3N1 (stage IIIB) colon cancer has been rarely reported. The indication and regimen of adjuvant chemotherapy are separately described in the guidelines. This study aimed to elucidate the prognostic factors and investigate proper adjuvant treatment in colon cancer patients at these stages. METHODS Patients who underwent R0 resection for pathological T4N0 (n = 49), T1-2N1 (n = 31), or T3N1 (n = 82) colon cancer between 2008 and 2016 at a single institute were retrospectively reviewed. The clinicopathological characteristics, status of adjuvant chemotherapy, and oncologic outcomes of patients with T4N0 tumors were compared with those of patients with T1-2N1 and T3N1 tumors. RESULTS The biological characteristics of T4N0 tumors were more aggressive compared with the characteristics of T1-2N1 tumors and were similar to those of T3N1 tumors. The usage rate of oxaliplatin as an adjuvant chemotherapy was significantly lower in T4N0 patients than in T1-2N1 and T3N1 patients. The rate of local recurrence was the highest in patients with T4N0 tumors, and the survival outcomes for patients with T4N0 tumors were significantly worse compared with those of T1-2N1 patients and were similar to those of T3N1 patients. A multivariate analysis revealed that lack of adequate use of oxaliplatin for adjuvant chemotherapy was the only prognostic factor. CONCLUSIONS T4N0 colon cancer had similar oncological characteristics and survival outcomes to T3N1 colon cancer. Systematic adjuvant chemotherapy, including oxaliplatin, should be incorporated into the therapy for T4N0 patients as well as T3N1 patients.
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Affiliation(s)
- Hiroki Shimizu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Yoshiaki Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tomohiro Arita
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Jun Kiuchi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yusuke Yamamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hirotaka Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Atsushi Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Takeshi Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kazuma Okamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kamigyo-ku, Kyoto, 602-8566, Japan
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Quezada-Diaz FF, Elfeki H, Emmertsen KJ, Pappou EP, Jimenez-Rodriguez R, Patil S, Laurberg S, Garcia-Aguilar J. Comparative analysis of the Memorial Sloan Kettering Bowel Function Instrument and the Low Anterior Resection Syndrome Questionnaire for assessment of bowel dysfunction in rectal cancer patients after low anterior resection. Colorectal Dis 2021; 23:451-460. [PMID: 33405307 PMCID: PMC8023229 DOI: 10.1111/codi.15515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022]
Abstract
AIM Neoadjuvant therapy and total mesorectal excision (TME) for rectal cancer are associated with bowel dysfunction symptoms known as low anterior resection syndrome (LARS). Our study compared the only two validated instruments-the LARS Questionnaire (LARS-Q) and the Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI)-in rectal cancer patients undergoing sphincter-preserving TME. METHODS One hundred and ninety patients undergoing sphincter-preserving TME for Stage I-III rectal cancer completed the MSK-BFI and LARS-Q simultaneously at a median time of 12 (range 1-43) months after restoration of bowel continuity. Associations between the MSK-BFI total/subscale scores and the LARS-Q score were investigated using Spearman rank correlation (r s ). Discriminant validity for the two questionnaires was assessed, and the questionnaires were compared with the European Quality of Life Instrument. RESULTS Major LARS was identified in 62% of patients. The median MSK-BFI scores for no LARS, minor LARS and major LARS were 76.5, 70 and 57, respectively. We found a strong association between MSK-BFI and LARS-Q (r s -0.79). The urgency/soilage subscale (r s -0.7) and the frequency subscale (rs -0.68) of MSK-BFI strongly correlated with LARS-Q. Low correlation was observed between the MSK-BFI diet subscale and LARS-Q (r s -0.39). On multivariate analysis, both questionnaires showed worse bowel function in patients with distal tumours. A low to moderate correlation with the European Quality of Life Instrument was observed for both questionnaires. CONCLUSIONS The MSK-BFI and LARS-Q showed good correlation and similar discriminant validity. As the LARS-Q is easier to complete, it may be considered the preferred tool to screen for bowel dysfunction.
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Affiliation(s)
| | - Hossam Elfeki
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - Katrine J. Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Emmanouil P. Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Søren Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
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Yoshino T, Yamanaka T, Oki E, Kotaka M, Manaka D, Eto T, Hasegawa J, Takagane A, Nakamura M, Kato T, Munemoto Y, Takeuchi S, Bando H, Taniguchi H, Gamoh M, Shiozawa M, Mizushima T, Saji S, Maehara Y, Ohtsu A, Mori M. Efficacy and Long-term Peripheral Sensory Neuropathy of 3 vs 6 Months of Oxaliplatin-Based Adjuvant Chemotherapy for Colon Cancer: The ACHIEVE Phase 3 Randomized Clinical Trial. JAMA Oncol 2021; 5:1574-1581. [PMID: 31513248 PMCID: PMC6743062 DOI: 10.1001/jamaoncol.2019.2572] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Question Can a shortened course of adjuvant oxaliplatin-based chemotherapy reduce peripheral sensory neuropathy (PSN) without compromising efficacy in patients with stage III colon cancer? Findings In this phase 3 randomized clinical trial of 1313 patients, 3 months of adjuvant therapy significantly reduced the rate of any grade of PSN at 3 years, compared with 6 months of treatment. The incidence of any grade of PSN lasting for 3 years was significantly lower for the chemotherapy drug capecitabine plus oxaliplatin (CAPOX) than for the drug modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6); these treatment outcomes were consistent with those of the International Duration Evaluation of Adjuvant Chemotherapy (IDEA) Collaboration. Meaning A 3-month chemotherapy regimen of CAPOX may be the most appropriate treatment option for colon cancer, particularly in low-risk patients. Importance Oxaliplatin-based chemotherapy is associated with debilitating peripheral sensory neuropathy (PSN) for patients with stage III colon cancer. Objective To assess disease-free survival (DFS) and long-lasting PSN in patients treated with 3 vs 6 months of adjuvant oxaliplatin-based chemotherapy. Design, Setting, and Participants An open-label, multicenter, phase 3 randomized clinical trial of 1313 Asian patients with stage III colon cancer was conducted investigating the noninferiority of 3 vs 6 months of adjuvant oxaliplatin-based chemotherapy. From August 1, 2012, to June 30, 2014, participants were randomized to the 2 treatment groups. Data were analyzed from July 2017 to June 2018. Interventions Patients were randomized to receive 3 or 6 months of adjuvant chemotherapy. The choice of chemotherapy regimen, with the drugs modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) or capecitabine plus oxaliplatin (CAPOX), was at the discretion of the treating physician. Main Outcomes and Measures The primary outcome was DFS. Secondary end points included the evaluation of PSN for up to 3 years and overall survival. Results Of the 1313 patients (651 were women and mean age was 66 [range, 28-85] years) enrolled and randomized, 22 were not treated because 10 were unable to begin treatment within 2 weeks of enrollment, 7 withdrew their consent, and 5 were not treated for various other reasons. Of 1291 patients treated (650 in the 3-month arm and 641 in the 6-month arm), 969 (75%) received the chemotherapy drug CAPOX. The hazard ratio (HR) for DFS of the 3-month arm compared with the 6-month arm was 0.95 (95% CI, 0.76-1.20). Hazard ratios were 1.07 (95% CI, 0.71-1.60) and 0.90 (95% CI, 0.68-1.20) for the drugs mFOLFOX6 and CAPOX, and 0.81 (95% CI, 0.53-1.24) and 1.07 (95% CI, 0.81-1.40) for patients with low-risk disease (TNM classification stages T1-3 and N1) and high-risk disease (stages T4 or N2), respectively. The rates of any grade of PSN lasting for 3 years in the 3-month vs 6-month treatment arms were 9.7% vs 24.3% (P < .001). Incidence of PSN lasting for 3 years was significantly lower for patients treated with CAPOX than for patients treated with mFOLFOX6 in both the 3-month (7.9% vs 15.7%; P = .04) and 6-month arms (21.0% vs 34.1%; P = .02). Conclusions and Relevance The incidence of long-lasting PSN was significantly lower for 3 months than for 6 months of therapy, and significantly lower for treatment with the drug CAPOX than with mFOLFOX6. Since the shortened therapy duration did not compromise outcomes, a 3-month course of CAPOX may be the most appropriate treatment option, particularly for patients with low-risk disease. Trial Registration UMIN Clinical Trials Registry: UMIN000008543
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Affiliation(s)
| | | | - Eiji Oki
- Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | | | | | - Tetsuya Eto
- Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | | | | | | | | | | | | | | | | | | | | | | | - Shigetoyo Saji
- Japanese Foundation for Multidisciplinary Treatment of Cancer, Tokyo, Japan
| | - Yoshihiko Maehara
- Japanese Foundation for Multidisciplinary Treatment of Cancer, Tokyo, Japan
| | | | - Masaki Mori
- Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Naidoo M, Gibbs P, Tie J. ctDNA and Adjuvant Therapy for Colorectal Cancer: Time to Re-Invent Our Treatment Paradigm. Cancers (Basel) 2021; 13:346. [PMID: 33477814 PMCID: PMC7832902 DOI: 10.3390/cancers13020346] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 02/07/2023] Open
Abstract
Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. While there have been significant developments in the treatments for patients with metastatic CRC in recent years, improving outcomes in the adjuvant setting has been more challenging. Recent technological advances in circulating tumour DNA (ctDNA) assay with the ability to detect minimal residual disease (MRD) after curative intent surgery will fundamentally change how we assess recurrence risk and conduct adjuvant trials. Studies in non-metastatic CRC have now demonstrated the prognostic impact of ctDNA analysis after curative intent surgery over and above current standard of care clinicopathological criteria. This ability of ctDNA analysis to stratify patients into low- and very-high-risk groups provides a window of opportunity to personalise adjuvant treatment where escalation/de-escalation of adjuvant systemic therapy could potentially increase cure rates and also reduce treatment-related physical and financial toxicity. Emerging data suggest that conversion of ctDNA from detectable to undetectable after adjuvant chemotherapy may reflect treatment efficacy. This real-time assessment of treatment benefit could be used as a surrogate endpoint for adjuvant novel drug development. Several ctDNA-based randomized adjuvant trials are ongoing internationally to confirm the clinical utility of ctDNA in colorectal cancer.
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Affiliation(s)
- Mahendra Naidoo
- Peter MacCallum Cancer Centre, Department of Medical Oncology, Melbourne, VIC 3000, Australia;
| | - Peter Gibbs
- Division of Personalised Oncology, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC 3052, Australia;
- Western Health, Department of Medical Oncology, Melbourne, VIC 3021, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Jeanne Tie
- Peter MacCallum Cancer Centre, Department of Medical Oncology, Melbourne, VIC 3000, Australia;
- Division of Personalised Oncology, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC 3052, Australia;
- Western Health, Department of Medical Oncology, Melbourne, VIC 3021, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC 3010, Australia
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83
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Pan DC, Krishnan V, Salinas AK, Kim J, Sun T, Ravid S, Peng K, Wu D, Nurunnabi M, Nelson JA, Niziolek Z, Guo J, Mitragotri S. Hyaluronic acid-doxorubicin nanoparticles for targeted treatment of colorectal cancer. Bioeng Transl Med 2021; 6:e10166. [PMID: 33532580 PMCID: PMC7823125 DOI: 10.1002/btm2.10166] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/04/2020] [Accepted: 05/09/2020] [Indexed: 12/13/2022] Open
Abstract
Colorectal cancer, common in both men and women, occurs when tumors form in the linings of the colon. Common treatments of colorectal cancer include surgery, chemotherapy, and radiation therapy; however, many colorectal cancer treatments often damage healthy tissues and cells, inducing severe side effects. Conventional chemotherapeutic agents such as doxorubicin (Dox) can be potentially used for the treatment of colorectal cancer; however, they suffer from limited targeting and lack of selectivity. Here, we report that doxorubicin complexed to hyaluronic acid (HA) (HA-Dox) exhibits an unusual behavior of high accumulation in the intestines for at least 24 hr when injected intravenously. Intravenous administrations of HA-Dox effectively preserved the mucosal epithelial intestinal integrity in a chemical induced colon cancer model in mice. Moreover, treatment with HA-Dox decreased the expression of intestinal apoptotic and inflammatory markers. The results suggest that HA-Dox could effectively inhibit the development of colorectal cancer in a safe manner, which potentially be used a promising therapeutic option.
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Affiliation(s)
- Daniel C. Pan
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Vinu Krishnan
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Alyssa K. Salinas
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Jayoung Kim
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Tao Sun
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Sagi Ravid
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Kevin Peng
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Debra Wu
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Md Nurunnabi
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Jeffery A. Nelson
- Faculty of Arts and Sciences, Division of SciencesHarvard UniversityCambridgeMassachusettsUSA
| | - Zachary Niziolek
- Faculty of Arts and Sciences, Division of SciencesHarvard UniversityCambridgeMassachusettsUSA
| | - Junling Guo
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
| | - Samir Mitragotri
- School of Engineering & Applied Sciences, Harvard UniversityWyss Institute of Biologically Inspired EngineeringCambridgeMassachusettsUSA
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84
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Nakayama G, Takano N, Taniguchi H, Ishigure K, Yokoyama H, Teramoto H, Hashimoto R, Sakai M, Ishiyama A, Kinoshita T, Hayashi N, Nakamura M, Hattori N, Sato Y, Umeda S, Uehara K, Aiba T, Sonohara F, Hayashi M, Kanda M, Kobayashi D, Tanaka C, Yamada S, Koike M, Fujiwara M, Murotani K, Ando M, Ando Y, Muro K, Kodera Y. Randomised phase II trial of capecitabine plus oxaliplatin with continuous versus intermittent use of oxaliplatin as adjuvant chemotherapy for stage II/III colon cancer (CCOG-1302 study). Eur J Cancer 2020; 144:61-71. [PMID: 33340853 DOI: 10.1016/j.ejca.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/18/2020] [Accepted: 11/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peripheral sensory neuropathy (PSN) caused by oxaliplatin-based adjuvant chemotherapy adversely affects patients' quality of life. This study evaluated the efficacy and safety of capecitabine plus oxaliplatin (CAPOX) with intermittent oxaliplatin use compared with the standard CAPOX in adjuvant therapy for colon cancer. PATIENTS AND METHODS Patients with curative resection for stage II/III colon cancer were randomly assigned to receive either CAPOX with continuous oxaliplatin (eight cycles of CAPOX) or CAPOX with intermittent oxaliplatin (two cycles of CAPOX, four cycles of capecitabine and two cycles of CAPOX). The primary end-point was the 1-year PSN rate, and the key secondary end-point was disease-free survival (DFS). RESULTS Two hundred patients were enrolled in the intent-to-treat population. After 4 patients withdrew, 196 patients were included in the safety analysis. The overall treatment completion rate was 65% for continuous vs. 89% for intermittent treatment (p < 0.001). The 1-year PSN rate was 60% (95% confidence interval [CI], 50%-70%) for continuous and 16% (95% CI, 10%-25%) for intermittent treatment (p < 0.001). After a median follow-up of 52 months, 40 events (20%) were observed. The 3-year DFS was 81% (95% CI, 71%-87%) for continuous and 84% (95% CI, 75%-90%) for intermittent treatment (hazard ratio [HR], 0.87; 95% CI, 0.47-1.63). Among patients with high-risk disease (T4 or N2-3), the 3-year DFS was 57% for continuous vs. 74% for intermittent treatment (HR, 0.66). CONCLUSION CAPOX with planned intermittent oxaliplatin may be feasible as an adjuvant therapy for colon cancer and substantially reduce the duration of long-lasting PSN. TRIAL IDENTIFIER UMIN000012535.
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Affiliation(s)
- Goro Nakayama
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan.
| | - Nao Takano
- Department of Surgery, Tokai Central Hospital, Kagamihara, Japan
| | - Hiroya Taniguchi
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | | | | | - Hitoshi Teramoto
- Department of Surgery, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Ryoji Hashimoto
- Department of Surgery, Nakatsugawa Municipal Hospital, Nakatsugawa, Japan
| | - Mitsuru Sakai
- Department of Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | | | - Takashi Kinoshita
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Naomi Hayashi
- Department of Medical Oncology, Cancer Institute Hospital, Tokyo, Japan
| | | | - Norifumi Hattori
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Yusuke Sato
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Shinichi Umeda
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Kei Uehara
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Toshisada Aiba
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Fuminori Sonohara
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | | | - Chie Tanaka
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Michitaka Fujiwara
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
| | | | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Kei Muro
- Department of Clinical Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Hospital, Nagoya, Japan
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85
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Piccart MJ, Hilbers FS, Bliss JM, Caballero C, Frank ES, Renault P, Naït Kaoudjt R, Schumacher E, Spears PA, Regan MM, Gelber RD, Davidson NE, Norton L, Winer EP. Road Map to Safe and Well-Designed De-escalation Trials of Systemic Adjuvant Therapy for Solid Tumors. J Clin Oncol 2020; 38:4120-4129. [PMID: 33052755 DOI: 10.1200/jco.20.01382] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 02/11/2024] Open
Abstract
An important challenge in the field of cancer is finding the balance between delivering effective treatments and avoiding adverse effects and financial toxicity caused by innovative, yet expensive, drugs. To address this, several treatment de-escalation trials have been conducted, but only a few of these have provided clear answers. A few trials had poor accrual or had design flaws that led to conflicting results. Members of the Breast International Group (BIG) and North American Breast Cancer Group (NABCG) believe the way forward is to understand the lessons from these trials and listen more carefully to what truly matters to our patients. We reviewed several adjuvant trials of different cancer types and developed a road map for improving the design and implementation of future de-escalation trials. The road map incorporates patients' insights obtained through focused group discussions across the BIG-NABCG networks. Considerations for the development of de-escalation trials for systemic adjuvant treatment, including noninferiority trial design, choice of end points, and prioritization of a patient's perspectives, are presented in this consensus article.
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Affiliation(s)
| | | | - Judith M Bliss
- The Institute of Cancer Research, Clinical Trials & Statistics Unit, London, United Kingdom
| | | | - Elizabeth S Frank
- Dana Farber Cancer Institute, Department of Medical Oncology, Boston, MA
| | | | | | | | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Meredith M Regan
- International Breast Cancer Study Group Statistical Center, Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Richard D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Harvard TH Chan School of Public Health, Boston, MA
- Frontier Science and Technology Research Foundation, Boston, MA
| | - Nancy E Davidson
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, Department of Medicine, New York, NY
| | - Eric P Winer
- Dana Farber Cancer Institute, Department of Medical Oncology, Boston, MA
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86
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Alonso S, Saltz L. The Landmark Series: Chemotherapy for Non-Metastatic Colon Cancer. Ann Surg Oncol 2020; 28:995-1001. [PMID: 33230749 DOI: 10.1245/s10434-020-09375-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023]
Abstract
Micrometastatic disease that is present at the time of surgery is responsible for the overwhelming majority of deaths in patients with what is otherwise perceived to be local and regional colon cancer. The goal of perioperative therapy is to eliminate microscopic residual disease that would otherwise be left behind following surgery. A secondary goal specific to neoadjuvant (preoperative) therapy is to downstage tumors deemed potentially not amenable to an R0 resection on the basis of a suspected T4b primary (locally invading into a surrounding structure). In this landmark series paper, we review the current standard for perioperative therapy in patients with colon cancer.
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Affiliation(s)
- Salvador Alonso
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Leonard Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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87
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Yamazaki K, Yamanaka T, Shiozawa M, Manaka D, Kotaka M, Gamoh M, Shiomi A, Makiyama A, Munemoto Y, Rikiyama T, Fukunaga M, Ueki T, Shitara K, Shinkai H, Tanida N, Oki E, Sunami E, Ohtsu A, Maehara Y, Yoshino T. Oxaliplatin-based adjuvant chemotherapy duration (3 versus 6 months) for high-risk stage II colon cancer: the randomized phase III ACHIEVE-2 trial. Ann Oncol 2020; 32:77-84. [PMID: 33121997 DOI: 10.1016/j.annonc.2020.10.480] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/24/2020] [Accepted: 10/16/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Oxaliplatin-based adjuvant chemotherapy may be associated with debilitating peripheral sensory neuropathy (PSN) in patients with high-risk stage II colon cancer. This open-label, multicenter, randomized phase III trial was conducted as a prospective pooled analysis to investigate the non-inferiority of 3 versus 6 months of adjuvant oxaliplatin-based chemotherapy. PATIENTS AND METHODS From 12 February 2014 to 31 January 2017, 525 Asian patients with high-risk stage II colon cancer were randomly assigned to 3- and 6-month treatment arms. The treatment consisted of either modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) or capecitabine combined with oxaliplatin (CAPOX). The primary end point was disease-free survival (DFS). The secondary end points were treatment compliance and safety. RESULTS Of the 525 randomized patients, 11 were not treated. Among the 514 participating patients (255 in the 3-month arm; 259 in the 6-month arm), 432 (84%) received CAPOX, and 184 (36%) presented with T4 as a high-risk factor for recurrence. The 3-year DFS rate was 88.2% in the 3-month arm and 87.9% in the 6-month arm [hazard ratio (HR), 1.12; 95% confidence interval (CI), 0.67-1.87]. With CAPOX, the 3-year DFS rate was 88.2% in the 3-month arm and 88.4% in the 6-month arm (HR, 1.13; 95% CI, 0.65-1.96). The discontinuation rate in the 3- and 6-month arms was 10% and 31% for mFOLFOX6 (P = 0.0193), and 15% and 35% for CAPOX (P < 0.0001), respectively. The incidence of grade ≥2 PSN was significantly lower in the 3-month arm than in the 6-month arm (16% and 43%, respectively, P < 0.0001). CONCLUSIONS Three months of combination therapy presented significantly less grade ≥2 PSN than the respective 6-month regimen. The shortened therapy duration did not affect the 3-year DFS rate, suggesting that a 3-month course of CAPOX can be an effective treatment option. CLINICAL TRIAL INFORMATION UMIN Clinical Trials Registry, UMIN000013036 and Japan Registry of Clinical Trials, jRCTs031180128.
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Affiliation(s)
- K Yamazaki
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - T Yamanaka
- Department of Biostatistics, Yokohama City University School of Medicine, Kanagawa, Japan
| | - M Shiozawa
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Kanagawa, Japan
| | - D Manaka
- Department of Surgery, Gastrointestinal Center, Kyoto Katsura Hospital, Kyoto, Japan
| | - M Kotaka
- Department of Gastrointestinal Cancer Center, Sano Hospital, Hyogo, Japan
| | - M Gamoh
- Department of Medical Oncology, Osaki Citizen Hospital, Miyagi, Japan
| | - A Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - A Makiyama
- Department of Hematology/Oncology, Japan Community Healthcare Organization Kyushu Hospital, Fukuoka, Japan
| | - Y Munemoto
- Department of Surgery, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - T Rikiyama
- Department of Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - M Fukunaga
- Department of Surgery, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - T Ueki
- Department of Surgery, Hamanomachi Hospital, Fukuoka, Japan
| | - K Shitara
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - H Shinkai
- Department of Surgery, Chigasaki Municipal Hospital, Kanagawa, Japan
| | - N Tanida
- Department of Surgery, Japanese Red Cross Kochi Hospital, Kochi, Japan
| | - E Oki
- Department of Surgery and Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - E Sunami
- Department of Tumor Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - A Ohtsu
- National Cancer Center Hospital East, Chiba, Japan
| | - Y Maehara
- Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - T Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan.
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88
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Koizumi M, Yamada T, Shinji S, Matsuda A, Yokoyama Y, Takahashi G, Iwai T, Takeda K, Hara K, Yoshida H. Even a partial pathological response is associated with lower relapse rates in patients with operable rectal cancer undergoing neoadjuvant chemotherapy. J Surg Oncol 2020; 123:286-292. [PMID: 33022767 DOI: 10.1002/jso.26245] [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: 04/30/2020] [Revised: 08/26/2020] [Accepted: 09/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy to treat locally advanced rectal cancer is an effective therapeutic strategy for the prevention of local recurrence and distant organ metastasis after surgery. OBJECTIVES To assess the prognostic significance of histopathological tumor response in rectal cancer patients undergoing neoadjuvant chemotherapy. METHODS This study included patients with operable rectal cancer who received neoadjuvant chemotherapy using the FOLFOX regimen (5-fluorouracil, l-leucovorin, and oxaliplatin) in a hospital between February 2012 and November 2017. The main outcome measure was disease-free survival with respect to histopathological response to neoadjuvant chemotherapy in resected specimens. RESULTS The median follow-up was 32 months. Of 48 patients treated with neoadjuvant FOLFOX, 24 (50%) were classified as responders, which included two patients with pathological complete response and 22 patients with partial response. The remaining 24 patients (50%) were classified as nonresponders. Responders had a significantly better 3-year disease-free survival than nonresponders (86% vs. 62%, p = .02). CONCLUSIONS Patients whose surgical specimens show a pathological complete response or partial response have good oncologic outcomes.
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Affiliation(s)
- Michihiro Koizumi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Goro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takuma Iwai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kohki Takeda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Keisuke Hara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Schmoll HJ, Stein A, Van Cutsem E, Price T, Hofheinz RD, Nordlinger B, Daisne JF, Janssens J, Brenner B, Reinel H, Hollerbach S, Caca K, Fauth F, Hannig CV, Zalcberg J, Tebbutt N, Mauer ME, Marreaud S, Lutz MP, Haustermans K. Pre- and Postoperative Capecitabine Without or With Oxaliplatin in Locally Advanced Rectal Cancer: PETACC 6 Trial by EORTC GITCG and ROG, AIO, AGITG, BGDO, and FFCD. J Clin Oncol 2020; 39:17-29. [PMID: 33001764 DOI: 10.1200/jco.20.01740] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The PETACC 6 trial investigates whether the addition of oxaliplatin to preoperative capecitabine-based chemoradiation and postoperative capecitabine improves disease-free survival (DFS) in locally advanced rectal cancer. METHODS Between November 2008 and September 2011, patients with rectal adenocarcinoma within 12 cm from the anal verge, T3/4 and/or node positive, were randomly assigned to 5 weeks preoperative capecitabine-based chemoradiation (45-50.4 Gy) followed by six cycles of adjuvant capecitabine, both without (control arm, 1) or with (experimental arm, 2) oxaliplatin. The primary end point was improvement of 3-year DFS by oxaliplatin from 65% to 72% (hazard ratio [HR], 0.763). RESULTS A total of 1,094 patients were randomly assigned (intention to treat), and 1,068 eligible patients started their allocated treatment (arm 1, 543; arm 2, 525), with completion of protocol treatment in 68% (arm 1) v 54% (arm 2). A higher rate of grade 3/4 adverse events was reported in the experimental arm (14.4% v 37.3% and 23.4% v 46.6% for neoadjuvant and adjuvant treatment, respectively). At a median follow-up of 68 months (interquartile range, 58-74 months), 157 and 156 DFS events were observed in arms 1 and 2, respectively (adjusted HR, 1.02; 95% CI, 0.82 to 1.28; P = .835). Three-year DFS rate was not different, with 76.5% (95% CI, 72.7% to 79.9%) in arm 1, which is higher than anticipated, and 75.8% (95% CI, 71.9% to 79.3%) in arm 2. The 7-year DFS and overall survival (OS) rates were not different as well, with DFS of 66.1% v 65.5% (HR, 1.02) and OS of 73.5% v 73.7% (HR, 1.19) in arms 1 and 2, respectively. Subgroup analyses revealed heterogeneity in treatment effect according to German versus non-German site location, without detectable confounding factors in multivariable analysis. CONCLUSION The addition of oxaliplatin to preoperative capecitabine-based chemoradiation and postoperative adjuvant chemotherapy impairs tolerability and feasibility and does not improve efficacy.
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Affiliation(s)
| | - Alexander Stein
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Timothy Price
- Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | | | - Bernard Nordlinger
- CHU Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France
| | - Jean-François Daisne
- Université Catholique de Louvain, CHU-UCL-Namur (Sainte-Elisabeth), Namur, Belgium
| | | | - Baruch Brenner
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hans Reinel
- Leopoldina-Krankenhaus der Stadt Schweinfurt gGmbH, Schweinfurt, Germany
| | | | - Karel Caca
- Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Carla V Hannig
- Gemeinschaftspraxis Haematologie und Onkologie, Bottrop, Germany
| | - John Zalcberg
- Alfred Health and School of Public Health, Monash University, Melbourne, Victoria, Australia
| | | | - Murielle E Mauer
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Sandrine Marreaud
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
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Argilés G, Tabernero J, Labianca R, Hochhauser D, Salazar R, Iveson T, Laurent-Puig P, Quirke P, Yoshino T, Taieb J, Martinelli E, Arnold D. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2020; 31:1291-1305. [PMID: 32702383 DOI: 10.1016/j.annonc.2020.06.022] [Citation(s) in RCA: 592] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- G Argilés
- Department of Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), Universitat Autònoma de Barcelona, Spain
| | - J Tabernero
- Department of Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), UVic-UCC, IOB-Quiron, Barcelona, Spain
| | - R Labianca
- Department Oncology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - R Salazar
- Department of Medical Oncology, Catalan Institute of Oncology, Oncobell Program (IDIBELL), CIBERONC, Hospitalet de Llobregat, Barcelona, Spain
| | - T Iveson
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - P Laurent-Puig
- Assitance Publique-Hôpitaux de Paris AP-HP Paris Centre, Paris, France; Paris Cancer Institute CARPEM, Centre de Recherche des Cordeliers, Paris Sorbonne University, Paris University, Paris, France; INSERM, CNRS, Paris, France
| | - P Quirke
- Pathology and Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - T Yoshino
- National Cancer Centre Hospital East, Kashiwa, Japan
| | - J Taieb
- Assitance Publique-Hôpitaux de Paris AP-HP Paris Centre, Paris, France; Paris Cancer Institute CARPEM, Centre de Recherche des Cordeliers, Paris Sorbonne University, Paris University, Paris, France; INSERM, CNRS, Paris, France; Department of Gastroenterology and GI Oncology, Georges Pompidou European Hospital, Paris Descartes University, Paris, France
| | - E Martinelli
- Università degli Studi della Campania Luigi Vanvitelli, Department of Precision Medicine, Naples, Italy
| | - D Arnold
- Asklepios Tumorzentrum Hamburg, AK Altona, Hamburg, Germany
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91
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A placebo-controlled, double-blind, randomized study of recombinant thrombomodulin (ART-123) to prevent oxaliplatin-induced peripheral neuropathy. Cancer Chemother Pharmacol 2020; 86:607-618. [PMID: 32965539 PMCID: PMC7561567 DOI: 10.1007/s00280-020-04135-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/04/2020] [Indexed: 01/15/2023]
Abstract
Purpose The purpose of this clinical study was to be the first to explore whether ART-123, a recombinant human soluble thrombomodulin, prevents oxaliplatin-induced peripheral neuropathy (OIPN). Methods This randomized, phase IIa trial enrolled stage II/III colon cancer patients who received adjuvant mFOLFOX6 chemotherapy. Participants were randomly allocated to 3 arms in a double-blind manner: placebo (placebo: days 1–3); 1-day ART (ART-123: day 1, placebo: days 2–3); and 3-day ART (ART-123: days 1–3). ART-123 (380 U/kg/day) or placebo was infused intravenously before each 2-week cycle of mFOLFOX6. OIPN was assessed with the Functional Assessment of Cancer Therapy/Gynecological Oncology Group-Neurotoxicity-12 (FACT/GOG-Ntx-12) score by participants and the NCI Common Terminology Criteria for Adverse Events (NCI-CTCAE) by investigators. Results Seventy-nine participants (placebo n = 28, 1-day ART n = 27, 3-day ART n = 24) received study drugs. The least-squares mean FACT/GOG-Ntx-12 scores at cycle 12 from the mixed effect model for repeated measures were 28.9 with placebo, 36.3 with 1-day ART (vs. placebo: 7.3 [95% CI 1.9 to12.8, p = 0.009]), and 32.3 with 3-day ART (vs. placebo: 3.4 [95% CI −.1 to 9.0, p = 0.222]). The cumulative incidence of NCI-CTCAE grade ≥ 2 sensory neuropathy at cycle 12 was 64.3% with placebo, 40.7% with 1-day ART (vs. placebo: −23.5 [95% CI −48.4 to 4.0], p = 0.108), and 45.8% with 3-day ART (vs. placebo: −18.5 [95% CI −44.2 to 9.4], p = 0.264). Common adverse events were consistent with those reported with mFOLFOX6; no severe bleeding adverse events occurred. Conclusion ART-123 showed a potential preventive effect against OIPN with good tolerability. A larger study with 1-day ART is warranted. NCT02792842, registration date: June 8, 2016 Electronic supplementary material The online version of this article (10.1007/s00280-020-04135-8) contains supplementary material, which is available to authorized users.
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92
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Jongeneel G, Greuter MJE, van Erning FN, Koopman M, Vink GR, Punt CJA, Coupé VMH. Model-based evaluation of the cost effectiveness of 3 versus 6 months' adjuvant chemotherapy in high-risk stage II colon cancer patients. Therap Adv Gastroenterol 2020; 13:1756284820954114. [PMID: 32994804 PMCID: PMC7502861 DOI: 10.1177/1756284820954114] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/11/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Our aim was to evaluate the cost effectiveness of 3 months' adjuvant chemotherapy versus 6 months in high-risk (T4 stage + microsatellite stable) stage II colon cancer (CC) patients. METHODS Using the validated PATTERN Markov cohort model, which simulates the disease progression of stage II CC patients from diagnosis to death, we first evaluated a reference strategy in which high-risk patients were treated with chemotherapy for 6 months. In the second strategy, treatment duration was shortened to 3 months. Both strategies were evaluated for CAPOX (capecitabine plus oxaliplatin) and FOLFOX (fluorouracil, leucovorin and oxaliplatin). Based on trial data, we assumed that shortened treatment duration compared with a 6-month regimen was equally effective for CAPOX and less effective for FOLFOX. Adverse events were highest in the 6-month strategy. Analyses were conducted from a societal perspective using a lifelong time horizon. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Incremental net monetary benefit (iNMB) was calculated using a willingness-to-pay value of €50,000/QALY. RESULTS For CAPOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €41,257 pp. The 3-month strategy resulted in an equal number of CC deaths, but higher QALYs (6.80 pp) and lower costs (€37,645 pp), leading to a iNMB of €8454 per person for 3 months versus 6 months. For FOLFOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €47,135 pp. The 3-month strategy resulted in more CC deaths (393), lower QALYs (6.19 pp) and lower costs (€44,389 pp). An iNMB of -€23,189 was found for 3 months versus 6 months. CONCLUSION Our findings indicate that 3 months' adjuvant chemotherapy should be considered as standard of care in high-risk stage II CC patients for CAPOX, but not for FOLFOX.
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Affiliation(s)
| | | | - Felice N. van Erning
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Miriam Koopman
- University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geraldine R. Vink
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands,University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis J. A. Punt
- Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | - Veerle M. H. Coupé
- Department of Epidemiology and Biostatistics, VU University, Amsterdam, The Netherlands
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93
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Collienne M, Arnold D. The Optimal Duration of Adjuvant Chemotherapy in Colon Cancer. Cancers (Basel) 2020; 12:E2509. [PMID: 32899406 PMCID: PMC7563599 DOI: 10.3390/cancers12092509] [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: 08/07/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022] Open
Abstract
Adjuvant chemotherapy for colon cancer (UICC stage II and III) has been under investigation over the last 30 years, regarding treatment duration and regimens. In this review, choice of regimen, its duration, possible limitations and future perspectives are discussed. Monotherapy with 5-fluorouracil was followed by addition of oxaliplatin, resulting in improved 3-yr disease free survival (DFS) and overall survival (OS) rates, but also increased peripheral sensory neurotoxicity (PSN). The International Duration Evaluation of Adjuvant therapy (IDEA) collaboration demonstrated less toxicity, especially PSN, when shortening treatment duration to 3 months. However, formally, the anticipated non-inferiority of 3 months with fluoropyrimidine (FP)/oxaliplatin over 6 months (at 3-yr DFS) was not met for all patients groups, although subgroup analyses showed non-inferiority with capecitabine/oxaliplatin (CAPOX) rather than with FOLFOX, and also in relation to the prognostic information (e.g., clinical low-risk group, pT1-3 N0). In addition, first data of newer parameters like Immunoscore® and ctDNA show promising results as stratification parameters. Further investigations to better define clinical risk groups and prognostic factors are mandatory. Besides this, individual decision-making of treatment intensity (FP or FP/oxaliplatin) and duration should always consider patient characteristics and preferences, also given the absolute relatively small differences and their clinical relevance.
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Affiliation(s)
| | - Dirk Arnold
- Department of Oncology and Hematology, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, 22763 Hamburg, Germany;
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94
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Knapen DG, Cherny NI, Zygoura P, Latino NJ, Douillard JY, Dafni U, de Vries EGE, de Groot DJ. Lessons learnt from scoring adjuvant colon cancer trials and meta-analyses using the ESMO-Magnitude of Clinical Benefit Scale V.1.1. ESMO Open 2020; 5:e000681. [PMID: 32893188 PMCID: PMC7476457 DOI: 10.1136/esmoopen-2020-000681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/13/2022] Open
Abstract
Click here to listen to the Podcast BACKGROUND: Form 1 of the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) serves to grade therapies with curative intent. Hitherto only few trials with curative intent have been field tested using form 1. We aimed to evaluate the applicability of the scale and to assess the reasonableness of the generated scores in early colon cancer, in order to identify shortcomings that may be rectified in future amendments. METHODS Adjuvant studies were identified in PubMed, Food and Drug Administration and European Medicines Agency registration sites, as well as ESMO and National Comprehensive Cancer Network guidelines. Studies meeting inclusion criteria were graded using form 1 of the ESMO-MCBS V.1.1 and field tested by ESMO Colorectal Cancer Faculty. Shortcomings of the scale were identified and evaluated. RESULTS Eighteen of 57 trials and 7 out of 14 meta-analyses identified met criteria for ESMO-MCBS V.1.1 grading. In stage III colon cancer, randomised clinical trials and meta-analyses of modulated 5-fluorouracil (5-FU) based chemotherapy versus surgery scored ESMO-MCBS grade A and randomised controlled trials (RCTs) and meta-analyses comprising oxaliplatin added to this 5-FU backbone showed a more modest additional overall survival benefit (grade A and B). For stage II colon cancer, the findings are less consistent. The fluoropyrimidine trials in stage II were graded 'no evaluable benefit' but the most recent meta-analysis demonstrated a 5.4% survival advantage after 8 years follow-up (grade A). RCTs and a meta-analysis adding oxaliplatin demonstrated no added benefit. Exploratory toxicity evaluation and annotation was problematic given inconsistent toxicity reporting and limited results of late toxicity. Field testers (n=37) reviewed the scores, 25 confirmed their reasonableness, 12 found them mostly reasonable. Moreover, they identified the inability of crediting improved convenience in non-inferiority trials as a shortcoming. CONCLUSION Form 1 of the ESMO-MCBS V.1.1 provided very reasonable grading for adjuvant colon cancer studies.
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Affiliation(s)
- Daan Geert Knapen
- Medical Oncology, University Medical Centre Groningen, Groningen, Groningen, Netherlands
| | - Nathan I Cherny
- Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Jerusalem, Israel
| | - Panagiota Zygoura
- Statistics, Frontier Science Foundation-Hellas, Statistics, Athens, Zografou, Greece
| | - Nicola Jane Latino
- ESMO-MCBS Working Group, European Society for Medical Oncology, Viganello, Switzerland
| | - Jean-Yves Douillard
- ESMO-MCBS Working Group, European Society for Medical Oncology, Viganello, Switzerland
| | - Urania Dafni
- Nursing, National and Kapodistrian University of Athens, Goudi-Athens, Greece; University of Athens, Athens, Greece
| | - Elisabeth G E de Vries
- Medical Oncology, University Medical Centre Groningen, Groningen, Groningen, Netherlands
| | - Derk Jan de Groot
- Medical Oncology, University Medical Centre Groningen, Groningen, Groningen, Netherlands.
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Advanced Lung Cancer Inflammation Index Predicts Outcomes of Patients With Colorectal Cancer After Surgical Resection. Dis Colon Rectum 2020; 63:1242-1250. [PMID: 33216495 DOI: 10.1097/dcr.0000000000001658] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The advanced lung cancer inflammation index is considered a useful prognostic biomarker of clinical outcomes in patients with malignancies. However, the prognostic value of the advanced lung cancer index in patients with colorectal cancer who underwent surgical resection remains unclear. OBJECTIVE In this study, we evaluated the prognostic value of the advanced lung cancer index in patients with colorectal cancer. DESIGN Prospectively obtained data of patients with colorectal cancer were retrospectively evaluated to clarify the clinical relevance of the advanced lung cancer index. SETTINGS We conducted this study at a single expert center. PATIENTS We enrolled 298 patients with colorectal cancer who underwent surgical resection in this retrospective study. MAIN OUTCOME MEASURES The primary outcome was the clinical relevance of the advanced lung cancer index in patients with rectal cancer. RESULTS Low status of advanced lung cancer index was significantly correlated with undifferentiated histology (p = 0.004), T stage progression (p < 0.001), R1/R2 resection for primary surgery (p = 0.004), and distant metastasis (p < 0.001). Multivariate analysis showed that low advanced lung cancer index status was an independent prognostic factor for both overall survival (HR = 3.21 (95% CI, 1.97-5.19); p < 0.001) and disease-free survival (HR = 2.13 (95% CI, 1.23-3.63); p = 0.008) in patients with colorectal cancer. Furthermore, the clinical burden of the advanced lung cancer index was consistent between sexes, and its prognostic value was verified in patients with clinically relevant stage III colorectal cancer. LIMITATIONS The present study had several limitations, including retrospective observation and a small sample size of Japanese patients from a single institution. CONCLUSIONS The advanced lung cancer index could be a useful prognostic indicator of clinical outcomes in patients who underwent surgical resection for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B267. EL ÍNDICE AVANZADO DE INFLAMACIÓN DEL CÁNCER DE PULMÓN, PREDICE LOS RESULTADOS DE LOS PACIENTES CON CÁNCER COLORRECTAL DESPUÉS DE LA RESECCIÓN QUIRÚRGICA: El índice avanzado de inflamación del cáncer de pulmón, es considerado como un útil biomarcador pronóstico, en los resultados clínicos de pacientes con neoplasias malignas. Sin embargo, aún no está claro el valor pronóstico del índice avanzado de cáncer de pulmón, en pacientes con cáncer colorrectal sometidos a resección quirúrgica.Evaluar el valor pronóstico del índice avanzado del cáncer de pulmón, en pacientes con cáncer colorrectal.Los datos obtenidos prospectivamente de pacientes con cáncer colorrectal, fueron evaluados retrospectivamente, para aclarar la relevancia clínica del índice avanzado del cáncer de pulmónEstudio realizado en un solo centro experto.Estudio retrospectivo, incluyendo 298 pacientes con cáncer colorrectal, sometidos a resección quirúrgica.El resultado primario fue la relevancia clínica del índice avanzado de cáncer de pulmón, en pacientes con cáncer rectal.Un índice avanzado de cáncer de pulmón bajo, se correlacionó significativamente con la histología indiferenciada (p = 0.004), la progresión de la etapa T (p <0.001), la resección R1 / R2 para cirugía primaria (p = 0.004) y la metástasis a distancia (p <0.001). El análisis multivariante mostró que el índice avanzado de cáncer de pulmón bajo, era un factor pronóstico independiente, tanto para la supervivencia general (HR = 3.21 IC 95% 1.97-5.19 p <0.001) como para la supervivencia libre de enfermedad (HR = 2.13, IC 95% 1.23-3.63, p = 0,008), en pacientes con cáncer colorrectal. Además, la carga clínica del índice avanzado de cáncer de pulmón, fue consistente entre los sexos y su valor pronóstico se verificó clínicamente relevante, en pacientes con cáncer colorrectal en estadio III.El presente estudio tuvo varias limitaciones, incluyendo la observación retrospectiva y la pequeña muestra de pacientes japoneses, en una sola institución.El índice avanzado de cáncer de pulmón, podría ser un indicador pronóstico útil, en los resultados clínicos de pacientes sometidos a resección quirúrgica por cáncer colorrectal. Consulte Video Resumen http://links.lww.com/DCR/B267.
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Huang CW, Ma CJ, Su WC, Chen YT, Tsai HL, Yeh YS, Chang TK, Hsu WH, Yu FJ, Wang JY. Prognostic Value of EGFR Expression for Patients With Stage III Colorectal Cancer Receiving Fluoropyrimidine Metronomic Maintenance Therapy After Radical Resection and Adjuvant Oxaliplatin-Based Chemotherapy. Oncol Res 2020; 28:701-714. [PMID: 32859280 PMCID: PMC8420899 DOI: 10.3727/096504020x15986099915822] [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] [Indexed: 12/17/2022] Open
Abstract
This study evaluated the survival effects of metronomic maintenance therapy with oral fluoropyrimidine in patients with stage III colorectal cancer (CRC) according to epidermal growth factor receptor (EGFR) expression. We enrolled 197 patients with stage III CRC who had undergone radical resection and FOLFOX regimen adjuvant chemotherapy. The clinicopathological features and effects of metronomic maintenance therapy with oral capecitabine (daily dose of 850 mg/m2, twice daily, on days 1–14 every 3 weeks for 6 months) on survival according to treatment group and EGFR expression were analyzed. By conducting an in vitro cell line study and in vivo study through knockout of the EGFR gene, we analyzed the capacities of cell proliferation and migration. Relapse and survival were significantly more common in the FOLFOX group. Metronomic maintenance therapy was a significantly independent associated factor of relapse and survival as well as a prognostic factor of disease-free survival and overall survival. Significant intergroup differences in survival were only observed in patients with positive EGFR expression. Thus, our findings suggest EGFR expression is a prognostic factor in patients with stage III CRC receiving metronomic maintenance therapy. Analysis of EGFR expression in these patients helps identify potential candidates who may receive the optimal survival benefit from metronomic maintenance therapy.
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Affiliation(s)
- Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Cheng-Jen Ma
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Yi-Ting Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Yung-Sung Yeh
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Tsung-Kun Chang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Fang-Jung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical UniversityKaohsiungTaiwan
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Outcomes and Utilization of Adjuvant Chemotherapy for Stage II Colon Cancer in the Oxaliplatin Period: A SEER-Medicare Analysis. Am J Clin Oncol 2020; 43:428-434. [PMID: 32187027 DOI: 10.1097/coc.0000000000000684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Previous SEER (Surveillance, Epidemiology, and End Results)-Medicare analyses have shown no definitive survival benefit for adjuvant chemotherapy (AC) with fluoropyrimidines. Impact of oxaliplatin-containing regimens for elderly stage II patients in real-world setting is unknown. We explored the utilization and outcome of AC after the Food and Drug Administration (FDA) approval of oxaliplatin. PATIENTS AND METHODS Patients with stage II colon cancer (2004-2011) who underwent resection were selected for this analysis. Medicare claims data were used to ascertain the administration of AC within 120 days after surgery. The primary endpoint of the analysis was overall survival. We used the Cox proportional hazards model to estimate the effect of AC while adjusting for clinical and sociodemographic variables available in SEER. To adjust for referral pattern, a source of selection bias, we conducted an instrumental variable analysis using the surgeon of record and health service area. RESULTS A total of 16,468 patients were identified and 12.1% received AC. AC recipients were significantly younger, more likely to be male, nonwhite, married, and had lower comorbidity index. Their tumors had a more advanced stage, more likely to be left sided, and were less differentiated. The hazard ratio (HR) from the Cox model showed a statistically significant survival advantage for AC (HR=0.847, 95% confidence interval: 0.782-0.916). However, results from the instrumental variable analysis indicated that there was no definitive benefit of survival in AC recipients (HR=1.779, 95% confidence interval: 0.927-3.415). AC use decreased over time. CONCLUSIONS After controlling for referral patterns, administration of AC provided no definitive survival benefit. Future studies may elucidate the elderly population who may benefit from AC.
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98
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Skelton WP, Franke AJ, Iqbal A, George TJ. Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer. J Gastrointest Oncol 2020; 11:790-802. [PMID: 32953161 PMCID: PMC7475336 DOI: 10.21037/jgo-20-184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/20/2020] [Indexed: 12/18/2022] Open
Abstract
The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.
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Affiliation(s)
- William Paul Skelton
- Division of Medical Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Florida, USA
| | - Aaron J. Franke
- Division of Medical Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Florida, USA
| | - Atif Iqbal
- Section of Colorectal Surgery, Baylor College of Medicine, Houston, USA
| | - Thomas J. George
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, Florida, USA
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Acute Peripheral Motor Neuropathy Induced by Oxaliplatin-Correlated Hypokalaemia. Oncol Ther 2020; 8:161-169. [PMID: 32700068 PMCID: PMC7360012 DOI: 10.1007/s40487-019-00102-3] [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: 09/19/2019] [Indexed: 11/05/2022] Open
Abstract
Neurotoxicity is one of the most common side effects of oxaliplatin-based therapy. Most patients who receive at least 3–4 months of treatment suffer from peripheral sensory neurotoxicity (PSN), characterised by the loss or impairment of tactile and proprioceptive sensory function. Motor impairment, such as muscle weakness or palsy, has been rarely described, and the physiopathology of PSN, as well as the motor symptoms due to oxaliplatin-based treatment, are not adequately understood. Here we report the case of a patient who experienced severe acute peripheral motor neuropathy as a side effect of oxaliplatin-based treatment. We also review other cases of PSN published in the literature and suggest a novel hypothesis on the physiopathology of this particular event. Take-away lessons: Not all of the neurological symptoms observed during oxaliplatin-based treatment can be traced back directly to the oxaliplatin itself, and other factors, such as electrolyte imbalances, may contribute to the symptoms. Patients with gastro-intestinal malignancies are the patients most affected by neurotoxicity due to the side effects of chemotherapy and the disease itself.
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100
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Taghizadeh H, Prager GW. Personalized Adjuvant Treatment of Colon Cancer. Visc Med 2020; 36:397-406. [PMID: 33178737 DOI: 10.1159/000508175] [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: 04/08/2020] [Accepted: 04/23/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction Colon cancer (CC) is one of the most frequent malignant diseases. Adjuvant chemotherapy is of utmost importance in the management of localized disease. With the emergence of precision medicine, treatment approaches are becoming increasingly personalized and complex. This review contributes to a broader understanding of the role and relevance of personalized adjuvant treatment strategies in colon carcinoma, and summarizes the current status in this disease entity. Methods We searched the websites ClinicalTrials.gov, PubMed, and ASCO (American Society of Medical Oncology) Meeting Library for clinical trials and retrospective analyses in the field of adjuvant treatment of CC with special attention to personalized approaches. Results Various factors, including gender, age, sidedness, stage, dMMR/MSI-H, mutations, molecular profile, CMS, immunoscore, minimal residual disease, type of adjuvant therapy, therapy duration, and the patient's wish play an important role in the adjuvant setting of CC and should be considered in treatment decision making. Conclusion Future molecular profiling ideally assessed and monitored by liquid biopsy might personalize decision making even more in the adjuvant setting of CC patients. Further research and clinical trials are needed to clarify relevant questions and to highlight important clinical aspects.
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Affiliation(s)
- Hossein Taghizadeh
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria.,Comprehensive Cancer Center Vienna, Vienna, Austria
| | - Gerald W Prager
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria.,Comprehensive Cancer Center Vienna, Vienna, Austria
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