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Niu L, Lv H, Zhang M, Zeng H, Fu S, Cui S, Liu Z, Yan M. Clinicopathological features and prognosis of breast cancer combined with symptomatic bone marrow metastases: A 10-year, single-center, real-world study of 67 cases. Cancer Med 2023; 12:10672-10683. [PMID: 36951543 PMCID: PMC10225181 DOI: 10.1002/cam4.5827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 11/17/2022] [Accepted: 03/09/2023] [Indexed: 03/24/2023] Open
Abstract
PURPOSE Bone marrow metastasis (BMM) is uncommon in breast cancer (BC), and early diagnosis is challenging. BMM lacks definitive treatment options and poses a great threat to the survival of patients. Herein, we investigated the clinical features, prognosis, and factors affecting the prognosis of BC patients with symptomatic BMM to help improve the understanding of this disease and provide effective diagnostic and treatment strategies. METHODS Clinical data of 67 patients with BC and BMM were retrospectively analyzed for clinical characteristics, treatment, and prognosis of BMM. Univariate and multivariate analyses were performed to determine factors affecting overall survival following BMM (BMMOS). RESULTS Among patients with BMM, 86.6% were diagnosed after bone metastasis (BM), while 13.4% were diagnosed simultaneously with BM. A total of 73.1%, 13.4%, and 13.4% of the patients had hormone receptor-positive/human epidermal growth factor 2-negative (HR+/HER2-) tumors, HER2+ tumors, and triple-negative tumors, respectively. The most common symptoms of BMM were the coexistence of anemia and thrombocytopenia (26.9%), anemia (19.4%), and pancytopenia (17.9%). The median BMMOS was 7.6 months (95% CI, 3.9-11.3). Univariate and multivariate analyses showed that BMMOS was associated with platelet count <75 × 109 /L at the time of BMM diagnosis. The BMMOS of patients who underwent endocrine therapy, combined chemotherapy, and mono-chemotherapy after BMM was 15.7, 9.7, and 8.6 months, respectively, whereas that of untreated patients was 2.9 months, and the difference among the results was statistically significant (χ2 = 20.102, p < 0.0001). Changes in patient hemogram and/or body temperature during treatment were consistent with the overall effect of the disease (p < 0.0001). CONCLUSION BMM should be considered in BC patients with BM, an unexplained reduction in hemogram parameters, especially anemia and thrombocytopenia, and/or fever without chills. Active, effective, individualized treatment strategies can prolong BMMOS.
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Affiliation(s)
- Limin Niu
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Huimin Lv
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Mengwei Zhang
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Huiai Zeng
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Shuzhen Fu
- Department of Clinical LaboratoryThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Shude Cui
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Zhenzhen Liu
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
| | - Min Yan
- Department of Breast Disease, Henan Breast Cancer CenterThe Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer HospitalZhengzhouChina
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Alzahrani M, Stober C, Liu M, Awan A, Ng TL, Pond G, Alshamsan B, Vandermeer L, Clemons M. Symptomatic skeletal-related events in patients receiving longer term bone-modifying agents for bone metastases from breast and castration resistant prostate cancers. Support Care Cancer 2022; 30:3977-3984. [DOI: 10.1007/s00520-021-06714-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022]
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Clemons M, Liu M, Stober C, Pond G, Jemaan Alzahrani M, Ong M, Ernst S, Booth C, Mates M, Abraham Joy A, Aseyev O, Blanchette P, Vandermeer L, Tu M, Thavorn K, Fergusson D. Two-year results of a randomised trial comparing 4- versus 12-weekly bone-targeted agent use in patients with bone metastases from breast or castration-resistant prostate cancer. J Bone Oncol 2021; 30:100388. [PMID: 34567960 PMCID: PMC8449269 DOI: 10.1016/j.jbo.2021.100388] [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: 07/05/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Optimal dosing interval of bone-targeting agents (BTAs) has not been fully defined. Study of 4 vs 12-weekly BTAs in breast or prostate cancer pts with bone metastases. Study arms showed no significant differences SSE rates, time to SSEs or toxicity. There were however significant differences in cost-effectiveness results. On study SSE (12-weekly arm) associated with slight increase in subsequent SSEs.
Background We present the 2-year results of a randomised trial comparing 4- versus 12-weekly bone-targeting agents (BTAs) in patients with bone metastases from breast or castration-resistant prostate cancer (CRPC). Patients and Methods Patients with bone metastases from breast or CRPC, who were going to start or were already receiving BTAs, were randomised to 4- or 12-weekly BTA treatment for 2 years. The endpoints were: symptomatic skeletal events (SSE) rates, time to SSEs, toxicity and cost-effectiveness. Results Of 263 patients (160 breast cancer, 103 CRPC), 133 (50.6%) and 130 (49.4%) were randomised to the 4- and 12-weekly groups, respectively. BTAs included denosumab (56.3%), zoledronate (24.0%) and pamidronate (19.8%). After 2 years, the cumulative incidence rate (95% CI) of SSEs was 32.7% (24.6% to 41.1%) and 28.1% (20.3% to 36.4%) for the 4- and 12-weekly intervention groups respectively. The hazard ratio for time to first SSE was 0.96 (95% CI = 0.63 to 1.47). However, in a post hoc analysis, those patients who had an on-study SSE, there was a small non-statistical increased risk of subsequent SSEs among patients on the 12-weekly dosing arm (HR = 1.14; 95% CI – 0.90–1.44). BTA-related toxicity rates were similar between study arms. A cost-utility analysis showed that 12-weekly BTA is cost-effective from a public payer’s perspective. Conclusion These results in addition to those previously reported for de-escalating zoledronate, would support that de-escalation of commonly used BTAs is a reasonable and economically valid treatment option. While not statistically significant, the increase in subsequent SSEs in the 12-weekly arm requires further exploration.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada
- Corresponding author at: Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, Canada.
| | - Michelle Liu
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada
| | - Gregory Pond
- Department of Oncology, McMaster University, 699 Concession Street, Suite 4-204, Hamilton, ON L8V 5C2, Canada
| | - Mashari Jemaan Alzahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada
| | - Michael Ong
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada
| | - Scott Ernst
- Division of Medical Oncology, Department of Oncology, London Regional Cancer Program, London Health Sciences Centre and University of Western Ontario, 800 Commissioners Road East, London, ON N6A 5W9, Canada
| | - Christopher Booth
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, ON K7L 5P9, Canada
| | - Mihaela Mates
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, ON K7L 5P9, Canada
| | - Anil Abraham Joy
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, 11560 University Avenue, Edmonton, AB T6G 1Z2, Canada
| | - Olexiy Aseyev
- Regional Cancer Care Northwest, Thunder Bay Regional Health Sciences Centre, 980 Oliver Road, Thunder Bay, ON P7B 6V4, Canada
| | - Phillip Blanchette
- Division of Medical Oncology, Department of Oncology, London Regional Cancer Program, London Health Sciences Centre and University of Western Ontario, 800 Commissioners Road East, London, ON N6A 5W9, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada
| | - Megan Tu
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, and the University of Ottawa, Ottawa, ON K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, and the University of Ottawa, Ottawa, ON K1H 8L6, Canada
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McGee S, Alzahrani M, Vandermeer L, Cole K, Larocque G, Awan A, Hutton B, Pond G, Saunders D, Clemons M. Adjuvant bisphosphonate use in patients with early stage breast cancer: a physician survey. Breast Cancer Res Treat 2021; 187:477-486. [PMID: 33755864 PMCID: PMC7985746 DOI: 10.1007/s10549-021-06147-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
Purpose Despite the increasing use of adjuvant bone-modifying agents (BMAs) such as zoledronate and clodronate in the treatment of patients with early stage breast cancer (EBC), little is known about real world practice patterns. A physician survey was performed to address this deficit and determine interest in clinical trials of alternative strategies for BMA administration. Methods Canadian oncologists treating patients with EBC were surveyed via an anonymized online survey. The survey collected information on: physician demographics, knowledge and interpretation of adjuvant bisphosphonate guidelines, and real world prescribing practices. Questions also determined thoughts around the design of future adjuvant BMA trials. Results Of 127 surveyed physicians, 53 eligible invitees responded (response rate 42%). The majority of physicians are offering high-risk postmenopausal patients adjuvant BMAs. The most common BMA regimen was adjuvant zoledronate (45/53, 85%) every 6 months for 3 years. Concerns around toxicities and repeated visits to the cancer centre were perceived as the greatest barriers to adjuvant bisphosphonate use. Respondents were interested in future trials of de-escalation of BMAs comparing a single infusion of zoledronate vs. 6-monthly zoledronate for 3 years. The most favoured primary endpoints for such a trial included disease recurrence and fragility fracture rates. Conclusion Questions around optimal use of adjuvant bisphosphonates in patients with EBC still exist. There is interest among physicians in performing trials of de-escalation of these agents. The results of this survey will assist in designing pragmatic clinical trials to address this question. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06147-1.
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Affiliation(s)
- Sharon McGee
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Mashari Alzahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Katherine Cole
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada
| | - Gail Larocque
- The Ottawa Hospital Cancer Program, The Ottawa Hospital, Ottawa, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Gregory Pond
- Department of Oncology, Juravinski Cancer Centre and McMaster University, Hamilton, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada. .,Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada.
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McGee S, AlZahrani M, Stober C, Ng TL, Cole K, Larocque G, Awan A, Sehdev S, Hilton J, Vandermeer L, Hutton B, Pond G, Saunders D, Clemons M. Adjuvant bisphosphonate use in patients with early stage breast cancer: Patient perspectives on treatment acceptability and potential de-escalation. J Bone Oncol 2021; 27:100351. [PMID: 33680749 PMCID: PMC7930351 DOI: 10.1016/j.jbo.2021.100351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 11/30/2022] Open
Abstract
Background Despite the increasing use of adjuvant bisphosphonates for early stage breast cancer (EBC), little is known about the patient experience with such treatments. A patient survey was performed to identify current prescribing practices, perceptions around the role of treatment, the impact of treatment on patients' quality of life, and future trial designs. Methods EBC patients who had either completed or were currently receiving adjuvant bisphosphonates were sent an anonymized survey. The survey collected information on patient and disease characteristics, bisphosphonate scheduling, compliance, and tolerance. Questions also assessed patient interest in trials of de-escalated bisphosphonate therapy. Results A total of 255 patients were contacted, with 164 eligible respondents (eligible response rate 164/255, 64.3%). Median patient age was 52 years (range 28 to 82 years). The majority (111/163, 68.1%) were postmenopausal at the time of diagnosis, 23.3% (38/163) were premenopausal, and 7.4% (12/163) were perimenopausal. Most patients (78%) had received chemotherapy. Zoledronate was the most commonly used bisphosphonate (92%), with the majority receiving treatment every 6 months for 3 years (73%). While 66% (107/161) of respondents had experienced side effects with treatment, most had, or expected to, complete treatment (154/163, 94%). Provided there was no detriment in breast cancer outcomes, there was strong interest in future studies of de-escalating adjuvant bisphosphonate therapy. Conclusion While most patients tolerate their treatment, there is interest in performing trials of de-escalation of these agents.
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Affiliation(s)
- Sharon McGee
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mashari AlZahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Terry L Ng
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katherine Cole
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Gail Larocque
- The Ottawa Hospital Cancer Program, The Ottawa Hospital, Ottawa, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sandeep Sehdev
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Gregory Pond
- Department of Oncology, Juravinski Cancer Centre and McMaster University, Hamilton, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Clemons M, Ong M, Stober C, Ernst S, Booth C, Canil C, Mates M, Robinson A, Blanchette P, Joy AA, Hilton J, Aseyev O, Pond G, Jeong A, Hutton B, Mazzarello S, Vandermeer L, Kushnir I, Fergusson D. A randomised trial of 4- versus 12-weekly administration of bone-targeted agents in patients with bone metastases from breast or castration-resistant prostate cancer. Eur J Cancer 2021; 142:132-140. [PMID: 33023785 PMCID: PMC7532126 DOI: 10.1016/j.ejca.2020.08.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/29/2020] [Accepted: 08/07/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Optimal dosing of bone-targeted agents (BTAs), in patients with bone metastases remains an important clinical question. This trial compared 4-weekly versus 12-weekly therapy. PATIENTS AND METHODS Patients with bone metastases from breast or castration-resistant prostate cancer (CRPC), who were going to start or already on BTAs, were randomised 1:1 to 4-weekly or 12-weekly BTA treatment for one year. Primary end point was change in health-related quality of life (HRQoL)-physical function European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30). Secondary end points included pain (EORTC-QLQ-BM22), global health status (EORTC-QLQ-C30), symptomatic skeletal events (SSEs) rates and time to SSEs. Primary analysis was per protocol and a non-inferiority margin of 5 points was used. RESULTS Of 263 patients (160 breast cancer, 103 CRPC), 133 (50.6%) and 130 (49.4%) were randomised to the 4- and 12-weekly groups, respectively. BTAs included denosumab (56.3%), zoledronate (24.0%) and pamidronate (19.8%). Using repeated-measures analysis, across all time points, patients in the 4-weekly arm had a mean HRQL-physical subdomain score which was 1.2 (95% confidence interval: -1.6 to 4.0) higher than the 12-weekly arm. The study met the definition of non-inferiority for our primary outcome. Secondary outcomes showed no significant difference in scores for pain, global health status, SSE rates and SSE-free survival between arms. Subgroup analyses for cancer type, prior BTA use or BTA type showed no significant difference between arms. CONCLUSION These results in addition to those previously reported for de-escalating zoledronate and systematic reviews in both breast and prostate cancers, would support that de-escalation of commonly used BTAs is a reasonable treatment option.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, Ontario, K1H 8L6, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada.
| | - Michael Ong
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, Ontario, K1H 8L6, Canada
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
| | - Scott Ernst
- Division of Medical Oncology, Department of Oncology, London Regional Cancer Program, London Health Sciences Centre and University of Western Ontario, 800 Commissioners Road East, London, Ontario, N6A 5W9, Canada
| | - Christopher Booth
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, Ontario, K7L 5P9, Canada
| | - Christina Canil
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, Ontario, K1H 8L6, Canada
| | - Mihaela Mates
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, Ontario, K7L 5P9, Canada
| | - Andrew Robinson
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, Ontario, K7L 5P9, Canada
| | - Phillip Blanchette
- Division of Medical Oncology, Department of Oncology, London Regional Cancer Program, London Health Sciences Centre and University of Western Ontario, 800 Commissioners Road East, London, Ontario, N6A 5W9, Canada
| | - Anil Abraham Joy
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, 11560 University Avenue, Edmonton, Alberta, T6G 1Z2, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, Ontario, K1H 8L6, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
| | - Olexiy Aseyev
- Regional Cancer Care Northwest, Thunder Bay Regional Health Sciences Centre, 980 Oliver Road, Thunder Bay, Ontario, P7B 6V4, Canada
| | - Gregory Pond
- Department of Oncology, McMaster University, 699 Concession Street, Suite 4-204, Hamilton, Ontario, L8V 5C2, Canada
| | - Ahwon Jeong
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
| | - Sasha Mazzarello
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
| | - Igal Kushnir
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, Ontario, K1H 8L6, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Box 511, Ottawa, Ontario, K1H 8L6, Canada
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Fazzari J, Sidhu J, Motkur S, Inman M, Buckley N, Clemons M, Vandermeer L, Singh G. Applying Serum Cytokine Levels to Predict Pain Severity in Cancer Patients. J Pain Res 2020; 13:313-321. [PMID: 32104053 PMCID: PMC7012636 DOI: 10.2147/jpr.s227175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/20/2020] [Indexed: 12/14/2022] Open
Abstract
Background and Aim Cancers originating in the breast, lung and prostate often metastasize to the bone, frequently resulting in cancer-induced bone pain that can be challenging to manage despite conventional analgesic therapy. This exploratory study’s aim was to identify potential biomarkers associated with cancer-induced pain by examining a sample population of breast cancer patients undergoing bisphosphonate therapy. Methods A secondary analysis of the primary study was performed to quantify serum cytokine levels for correlation to pain scores. Cytokines with statistically significant correlations were then input into a stepwise regression analysis to generate a predictive equation for a patient’s pain severity. In an effort to find additional potential biomarkers, correlation analysis was performed between these factors and a more comprehensive panel of cytokines and chemokines from breast, lung, and prostate cancer patients. Results Statistical analysis identified nine cytokines (GM-CSF, IFNγ, IL-1β, IL-2, IL-4, IL-5, IL-12p70, IL-17A, and IL-23) that had significant negative correlations with pain scores and they could best predict pain severity through a predictive equation generated for this specific evaluation. After performing a correlation analysis between these factors and a larger panel of cytokines and chemokines, samples from breast, lung and prostate patients showed distinct correlation profiles, highlighting the clinical challenge of applying pain-associated cytokines related to more defined nociceptive states, such as arthritis, to a cancer pain state. Conclusion Exploratory analyses such as the ones presented here will be a beneficial tool to expand insights into potential cancer-specific nociceptive mechanisms and to develop novel therapeutics.
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Affiliation(s)
- Jennifer Fazzari
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jesse Sidhu
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shreya Motkur
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Inman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Norman Buckley
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, Ottawa, Canada.,Cancer Research Program, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Research Program, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Gurmit Singh
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
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Luo Q, Men P, Liu Z, Zhai S, Jiang M. Is De-escalated Bisphosphonates Therapy a Suitable Alternative to Standard Dosing in Malignant Tumor Patients With Bone Metastases: A Systematic Review and Meta-Analysis. Front Oncol 2019; 9:774. [PMID: 31475116 PMCID: PMC6702312 DOI: 10.3389/fonc.2019.00774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have preliminarily identified the non-inferior efficacy for reducing skeletal-related event (SRE) rates between de-escalated (Q12w) and standard (Q3-4w) bone-targeting agents therapy in malignant tumor patients with bone metastases. In this study, we aim to make further efforts to analyze whether the de-escalated bisphosphonates (BPs) strategy is a suitable option by comprehensively retrieving and synthesizing state-of-the-art evidence. Methods: An extensive electronic search for randomized controlled trials (RCTs) comparing a BPs standard strategy with the de-escalated one in patients with bone metastases was performed up to June 2018. Outcomes of interest were general and found individual types of SRE, skeletal morbidity rate (SMR), bone pain, bone turnover biomarkers and adverse events (AEs). Continuous and dichotomous outcomes were summarized by the weighted mean difference (WMD) and risk ratio (RR), respectively, with 95% confidence intervals (CIs). Results: A total of eight studies, representing six unique trials (involving 3114 patients), were included. Pooled results indicated comparable efficacy on general SRE (RR 0.99, 95% CI 0.87-1.12; P = 0.86; I 2 = 0%) and SMR (WMD 0.00, 95% CI -0.02 -0.03; P = 0.81; I 2 = 0%). However, the rate of surgery involving bones was significantly higher in de-escalated group than standard group (RR 1.92, 95% CI 1.17-3.15; P = 0.01; I 2 = 0%) among individual types of SRE. Several trials also demonstrated increased levels of C-terminal or N-terminal telopeptide in de-escalated group. Meta-analyses for gastrointestinal disorders, dizziness and back pain showed significant reductions by 27% (RR 0.73, 95% CI 0.57-0.94; P = 0.01; I 2 = 0%), 48% (RR 0.52 95% CI 0.32-0.86; P = 0.01; I 2 = 0%), and 29% (RR 0.71, 0.51-0.99; P = 0.04; I 2 = 0%), respectively, compared to the standard therapy. Conclusion: For malignant tumor patients with bone metastases, a de-escalated BPs strategy is proved to have a better safety profile compared to standard dosing. Although the efficacy is generally comparable on SRE and SMR between the two dosing regimens, trials with long duration and large sample sizes are still warranted to make a solid judgment.
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Affiliation(s)
- Qiuhua Luo
- Department of Pharmacy, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Zhiyong Liu
- Liaoning Center for Drug and Device Evaluation and Monitoring, Shenyang, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Mingyan Jiang
- Department of Pharmacy, The First Affiliated Hospital of China Medical University, Shenyang, China
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9
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Tella SH, Kommalapati A, Singhi RK. Cost-effectiveness in managing skeletal related events in breast cancer: a strategy of less-intense dosing schedule of bone modifying agents. Transl Cancer Res 2018; 7:S81-S84. [PMID: 29863174 DOI: 10.21037/tcr.2018.01.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sri Harsha Tella
- National Institutes of Health (NIH), Bethesda, USA.,Department of Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Anuhya Kommalapati
- Department of Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Ryan K Singhi
- Department of Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
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Abotaleb M, Kubatka P, Caprnda M, Varghese E, Zolakova B, Zubor P, Opatrilova R, Kruzliak P, Stefanicka P, Büsselberg D. Chemotherapeutic agents for the treatment of metastatic breast cancer: An update. Biomed Pharmacother 2018; 101:458-477. [PMID: 29501768 DOI: 10.1016/j.biopha.2018.02.108] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 12/17/2022] Open
Abstract
Breast cancer is the second greatest cause of death among women worldwide; it comprises a group of heterogeneous diseases that evolves due to uncontrolled cellular growth and differentiation and the loss of normal programmed cell death. There are different molecular sub-types of breast cancer; therefore, various options are selected for treatment of different forms of metastatic breast cancer. However, the use of chemotherapeutic drugs is usually accompanied by deleterious side effects and the development of drug resistance when applied for a longer period. This review offers a classification of these chemotherapeutic agents according to their modes of action and therefore improves the understanding of molecular targets that are affected during treatment. Overall, it will allow the clinician to identify more specific targets to increase the effectiveness of a drug and to reduce general toxicity, resistance and other side effects.
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Affiliation(s)
- Mariam Abotaleb
- Weill Cornell Medicine in Qatar, Qatar Foundation-Education City, Doha, Qatar
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia; Department of Experimental Carcinogenesis, Division of Oncology, Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Martin Caprnda
- 1st Department of Internal Medicine, Medical Faculty, Comenius University in Bratislava, Bratislava, Slovakia
| | - Elizabeth Varghese
- Weill Cornell Medicine in Qatar, Qatar Foundation-Education City, Doha, Qatar
| | - Barbora Zolakova
- Department of Experimental Carcinogenesis, Division of Oncology, Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Pavol Zubor
- Clinic of Gynecology and Obsterics, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Radka Opatrilova
- Department of Chemical Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | - Peter Kruzliak
- Department of Internal Medicine, Brothers of Mercy Hospital, Brno, Czech Republic; 2nd Department of Surgery, Faculty of Medicine, Masaryk University and St. Anne´s University Hospital, Brno, Czech Republic.
| | - Patrik Stefanicka
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Comenius University and University Hospital, Antolska 11, 851 07, Bratislava, Slovakia.
| | - Dietrich Büsselberg
- Weill Cornell Medicine in Qatar, Qatar Foundation-Education City, Doha, Qatar.
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11
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Hilton JF, Clemons M, Pond G, Zhao H, Mazzarello S, Vandermeer L, Addison CL. Effects on bone resorption markers of continuing pamidronate or switching to zoledronic acid in patients with high risk bone metastases from breast cancer. J Bone Oncol 2017; 10:6-13. [PMID: 29204337 PMCID: PMC5709351 DOI: 10.1016/j.jbo.2017.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 02/02/2023] Open
Abstract
Background Switching patients who remain at high risk of skeletal related events (SREs) despite pamidronate to the more potent bisphosphonate zoledronate, may be an effective treatment strategy. As part of a previously reported clinic study in this setting, we evaluated whether biomarkers for bone resorption, such as Bone-Specific Alkaline Phosphatase (BSAP), bone sialoprotein (BSP), and N-terminal telopeptide (NTX) correlated with subsequent SRE risk. Methods Breast cancer patients who remained at high risk of SREs despite at least 3 months of q.3–4 weekly pamidronate were randomized to either continue on pamidronate or to switch to zoledronate (4 mg) once every 4 weeks for 12-weeks. High risk bone metastases were defined by either: occurrence of a prior SRE, bone pain, radiologic progression of bone metastases and/or serum C-terminal telopeptide (CTx) levels > 400 ng/L despite pamidronate use. Serum samples were collected at baseline and weeks 1, 4, 8 and 12 (CTx and BSAP) and baseline and week 12 (NTx and BSP), and all putative biomarkers were measured by ELISA. Follow up was extended to 2 years post trial entry for risk of subsequent SREs. The Kaplan-Meier method was used to estimate time-to-event outcomes. Generalized estimating equations (GEE) were used to evaluate if laboratory values over time or the change in laboratory values from baseline were associated with having a SRE within the time frame of this study. Results From March 2012 to May 2014, 76 patients were screened, with 73 eligible for enrolment. All 73 patients were available for biochemical analysis, with 35 patients receiving pamidronate and 38 patients receiving zoledronate. The GEE analysis found that no laboratory value was associated with having a subsequent SRE. Interaction between visit and laboratory values was also investigated, but no interaction effect was statistically significant. Only increased number of lines of prior hormonal treatment was associated with subsequent SRE risk. Conclusion Our analysis failed to find any association between serum BSAP, BSP, CTx or NTx levels and subsequent SRE risk in this cohort of patients. This lack of correlation between serum biomarkers and clinical outcomes could be due to influences of prior bisphosphonate treatment or presence of extra-osseous metastases in a significant proportion of enrolled patients. As such, caution should be used in biomarker interpretation and use to direct decision making regarding SRE risk for high risk patients in this setting.
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Affiliation(s)
- J F Hilton
- Division of Medical Oncology and Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - M Clemons
- Division of Medical Oncology and Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - G Pond
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - H Zhao
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - S Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - L Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - C L Addison
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
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12
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O'Carrigan B, Wong MHF, Willson ML, Stockler MR, Pavlakis N, Goodwin A. Bisphosphonates and other bone agents for breast cancer. Cochrane Database Syst Rev 2017; 10:CD003474. [PMID: 29082518 PMCID: PMC6485886 DOI: 10.1002/14651858.cd003474.pub4] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Bone is the most common site of metastatic disease associated with breast cancer (BC). Bisphosphonates inhibit osteoclast-mediated bone resorption, and novel targeted therapies such as denosumab inhibit other key bone metabolism pathways. We have studied these agents in both early breast cancer and advanced breast cancer settings. This is an update of the review originally published in 2002 and subsequently updated in 2005 and 2012. OBJECTIVES To assess the effects of bisphosphonates and other bone agents in addition to anti-cancer treatment: (i) in women with early breast cancer (EBC); (ii) in women with advanced breast cancer without bone metastases (ABC); and (iii) in women with metastatic breast cancer and bone metastases (BCBM). SEARCH METHODS In this review update, we searched Cochrane Breast Cancer's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 19 September 2016. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing: (a) one treatment with a bisphosphonate/bone-acting agent with the same treatment without a bisphosphonate/bone-acting agent; (b) treatment with one bisphosphonate versus treatment with a different bisphosphonate; (c) treatment with a bisphosphonate versus another bone-acting agent of a different mechanism of action (e.g. denosumab); and (d) immediate treatment with a bisphosphonate/bone-acting agent versus delayed treatment of the same bisphosphonate/bone-acting agent. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, and assessed risk of bias and quality of the evidence. The primary outcome measure was bone metastases for EBC and ABC, and a skeletal-related event (SRE) for BCBM. We derived risk ratios (RRs) for dichotomous outcomes and the meta-analyses used random-effects models. Secondary outcomes included overall survival and disease-free survival for EBC; we derived hazard ratios (HRs) for these time-to-event outcomes where possible. We collected toxicity and quality-of-life information. GRADE was used to assess the quality of evidence for the most important outcomes in each treatment setting. MAIN RESULTS We included 44 RCTs involving 37,302 women.In women with EBC, bisphosphonates were associated with a reduced risk of bone metastases compared to placebo/no bisphosphonate (RR 0.86, 95% confidence interval (CI) 0.75 to 0.99; P = 0.03, 11 studies; 15,005 women; moderate-quality evidence with no significant heterogeneity). Bisphosphonates provided an overall survival benefit with time-to-event data (HR 0.91, 95% CI 0.83 to 0.99; P = 0.04; 9 studies; 13,949 women; high-quality evidence with evidence of heterogeneity). Subgroup analysis by menopausal status showed a survival benefit from bisphosphonates in postmenopausal women (HR 0.77, 95% CI 0.66 to 0.90; P = 0.001; 4 studies; 6048 women; high-quality evidence with no evidence of heterogeneity) but no survival benefit for premenopausal women (HR 1.03, 95% CI 0.86 to 1.22; P = 0.78; 2 studies; 3501 women; high-quality evidence with no heterogeneity). There was evidence of no effect of bisphosphonates on disease-free survival (HR 0.94, 95% 0.87 to 1.02; P = 0.13; 7 studies; 12,578 women; high-quality evidence with significant heterogeneity present) however subgroup analyses showed a disease-free survival benefit from bisphosphonates in postmenopausal women only (HR 0.82, 95% CI 0.74 to 0.91; P < 0.001; 7 studies; 8314 women; high-quality evidence with no heterogeneity). Bisphosphonates did not significantly reduce the incidence of fractures when compared to placebo/no bisphosphonates (RR 0.77, 95% CI 0.54 to 1.08, P = 0.13, 6 studies, 7602 women; moderate-quality evidence due to wide confidence intervals). We await mature overall survival and disease-free survival results for denosumab trials.In women with ABC without clinically evident bone metastases, there was no evidence of an effect of bisphosphonates on bone metastases (RR 0.96, 95% CI 0.65 to 1.43; P = 0.86; 3 studies; 330 women; moderate-quality evidence with no heterogeneity) or overall survival (RR 0.89, 95% CI 0.73 to 1.09; P = 0.28; 3 studies; 330 women; high-quality evidence with no heterogeneity) compared to placebo/no bisphosphonates however the confidence intervals were wide. One study reported a trend towards an extended period of time without a SRE with bisphosphonate compared to placebo (low-quality evidence). One study reported quality of life and there was no apparent difference in scores between bisphosphonate and placebo (moderate-quality evidence).In women with BCBM, bisphosphonates reduced the SRE risk by 14% (RR 0.86, 95% CI 0.78 to 0.95; P = 0.003; 9 studies; 2810 women; high-quality evidence with evidence of heterogeneity) compared with placebo/no bisphosphonates. This benefit persisted when administering either intravenous or oral bisphosphonates versus placebo. Bisphosphonates delayed the median time to a SRE with a median ratio of 1.43 (95% CI 1.29 to 1.58; P < 0.00001; 9 studies; 2891 women; high-quality evidence with no heterogeneity) and reduced bone pain (in 6 out of 11 studies; moderate-quality evidence) compared to placebo/no bisphosphonate. Treatment with bisphosphonates did not appear to affect overall survival (RR 1.01, 95% CI 0.91 to 1.11; P = 0.85; 7 studies; 1935 women; moderate-quality evidence with significant heterogeneity). Quality-of-life scores were slightly better with bisphosphonates than placebo at comparable time points (in three out of five studies; moderate-quality evidence) however scores decreased during the course of the studies. Denosumab reduced the risk of developing a SRE compared with bisphosphonates by 22% (RR 0.78, 0.72 to 0.85; P < 0.001; 3 studies, 2345 women). One study reported data on overall survival and observed no difference in survival between denosumab and bisphosphonate.Reported toxicities across all settings were generally mild. Osteonecrosis of the jaw was rare, occurring less than 0.5% in the adjuvant setting (high-quality evidence). AUTHORS' CONCLUSIONS For women with EBC, bisphosphonates reduce the risk of bone metastases and provide an overall survival benefit compared to placebo or no bisphosphonates. There is preliminary evidence suggestive that bisphosphonates provide an overall survival and disease-free survival benefit in postmenopausal women only when compared to placebo or no bisphosphonate. This was not a planned subgroup for these early trials, and we await the completion of new large clinical trials assessing benefit for postmenopausal women. For women with BCBM, bisphosphonates reduce the risk of developing SREs, delay the median time to an SRE, and appear to reduce bone pain compared to placebo or no bisphosphonate.
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Affiliation(s)
- Brent O'Carrigan
- Chris O'Brien LifehouseMedical Oncology119‐143 Missenden RdCamperdownSydneyNSWUK2050
- The University of SydneyCamperdownAustralia
| | - Matthew HF Wong
- Gosford HospitalDepartment of Medical OncologyGosfordNew South WalesAustralia
| | - Melina L Willson
- NHMRC Clinical Trials Centre, The University of SydneySystematic Reviews and Health Technology AssessmentsLocked Bag 77SydneyNSWAustralia1450
| | - Martin R Stockler
- The University of SydneyNHMRC Clinical Trials Centre and Sydney Cancer CentreGH6 RPAHMissenden RoadCamperdownNSWAustralia2050
| | - Nick Pavlakis
- Royal North Shore HospitalDepartment of Medical OncologyPacific HighwaySt LeonardsNew South WalesAustralia2065
| | - Annabel Goodwin
- The University of Sydney, Concord Repatriation General HospitalConcord Clinical SchoolConcordNSWAustralia2137
- Concord Repatriation General HospitalMedical Oncology DepartmentConcordAustralia
- Sydney Local Health District and South Western Sydney Local Health DistrictCancer Genetics DepartmentSydneyAustralia
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13
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Addison CL, Simos D, Wang Z, Pond G, Smith S, Robertson S, Mazzarello S, Singh G, Vandermeer L, Fernandes R, Iyengar A, Verma S, Clemons M. A phase 2 trial exploring the clinical and correlative effects of combining doxycycline with bone-targeted therapy in patients with metastatic breast cancer. J Bone Oncol 2016; 5:173-179. [PMID: 28008379 PMCID: PMC5154696 DOI: 10.1016/j.jbo.2016.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/14/2016] [Accepted: 06/28/2016] [Indexed: 11/25/2022] Open
Abstract
Background Bone-targeting agents (BTAs), such as bisphosphonates and denosumab, have demonstrated no discernable effects on tumour response or disease free/overall survival in patients with bone metastases from breast cancer. Doxycycline is both osteotropic and has anti-cancer effects. When combined with zoledronate in animal models, doxycycline showed significantly increased inhibition of tumour burden and increased bone formation. We evaluated the effects of adding doxycycline to ongoing anti-cancer therapy in patients with metastatic breast cancer. Methods Breast cancer patients with bone metastases and ≥3 months of BTA use, entered this single-arm study. Patients received doxycycline 100 mg orally, twice a day for 12 weeks. The co-primary endpoints were; effect on validated pain scores (FACT-Bone pain and Brief Pain Inventory) and bone resorption markers (serum C-telopeptide, [sCTx]). All endpoints (pain scores, sCTx, bone-specific alkaline phosphatase, skeletal-related events, toxicity) were evaluated at baseline, 4, 8 and 12 weeks. Bone marrow was sampled at baseline and week 12 for exploratory biomarker analysis. Results Out of 37 enroled patients, 27 (73%) completed 12 weeks of therapy. No significant changes were seen in pain scores or bone turnover markers. Failure to complete treatment: drug toxicity (70%) and disease progression (30%). Sixteen (43%) patients had GI adverse events. Conclusions Doxycycline 100 mg twice daily for 12 weeks had no significant effects on either bone pain or bone turnover markers. Its toxicity profile in this patient population would make further evaluation challenging.
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Affiliation(s)
- C L Addison
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - D Simos
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Z Wang
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - G Pond
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - S Smith
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - S Robertson
- Department of Pathology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - S Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - G Singh
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - L Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - R Fernandes
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - A Iyengar
- Division of Hematology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - S Verma
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - M Clemons
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada; Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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14
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Fernandes R, Siegel P, Komarova S, Hilton J, Addison C, Ibrahim MFK, Werier J, Dennis K, Singh G, Amir E, Jarvis V, Emmenegger U, Mazzarello S, Clemons M. Future directions for bone metastasis research - highlights from the 2015 bone and the Oncologist new updates conference (BONUS). J Bone Oncol 2016; 5:57-62. [PMID: 27335772 PMCID: PMC4908181 DOI: 10.1016/j.jbo.2016.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 12/21/2022] Open
Abstract
In an era of reduced peer-reviewed grant funding, performing academic bone oncology-related research has become increasingly challenging. Over the last 10 years we have held an annual meeting to bring together clinicians, clinician/scientists and basic biomedical researchers interested in the effects of cancer and its treatment on skeletal tissues. In the past these "Bone and the Oncologist New Updates Conference (BONUS)" meetings have served as critical catalyst for initiating productive research collaborations between attendees. The 2015 BONUS meeting format focused on potential key research themes that could form the basis of a coordinated national research strategy to tackle unmet clinical and research needs related to complications associated with cancer metastasis to bone. The three themes planned for discussion were: Is bone metastases-related pain the main issue facing patients? Are there new therapeutic targets for patients with bone metastases? How do we more firmly link basic science with clinical practice? We present a summary of lectures and commentaries from the attendees to serve as an example that other similarly motivated groups can model and share their experiences. It is our hope that these presentations will result in comments, feedback and suggestions from all those researchers interested in this important area.
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Affiliation(s)
- Ricardo Fernandes
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Peter Siegel
- Department of Medicine, Goodman Cancer Research Centre, McGill University, Montreal, Canada
| | - Svetlana Komarova
- Department of Medicine, Goodman Cancer Research Centre, McGill University, Montreal, Canada
- Faculty of Dentistry, McGill University, Montreal, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Christina Addison
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Mohammed F K Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Joel Werier
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
- Department of Surgery, Division of Orthopaedic Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Kristopher Dennis
- Ottawa Hospital Division of Radiation Oncology and University of Ottawa, Ottawa, Ontario, Canada
| | | | - Eitan Amir
- Division of Medical Oncology, Department of Medicine, University Health Network and Princess Margaret Hospital and University of Toronto, Toronto, Canada
| | - Virginia Jarvis
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sasha Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
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15
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Van Acker HH, Anguille S, Willemen Y, Smits EL, Van Tendeloo VF. Bisphosphonates for cancer treatment: Mechanisms of action and lessons from clinical trials. Pharmacol Ther 2015; 158:24-40. [PMID: 26617219 DOI: 10.1016/j.pharmthera.2015.11.008] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A growing body of evidence points toward an important anti-cancer effect of bisphosphonates, a group of inexpensive, safe, potent, and long-term stable pharmacologicals that are widely used as osteoporosis drugs. To date, they are already used in the prevention of complications of bone metastases. Because the bisphosphonates can also reduce mortality in among other multiple myeloma, breast, and prostate cancer patients, they are now thoroughly studied in oncology. In particular, the more potent nitrogen-containing bisphosphonates have the potential to improve prognosis. The first part of this review will elaborate on the direct and indirect anti-tumoral effects of bisphosphonates, including induction of tumor cell apoptosis, inhibition of tumor cell adhesion and invasion, anti-angiogenesis, synergism with anti-neoplastic drugs, and enhancement of immune surveillance (e.g., through activation of γδ T cells and targeting macrophages). In the second part, we shed light on the current clinical position of bisphosphonates in the treatment of hematological and solid malignancies, as well as on ongoing and completed clinical trials investigating the therapeutic effect of bisphosphonates in cancer. Based on these recent data, the role of bisphosphonates is expected to further expand in the near future outside the field of osteoporosis and to open up new avenues in the treatment of malignancies.
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Affiliation(s)
- Heleen H Van Acker
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.
| | - Sébastien Anguille
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium; Center for Cell Therapy and Regenerative Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Yannick Willemen
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Evelien L Smits
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium; Center for Cell Therapy and Regenerative Medicine, Antwerp University Hospital, Edegem, Belgium; Center for Oncological Research (CORE), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Viggo F Van Tendeloo
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
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16
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Are adjuvant bisphosphonates now standard of care of women with early stage breast cancer? A debate from the Canadian Bone and the Oncologist New Updates meeting. J Bone Oncol 2015; 4:54-8. [PMID: 26579489 PMCID: PMC4620967 DOI: 10.1016/j.jbo.2015.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/14/2015] [Indexed: 01/07/2023] Open
Abstract
The 9th Bone and the Oncologist New Updates conference was held in Ottawa, Canada during 2014. This annual meeting focuses on innovative research into the mechanisms and consequences of treatment-induced and metastatic bone disease. Given the recent presentation of the Oxford overview's “Effects of bisphosphonate treatment on recurrence and cause-specific mortality in women with early breast cancer: A meta-analysis of individual patient data from randomized trials” at the San Antonio Breast Cancer Symposium, a debate as to the pro's and con's of adjuvant bisphosphonate use in early stage breast cancer was undertaken. As bisphosphonate treatment in post-menopausal women appeared to demonstrate a similar magnitude of benefit to that of other commonly used adjuvant strategies the debate assessed whether or not there was sufficient data to incorporate adjuvant bisphosphonates into standard practice and if so, in which patient populations.
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Addison CL, Pond GR, Cochrane B, Zhao H, Chia SK, Levine MN, Clemons M. Correlation of baseline biomarkers with clinical outcomes and response to fulvestrant with vandetanib or placebo in patients with bone predominant metastatic breast cancer: An OCOG ZAMBONEY sub-study. J Bone Oncol 2015; 4:47-53. [PMID: 26579488 PMCID: PMC4620970 DOI: 10.1016/j.jbo.2015.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/16/2015] [Accepted: 04/17/2015] [Indexed: 12/14/2022] Open
Abstract
Background Bone metastases are common in women with breast cancer and often result in skeletal related events (SREs). As the angiogenic factor vascular endothelial growth factor (VEGF) regulates osteoclast activity and is associated with more extensive bone metastases and SRE risk in metastatic breast cancer, we hypothesized that blockade of VEGF signaling could be a therapeutic strategy for inhibiting bone metastases progression and possibly prolonging overall (OS) or progression-free survival (PFS). The Zamboney trial was a randomized placebo-controlled study designed to assess whether patients with bone predominant metastatic breast cancer benefited from addition of the VEGF receptor (VEGFR) targeting agent, vandetanib, to endocrine therapy with fulvestrant. As a companion study, evaluation of biomarkers and their potential association with response to vandetanib or SRE risk was performed. Methods Baseline overnight fasted serum from enrolled patients was analyzed for levels of various putative biomarkers including; VEGF-A, soluble (s)VEGFR2, sVEGFR3, transforming growth factor (TGF)-β1 and activinA by ELISA. Spearman correlation coefficients and Wilcoxon rank sum tests were used to investigate potential relationships between biomarker values and baseline clinical parameters. Prognostic and predictive ability of each marker was investigated using Cox proportional hazards regression with adjustments for treatment and baseline strata of serum CTx (<400 versus ≥400 ng/L). Results Of 129 enrolled patients, serum was available for analysis in 101; 51 in vandetanib and 50 in placebo arm. Mean age amongst consenting patients was 59.8 years. Clinical characteristics were not significantly different between patients with or without serum biomarker data and serum markers were similar for patients by treatment arm. Baseline sVEGFR2 was prognostic for OS (HR=0.77, 95% CI=0.61–0.96, p=0.020), and although a modest association was observed, it was not significant for PFS (HR=0.90, 95% CI=0.80–1.01, p=0.085) nor time to first SRE (HR=0.82, 95% CI=0.66–1.02, p=0.079). When interaction terms were evaluated, sVEGFR2 was not found to be predictive of response to vandetanib, although a modest association remained with respect to PFS (interaction p=0.085). No other marker showed any significant prognostic or predictive ability with any measured outcome. Conclusions In this clinical trial, sVEGFR2 appeared prognostic for OS, hence validation of sVEGFR2 should be conducted. Moreover, the role of sVEGFR2 in breast cancer bone metastasis progression should be elucidated. Baseline VEGF, sVEGFR3, TGF-β or activinA were not associated with clinical outcomes in patients treated with fulvestrant in conjunction with vandetanib or placebo. Baseline sVEGFR2 was modestly associated with clinical outcomes including PFS, OS and time to first skeletal event. Increased baseline sVEGFR2 was associated with improved clinical outcomes in this study sample. These findings support the need for future studies of the role of sVEGFR2 in bone metastasis progression.
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Key Words
- BP, bisphosphonate
- BPI, brief pain inventory
- Biomarker
- Bone metastasis
- Breast cancer
- CTx, C-telopeptide
- ER, estrogen receptor
- FACT-BP, Functional assessment of cancer therapy-bone pain
- OS, overall survival
- PFS, progression free survival
- PR, progesterone receptor
- Patient outcome
- RANKL, Receptor Activator NF-KB ligand
- SRE, skeletal related event
- Skeletal related event
- TGF-β, transforming growth factor beta
- VEGF, vascular endothelial growth factor
- Vandetanib
- sVEGFR, soluble vascular endothelial growth factor receptor
- uNTx, urinary N-telopeptide
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Affiliation(s)
- Christina L Addison
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Box 926, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 ; Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Department of Biochemistry, Microbiology and Immunology University of Ottawa, Ottawa, ON, Canada
| | - Gregory R Pond
- McMaster University and Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | - Brandy Cochrane
- McMaster University and Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | - Huijun Zhao
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Box 926, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
| | | | - Mark N Levine
- McMaster University and Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | - Mark Clemons
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Box 926, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 ; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Ferreira A, Alho I, Casimiro S, Costa L. Bone remodeling markers and bone metastases: From cancer research to clinical implications. BONEKEY REPORTS 2015; 4:668. [PMID: 25908969 DOI: 10.1038/bonekey.2015.35] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/19/2015] [Indexed: 12/12/2022]
Abstract
Bone metastasis is a frequent finding in the natural history of several types of cancers. However, its anticipated risk, diagnosis and response to therapy are still challenging to assess in clinical practice. Markers of bone metabolism are biochemical by-products that provide insight into the tumor-bone interaction, with potential to enhance the clinical management of patients with bone metastases. In fact, these markers had a cornerstone role in the development of bone-targeted agents; however, its translation to routine practice is still unclear, as reflected by current international guidelines. In this review, we aimed to capture several of the research and clinical translational challenges regarding the use of bone metabolism markers that we consider relevant for future research in bone metastasis.
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Affiliation(s)
- Arlindo Ferreira
- Hospital de Santa Maria , Lisbon, Portugal ; Instituto de Medicina Molecular, Faculdade de Medicina , Universidade de Lisboa, Lisbon, Portugal
| | - Irina Alho
- Instituto de Medicina Molecular, Faculdade de Medicina , Universidade de Lisboa, Lisbon, Portugal
| | - Sandra Casimiro
- Instituto de Medicina Molecular, Faculdade de Medicina , Universidade de Lisboa, Lisbon, Portugal
| | - Luís Costa
- Hospital de Santa Maria , Lisbon, Portugal ; Instituto de Medicina Molecular, Faculdade de Medicina , Universidade de Lisboa, Lisbon, Portugal
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Mazzarello S, Clemons M, Jacobs C, Arnaout A, Fralick M. Publishing clinical research: ten pearls for oncology trainees and junior oncologists. ACTA ACUST UNITED AC 2015; 22:e1-5. [PMID: 25684991 DOI: 10.3747/co.22.2258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The old adage of “publish or perish” bears some truth. As the lines between “academic” and “community” practice blur, more physicians are expected to participate in “scholarly activities.”[...]
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Affiliation(s)
- S Mazzarello
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Research Institute, The Ottawa Hospital and University of Ottawa, Ottawa, ON
| | - M Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Research Institute, The Ottawa Hospital and University of Ottawa, Ottawa, ON
| | - C Jacobs
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Research Institute, The Ottawa Hospital and University of Ottawa, Ottawa, ON
| | - A Arnaout
- Division of General Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON
| | - M Fralick
- Department of Medicine, University of Toronto, Toronto, ON
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Long-term benefits versus side-effects from bone-targeted therapies for cancer patients. Curr Opin Support Palliat Care 2014; 8:420-8. [DOI: 10.1097/spc.0000000000000084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Addison CL, Pond GR, Zhao H, Mazzarello S, Vandermeer L, Goldstein R, Amir E, Clemons M. Effects of de-escalated bisphosphonate therapy on bone turnover biomarkers in breast cancer patients with bone metastases. SPRINGERPLUS 2014; 3:577. [PMID: 25332877 PMCID: PMC4194305 DOI: 10.1186/2193-1801-3-577] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 09/09/2014] [Indexed: 01/10/2023]
Abstract
While de-escalation of bisphosphonates from 4 to 12-weekly dosing has been shown to be clinically non-inferior to standard dosing, there is evidence the de-escalation is associated with increased bone turnover biomarkers. Here we evaluated the effect of de-escalated dosing on a panel of biomarkers and determined their association with incidence of skeletal related events (SREs) in breast cancer patients with ‘low risk’ bone metastases. As part of a pilot randomized trial, women with baseline C-telopeptide levels <600 ng/L after >3 months of 3–4 weekly pamidronate were randomized to continue pamidronate every 4 weeks or de-escalation to 12-weekly treatment. Serum was analysed for bone biomarkers (C-telopeptide, N-telopeptide, bone-specific alkaline phosphatase, transforming growth factor-β, procollagen type 1 N-propeptide, activinA and bone sialoprotein) using ELISA. The associations between changes in biomarkers, pain scores and SREs were assessed by univariable logistic regression. Numerical increases in all biomarkers were observed between baseline and 12 weeks but were of higher magnitude in the de-escalated arm. Pain scores in the de-escalated treatment arm showed a greater magnitude of pain reduction from baseline to 12 weeks. Neither baseline levels nor changes in biomarkers from baseline to 12 weeks on treatment were associated with on study SREs. Baseline pain as measured by the FACT-BP was associated with increased risk of SRE. In conclusion, biomarkers of bone activity do not appear to predict for SREs in ‘low risk’ cohorts. However, baseline bone pain appears to be associated with SRE occurrence, a finding which warrants evaluation in larger cohorts.
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Affiliation(s)
- Christina L Addison
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, ON Canada ; Department of Medicine, University of Ottawa, Ottawa, ON Canada ; Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON Canada
| | - Gregory R Pond
- Department of Oncology, McMaster University, Hamilton, Canada
| | - Huijun Zhao
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Sasha Mazzarello
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Lisa Vandermeer
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | | | - Eitan Amir
- Princess Margaret Hospital, Toronto, ON Canada
| | - Mark Clemons
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, ON Canada ; Department of Medicine, University of Ottawa, Ottawa, ON Canada
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A phase II, multicentre trial evaluating the efficacy of de-escalated bisphosphonate therapy in metastatic breast cancer patients at low-risk of skeletal-related events. Breast Cancer Res Treat 2014; 144:615-24. [PMID: 24638849 PMCID: PMC3962742 DOI: 10.1007/s10549-014-2906-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 03/03/2014] [Indexed: 11/27/2022]
Abstract
The optimal frequency of intravenous (IV) bisphosphonate administration is unclear. We thus performed a study evaluating the effects of switching from 3–4 to 12 weekly therapy in patients with biochemically defined low-risk bone metastases. Patients with serum C-telopeptide (CTx) levels ≤600 ng/L after ≥3 months of 3–4 weekly IV pamidronate were switched to 12 weekly therapy for 48 weeks. Primary endpoint was the proportion of patients maintaining CTx levels in the lower-risk range. All endpoints (serum CTx and bone-specific alkaline phosphatase (BSAP), skeletal-related events (SREs) and self-reported pain) were measured at baseline, 6, 12, 24, 36 and 48 weeks. Treatment failure was defined as biochemical failure (CTx > 600 ng/L) or a SRE. Exploratory biomarkers including; serum TGF-β, activin-A, bone sialoprotein (BSP), procollagen type 1 N-terminal propeptide and urinary N-telopeptide (NTx) were assessed at baseline as predictors for failure to complete treatment. Seventy-one patients accrued and 43 (61 %) completed 48 weeks of de-escalated therapy. Reasons for failure to complete treatment included; biochemical failure (CTx > 600 ng/L) (n = 10, 14.1 %), on-study SRE (n = 9, 12.7 %), disease progression (n = 7, 9.9 % including death from disease [n = 1, 1.4 %]) or patient choice (n = 2, 2.8 %). Elevated baseline levels of CTx, BSAP, NTx and BSP were associated with treatment failure. The majority of patients in this biochemically defined low-risk population could switch from 3–4 weekly to 12 weekly bisphosphonate therapy with no effect on CTx levels or SREs during the 48 week study. Larger trials are required to assess the roles of biomarkers as predictors of adequacy of de-escalated therapy.
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Hutton B, Addison CL, Campbell K, Fergusson D, Mazarello S, Clemons M. A systematic review of dosing frequency with bone-targeted agents for patients with bone metastases from breast cancer. J Bone Oncol 2013; 2:123-31. [PMID: 26909282 PMCID: PMC4723383 DOI: 10.1016/j.jbo.2013.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/06/2013] [Accepted: 05/08/2013] [Indexed: 11/16/2022] Open
Abstract
Background Bone-targeted agents are usually administered to breast cancer patients with bone metastases every 3–4 weeks. Less frequent (‘de-escalated’) treatment may provide similar benefits with improved safety and reduced cost. Methods To systematically review randomised trials comparing de-escalated treatment with bone-targeted agents (i.e. every 12–16 weeks) to standard treatment (i.e. every 3–4 weeks), a formal systematic review of the literature was performed. Two individuals independently screened citations and full text articles. Random effects meta-analyses of clinically important outcomes were planned provided homogeneous studies were identified. Results Five relevant studies (n=1287 patients) were identified. Sample size ranged from 38 to 425. Information on outcomes including occurrence of SREs, bone pain, urinary N-telopeptide concentrations, serum C-telopeptide concentrations, pain medication use and safety outcomes was not consistently available. Two trials were non-inferiority studies, two dose-response evaluations and one was a pilot study. Bone-targeted agents use varied between studies, as did duration of prior therapy. Patient populations were considered heterogeneous in several ways, and thus no meta-analyses were performed. Observations from the included studies suggest there is potential that 3 month de-escalated treatment may provide similar benefits compared to 3–4 weekly treatment and that lower doses of zoledronic acid and denosumab might be equally effective. Conclusions Studies comparing standard and de-escalated treatment with bone-targeted agents in breast cancer are rare. The benefits of standard treatment compared to de-escalated therapy on important clinical outcomes remain unclear. Future pragmatic studies must be conducted to determine the merits of this approach.
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Affiliation(s)
- Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada; University of Ottawa, Department of Epidemiology and Community Medicine, Ottawa, Canada
| | - Christina L Addison
- Ottawa Hospital Research Institute, Ottawa, Canada; Ottawa Regional Cancer Centre, Ottawa, Canada
| | - Kaitryn Campbell
- Programs for the Assessment of Technology in Health (PATH) Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Dean Fergusson
- Ottawa Hospital Research Institute, Ottawa, Canada; University of Ottawa, Department of Epidemiology and Community Medicine, Ottawa, Canada
| | | | - Mark Clemons
- Ottawa Hospital Research Institute, Ottawa, Canada; Ottawa Regional Cancer Centre, Ottawa, Canada; University of Ottawa, Department of Medicine, Ottawa, Ontario Canada
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