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Untch M, Pérol D, Mayer EL, Cortes J, Nusch A, Cameron D, Barrios C, Delea T, Danyliv A, Mishra N, Gupta R, Pathak P, Fasching PA. Disease-free survival as a surrogate for overall survival in HR+/HER2- early breast cancer: A correlation analysis. Eur J Cancer 2024; 202:113977. [PMID: 38460476 DOI: 10.1016/j.ejca.2024.113977] [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: 11/10/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Overall survival (OS) is a universally accepted measure of clinical benefit; however, prolonged follow-up is needed to observe sufficient events. Disease-free survival (DFS) has been widely adopted as a primary endpoint for early breast cancer (EBC) trials, as follow-up is comparatively shorter. Here, we present an analysis evaluating DFS as a surrogate for OS for adjuvant treatment of hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) EBC. METHODS A systematic literature review which included randomized controlled trials (RCTs) with ≥80% of adult patients with HR+/HER2- EBC was conducted. The RCTs evaluated various systemic therapeutic categories; key inclusion criteria included reporting of DFS and OS hazard ratios (HRs) and mature OS data. Spearman rank correlation and weighted linear regression analyses evaluated DFS and OS HR correlation. A scenario analysis tested base-case analysis robustness, and a parallel analysis using patient-level data was conducted. RESULTS The base case (N = 14 RCTs) showed an unweighted Spearman coefficient of 0.81 between OS and DFS (weighted: 0.81), with 84% of the variability in OS explained by DFS differences (R2 from weighted regression). The surrogate threshold effect (Burzykowski T, Buyse M. Pharm Stat. 2006;5:173-186) was 0.82 for DFS/OS HR. Scenario analysis (n = 9 RCTs), which excluded chemotherapy trials, and patient-level analysis using FACE trial data were consistent with the base-case analysis. CONCLUSIONS These analyses support DFS as a reliable surrogate endpoint for OS in adjuvant HR+/HER2- EBC trials. Using DFS as a surrogate measure will permit timelier access to novel treatments for patients with HR+/HER2- EBC.
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Affiliation(s)
- Michael Untch
- Interdisciplinary Breast Cancer Center, Helios Klinikum Berlin-Buch, Berlin, Germany.
| | | | - Erica L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Grupo Quiron, Madrid & Barcelona, Spain
| | - Arnd Nusch
- Practice for Hematology and Internal Oncology, Velbert, Germany
| | - David Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Carlos Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | | | | | | | - Rhea Gupta
- Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Purnima Pathak
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Peter A Fasching
- University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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2
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Blondeaux E, Xie W, Carmisciano L, Mura S, Sanna V, De Laurentiis M, Caputo R, Turletti A, Durando A, De Placido S, De Angelis C, Bisagni G, Gasparini E, Rimanti A, Puglisi F, Mansutti M, Landucci E, Fabi A, Arecco L, Perachino M, Bruzzone M, Boni L, Lambertini M, Del Mastro L, Regan MM. Intermediate clinical endpoints in early-stage breast cancer: an analysis of individual patient data from the Gruppo Italiano Mammella and Mammella Intergruppo trials. EClinicalMedicine 2024; 70:102501. [PMID: 38685923 PMCID: PMC11056413 DOI: 10.1016/j.eclinm.2024.102501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 05/02/2024] Open
Abstract
Background Intermediate clinical endpoints (ICEs) are frequently used as primary endpoint in randomised trials (RCTs). We aim to assess whether changes in different ICEs can be used to predict changes in overall survival (OS) in adjuvant breast cancer trials. Methods Individual patient level data from adjuvant phase III RCTs conducted by the Gruppo Italiano Mammella (GIM) and Mammella Intergruppo (MIG) study groups were used. ICEs were computed according to STEEP criteria. Using a two-stage meta-analytic model, we assessed the surrogacy of each ICE at both the outcome (i.e., OS and ICE are correlated irrespective of treatment) and trial (i.e., treatment effects on ICE and treatment effect on OS are correlated) levels. The following ICEs were considered as potential surrogate endpoints of OS: disease-free survival (DFS), distant disease-free survival (DDFS), distant relapse-free survival (DRFS), recurrence-free survival (RFS), recurrence-free interval (RFI), distant recurrence-free interval (DRFI), breast cancer-free interval (BCFI), and invasive breast cancer-free survival (IBCFS). The estimates of the degree of correlation were obtained by copula models and weighted linear regression. Kendall's τ and R2 ≥ 0.70 were considered as indicators of a clinically relevant surrogacy. Findings Among the 12,397 patients enrolled from November 1992 to July 2012 in six RCTs, median age at enrolment was 57 years (interquartile range (IQR) 49-65). After a median follow-up of 10.3 years (IQR 6.4-14.5), 2131 (17.2%) OS events were observed, with 1390 (65.2%) attributed to breast cancer. At the outcome-level, Kendall's τ ranged from 0.69 for BCFI to 0.84 for DRFS. For DFS, DDFS, DRFS, RFS, RFI, DRFI, BCFI, and IBCFS endpoints, over 95% of the 8-year OS variability was attributable to the variation of the 5-year ICE. At the trial-level, treatment effects for the different ICEs and OS were strongly correlated, with the highest correlation for RFS and DRFS and the lowest for BCFI. Interpretation Our results provide evidence supporting the use of DFS, DDFS, DRFS, RFS, RFI, DRFI, and IBCFS as primary endpoint in breast cancer adjuvant trials. Funding This analysis was supported by the Italian Association for Cancer Research ("Associazione Italiana per la Ricerca sul Cancro", AIRC; IG 2017/20760) and by Italian Ministry of Health-5 × 1000 funds (years 2021-2022).
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Affiliation(s)
- Eva Blondeaux
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Wanling Xie
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, USA
| | - Luca Carmisciano
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | - Silvia Mura
- Department of Medical Oncology, UOC Oncologia Medica, University Hospital of Sassari, Sassari, Italy
| | - Valeria Sanna
- Department of Medical Oncology, UOC Oncologia Medica, University Hospital of Sassari, Sassari, Italy
| | - Michelino De Laurentiis
- Istituto Nazionale per lo Studio e la Cura dei Tumouri, Fondazione Pascale IRCCS, Napoli, Italy
| | - Roberta Caputo
- Istituto Nazionale per lo Studio e la Cura dei Tumouri, Fondazione Pascale IRCCS, Napoli, Italy
| | - Anna Turletti
- Medical Oncology, Ospedale Martini ASL Città di Torino, Torino, Italy
| | - Antonio Durando
- Breast Unit, Città della Salute e della Scienza, Ospedale S. Anna, Torino, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Carmine De Angelis
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Giancarlo Bisagni
- Department of Oncology and Advanced Technology, Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elisa Gasparini
- Department of Oncology and Advanced Technology, Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Anita Rimanti
- ASST Mantova, Azienda Ospedaliera Carlo Poma, Mantova, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mauro Mansutti
- Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Alessandra Fabi
- Precision Medicine Breast Unit, Scientific Directorate, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Arecco
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Marta Perachino
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Marco Bruzzone
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Boni
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Lambertini
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Lucia Del Mastro
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Meredith M. Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, USA
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3
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Mittal A, Tamimi F, Molto C, Di Iorio M, Amir E. Benefit of adjuvant bisphosphonates in early breast cancer treated with contemporary systemic therapy: A meta-analysis of randomized control trials. Heliyon 2024; 10:e24793. [PMID: 38312616 PMCID: PMC10835314 DOI: 10.1016/j.heliyon.2024.e24793] [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: 03/31/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/06/2024] Open
Abstract
Background The absolute and relative benefits of adjuvant bisphosphonates on disease-free survival and overall survival in patients receiving contemporary systemic therapy for early breast cancer is uncertain. Methods Data from randomized trials of adjuvant bisphosphonates that recruited patients exclusively after 2000 and reported disease free survival and overall survival was utilized. Five-year disease-free survival and overall survival in bisphosphonates and control group along with associated hazard ratios were extracted. Absolute data were weighted by sample size and hazard ratios were pooled using inverse variance and random effects modelling. Meta-regression comprising linear regression weighted by sample size (mixed effects) was performed to explore association between disease and treatment related factors and absolute differences in benefit from bisphosphonates. Results Eleven trials comprising 24023 patients were included in the analysis. For disease free survival, pooled hazard ratio was 0.89 (0.81-0.97, p = 0.008) with a 1.5 % weighted mean difference favoring bisphosphonates over control. There was no significant overall survival benefit (0.92, 0.82-1.03, p = 0.16). Among patients receiving anthracycline and taxane based chemotherapy, there were no differences in either disease free survival (0.95, 0.80-1.12) or overall survival (1.04, 0.81-1.32). Meta-regression showed lower benefits in higher risk patients (node-positive, larger tumor size, estrogen receptor-, grade 3 or those receiving chemotherapy). Overall, 1 % (95 % CI 0.75-1.15) of patients experienced osteonecrosis of jaw related to zoledronic acid. Conclusions Compared to the Early Breast Cancer Trialist's Collaborative Group meta-analysis, benefit from adjuvant bisphosphonates is lower in recent trials especially in higher risk patients receiving contemporary chemotherapy. The balance between benefits and risks of adjuvant bisphosphonates should be considered in individual patients.
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Affiliation(s)
- Abhenil Mittal
- North East Cancer Centre, Health Sciences North, Northern Ontario School of Medicine (NOSM U), Sudbury, ON, Canada
- Princess Margaret Cancer Centre, Division of Medical Oncology, Toronto, ON, Canada
- University of Toronto, Department of Medicine, Toronto, ON, Canada
| | - Faris Tamimi
- Princess Margaret Cancer Centre, Division of Medical Oncology, Toronto, ON, Canada
- University of Toronto, Department of Medicine, Toronto, ON, Canada
| | - Consolacion Molto
- Princess Margaret Cancer Centre, Division of Medical Oncology, Toronto, ON, Canada
- University of Toronto, Department of Medicine, Toronto, ON, Canada
| | - Massimo Di Iorio
- Princess Margaret Cancer Centre, Division of Medical Oncology, Toronto, ON, Canada
- University of Toronto, Department of Medicine, Toronto, ON, Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre, Division of Medical Oncology, Toronto, ON, Canada
- University of Toronto, Department of Medicine, Toronto, ON, Canada
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4
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MacPhail C, Wood LA, Thana M. Perioperative systemic therapy in renal cell carcinoma. Curr Opin Support Palliat Care 2023; 17:301-307. [PMID: 37800628 DOI: 10.1097/spc.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW Renal cell carcinoma (RCC) is the most common kidney neoplasm. Localized RCC can be cured with nephrectomy. However, a proportion of patients will recur with incurable distant metastatic disease. There is a clear need for treatments to reduce the risk of RCC recurrence and thus improve survival. This review describes the landscape of perioperative therapy for RCC, focusing on more recent trials involving immune checkpoint inhibitors (ICIs). RECENT FINDINGS ICIs have significantly changed outcomes in advanced RCC. Four trials investigating the role of perioperative ICI for RCC are now reported. Only one trial utilizing adjuvant pembrolizumab (Keynote-564) has shown a disease-free survival benefit in resected RCC. SUMMARY Patients with resected RCC should be counselled on their risk of recurrence and the potential option of adjuvant pembrolizumab, recognizing that overall survival data are not yet available.
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Affiliation(s)
- Ceilidh MacPhail
- Division of Medical Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
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Gao T, Yang Y, Zhang Z, Yang Y, Liu S, Hu Y, Zhu Y, Yang H, Fu J, Wang J, Lin T, Xi M, Li Q, Liu M, Zhao L. A Surrogate Endpoint for Overall Survival in Locally Advanced and Resectable Esophageal Squamous Cell Carcinoma: A Reanalysis of Data From the NEOCRTEC5010 Trial. Int J Radiat Oncol Biol Phys 2023; 117:809-820. [PMID: 37210047 DOI: 10.1016/j.ijrobp.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE This study aimed to investigate disease-free survival (DFS) as a surrogate endpoint for overall survival (OS) in patients with locally advanced and resectable esophageal squamous cell carcinoma. METHODS AND MATERIALS We re-analyzed patient data from the NEOCRTEC5010 randomized controlled trial (N = 451 patients) to compare their OS with that of an age- and sex-matched cohort from the general population of China. We used expected survival and the standardized mortality ratio, respectively, in our analysis of data collected from a neoadjuvant chemoradiation therapy (NCRT) plus surgery group and a surgery-only group. Published data from 6 randomized controlled trials and 20 retrospective studies were used to examine the correlation between DFS and OS at the trial level. RESULTS The annual hazard rate of disease progression decreased to 4.9% and 8.1% within 3 years in the NCRT and surgery groups, respectively. Patients who were disease-free at 36 months had a 5-year OS of 93.9% (95% CI, 89.7%-98.4%) in the NCRT group with a standardized mortality ratio of 1.1 (95% CI, 0.7-1.8; P = .5639). In contrast, the 5-year OS was only 12.9% (95% CI, 7.3%-22.6%) for patients in the NCRT group who exhibited disease progression within 36 months. At the trial level, DFS and OS were correlated with treatment effect (R2 = 0.605). CONCLUSIONS Disease-free status at 36 months is a valid surrogate endpoint for 5-year OS in patients with locally advanced and resectable esophageal squamous cell carcinoma. Patients who were disease-free at 36 months showed a favorable OS, which was indistinguishable from that of the age- and sex-matched comparison group from the general population; otherwise, their 5-year OS was extremely poor.
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Affiliation(s)
- Tiantian Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yong Yang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Zewei Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yuxian Yang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shiliang Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Yonghong Hu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Yujia Zhu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Hong Yang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China; Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jianhua Fu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China; Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Junye Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ting Lin
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China; Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Mian Xi
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Qiaoqiao Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Mengzhong Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China.
| | - Lei Zhao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China.
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Wright K, Mittal A, Gyawali B. Surrogate endpoints for HTA decisions of breast cancer drugs: utility and pitfalls. Curr Opin Oncol 2023; 35:513-521. [PMID: 37621175 DOI: 10.1097/cco.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE OF REVIEW Health technology assessment (HTA) of cancer drugs is important to identify whether drugs should be publicly funded. With increasing use of surrogate end points in clinical trials including breast cancer, a review of literature was done to synthesize evidence for validation of these surrogate end points and their potential role in HTA decisions pertaining to breast cancer. FINDINGS Disease free survival (DFS) in human epidermal receptor 2 (HER2) positive early breast cancer remains the only validated surrogate end point. Other surrogate end points like pathological complete response (pCR) and event free survival (EFS) in early breast cancer (EBC) and objective response rate (ORR) and progression free survival (PFS) in advanced disease have not been validated for overall survival (OS). Moreover, surrogate end points for quality of life (QOL) have not been established and drugs that improve PFS can have detrimental effect on QOL. End points like pCR have excellent prognostic utility in individual patients but have weak correlation with survival at trial level. SUMMARY Most surrogate end points used in breast cancer do not predict OS or QOL which makes it challenging to use them for decisions regarding public funding of cancer drugs. These findings are relevant to HTA agencies prior to making drug reimbursement decisions.
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Affiliation(s)
| | - Abhenil Mittal
- Division of Hematology and Oncology, Department of Medicine, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario
| | - Bishal Gyawali
- Department of Oncology, Queen's University
- Department of Public Health Sciences
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
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7
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Yang L, Zhang S, Pu P. Comprehensive analysis of ACKR family members in breast cancer using prognostic values. Oncol Lett 2023; 26:425. [PMID: 37664667 PMCID: PMC10472033 DOI: 10.3892/ol.2023.14011] [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: 05/12/2023] [Accepted: 07/25/2023] [Indexed: 09/05/2023] Open
Abstract
Breast cancer (BC) is by far the most prevalent malignancy found in the female population. Atypical chemokine receptors (ACKRs) are a subclass of G-protein-coupled receptors, which are characterized by disrupted ligand binding and a breakdown of signaling following ligand binding. The evolution and function of multiple ACKRs in BC have yet to be fully elucidated, although certain findings on this family have been reported in several studies in Homo sapiens and other species. The present study identified that the expression level of ACKRs was significantly lower in breast carcinoma (BRCA) tissues compared with normal breast tissues through searches of the Tumor Immune Estimation Resource, UALCAN and Gene Expression Profiling Interactive Analysis databases. Additionally, when comparing BRCA tissues with normal breast tissues, it was found that there was obvious hypomethylation in the promoters of ACKR1, ACKR3 and ACKR5, as well as a marked hypermethylation in the promoters of ACKR2 and ACKR6. In determining the prognosis of patients with BRCA, the expression levels of ACKR1, ACKR2, ACKR3, ACKR4 and ACKR6 were all found to be important factors. The values for distant metastasis-free survival (DMFS), overall survival (OS) and recurrence-free survival (RFS) were all found to be lower in patients with BRCA who had a low expression level of ACKR1. In addition, the RFS rates for patients with BRCA were lower when the expression of ACKR2 was low, and worse values for DMFS, OS and RFS were found to be highly correlated with higher expression levels of ACKR3. Moreover, the DMFS, OS, RFS and predictive power score values were worse in those patients with low ACKR4 expression, and the RFS values for patients with BRCA were also found to be lower when the expression level of ACKR6 was low. Additionally, dendritic cells, macrophages, neutrophils, T cells with CD4+ status, T cells with CD8+ status and B cells were all substantially linked with ACKR expression, as well as immune cell infiltration. Taken together, the findings of the present study may offer a theoretical foundation for the creation of novel targets and prognostic indicators for BRCA therapy.
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Affiliation(s)
- Lixian Yang
- Department of Breast Surgery, Xingtai People's Hospital, Xingtai, Hebei 054000, P.R. China
| | - Shiyu Zhang
- Department of Breast Surgery, Xingtai People's Hospital, Xingtai, Hebei 054000, P.R. China
| | - Pengpeng Pu
- Department of Breast Surgery, Xingtai People's Hospital, Xingtai, Hebei 054000, P.R. China
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8
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Puglisi S, Calabrese A, Ferraù F, Violi MA, Laganà M, Grisanti S, Ceccato F, Scaroni C, Di Dalmazi G, Stigliano A, Altieri B, Canu L, Loli P, Pivonello R, Arvat E, Morelli V, Perotti P, Basile V, Berchialla P, Urru S, Fiori C, Porpiglia F, Berruti A, Pia A, Reimondo G, Cannavò S, Terzolo M. New Findings on Presentation and Outcome of Patients With Adrenocortical Cancer: Results From a National Cohort Study. J Clin Endocrinol Metab 2023; 108:2517-2525. [PMID: 37022947 DOI: 10.1210/clinem/dgad199] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
CONTEXT Because of the rarity of adrenocortical cancer (ACC), only a few population-based studies are available, and they reported limited details in the characterization of patients and their treatment. OBJECTIVE To describe in a nationwide cohort the presentation of patients with ACC, treatment strategies, and potential prognostic factors. METHODS Retrospective analysis of 512 patients with ACC, diagnosed in 12 referral centers in Italy from January 1990 to June 2018. RESULTS ACC diagnosed as incidentalomas accounted for overall 38.1% of cases, with a frequency that increases with age and with less aggressive pathological features than symptomatic tumors. Women (60.2%) were younger than men and had smaller tumors, which more frequently secreted hormones. Surgery was mainly done with an open approach (72%), and after surgical resection, 62.7% of patients started adjuvant mitotane therapy. Recurrence after tumor resection occurred in 56.2% of patients. In patients with localized disease, cortisol secretion, ENSAT stage III, Ki67%, and Weiss score were associated with an increased risk of recurrence, whereas margin-free resection, open surgery, and adjuvant mitotane treatment were associated with reduced risk. Death occurred in 38.1% of patients and recurrence-free survival (RFS) predicted overall survival (OS). In localized disease, age, cortisol secretion, Ki67%, ENSAT stage III, and recurrence were associated with increased risk of mortality. ACCs presenting as adrenal incidentalomas showed prolonged RFS and OS. CONCLUSION Our study shows that ACC is a sex-related disease and demonstrates that an incidental presentation is associated with a better outcome. Given the correlation between RFS and OS, RFS may be used as a surrogate endpoint in clinical studies.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
| | - Anna Calabrese
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
| | - Francesco Ferraù
- Endocrine Unit of University Hospital of Messina, University of Messina, 98124 Messina, Italy
| | - Maria Antonia Violi
- Endocrine Unit of University Hospital of Messina, University of Messina, 98124 Messina, Italy
| | - Marta Laganà
- Oncology Unit, University of Brescia, 25123 Brescia, Italy
| | | | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, 35128 Padua, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, 35128 Padua, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care Unit, IRCCS, University Hospital of Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Antonio Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, 00189 Rome, Italy
| | - Barbara Altieri
- Division of Endocrinology and Metabolic Diseases, University-Hospital Gemelli, IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Letizia Canu
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy
| | - Paola Loli
- Endocrinology, Clinica Polispecialistica San Carlo, 20037 Milan, Italy
| | - Rosario Pivonello
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Emanuela Arvat
- Oncological Endocrinology Unit, Department of Medical Sciences, University of Turin, 10043 Turin, Italy
| | - Valentina Morelli
- Department of Endocrine and Metabolic Disease, Istituto Auxologico Italiano, IRCSS, 20145 Milan, Italy
| | - Paola Perotti
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
| | - Vittoria Basile
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
| | - Paola Berchialla
- Statistical Unit, Department of Clinical and Biological Sciences, University of Turin, 10043 Turin, Italy
| | - Sara Urru
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35121 Padua, Italy
| | - Cristian Fiori
- Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10043 Turin, Italy
| | - Francesco Porpiglia
- Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10043 Turin, Italy
| | | | - Anna Pia
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
| | - Giuseppe Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
| | - Salvatore Cannavò
- Endocrine Unit of University Hospital of Messina, University of Messina, 98124 Messina, Italy
| | - Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, University of Turin, 10043 Turin, Italy
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9
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Ivanovic N, Bjelica D, Loboda B, Bogdanovski M, Colakovic N, Petricevic S, Gojgic M, Zecic O, Zecic K, Zdravkovic D. Changing the role of pCR in breast cancer treatment - an unjustifiable interpretation of a good prognostic factor as a "factor for a good prognosis". Front Oncol 2023; 13:1207948. [PMID: 37534241 PMCID: PMC10391828 DOI: 10.3389/fonc.2023.1207948] [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: 04/18/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
Pathologic complete response (pCR) after neoadjuvant systemic therapy (NAST) of early breast cancer (EBC) has been recognized as a good prognostic factor in the treatment of breast cancer because of its significant correlation with long-term disease outcome. Based on this correlation, pCR has been accepted by health authorities (FDA, EMA) as a surrogate endpoint in clinical trials for accelerated drug approval. Moreover, in recent years, we have observed a tendency to treat pCR in routine clinical practice as a primary therapeutic target rather than just one of the pieces of information obtained from clinical trials. These trends in routine clinical practice are the result of recommendations in treatment guidelines, such as the ESMO recommendation "…to deliver all planned (neoadjuvant) treatment without unnecessary breaks, i.e. without dividing it into preoperative and postoperative periods, irrespective of the magnitude of tumor response", because "…this will increase the probability of achieving pCR, which is a proven factor for a good prognosis…". We hypothesize that the above recommendations and trends in routine clinical practice are the consequences of misunderstanding regarding the concept of pCR, which has led to a shift in its importance from a prognostic factor to a desired treatment outcome. The origin of this misunderstanding could be a strong subconscious incentive to achieve pCR, as patients who achieved pCR after NAST had a better long-term outcome compared with those who did not. In this paper, we attempt to prove our hypothesis. We performed a comprehensive analysis of the therapeutic effects of NAST and adjuvant systemic therapy (AST) in EBC to determine whether pCR, as a phenomenon that can only be achieved at NAST, improves prognosis per se. We used published papers as a source of data, which had a decisive influence on the formation of the modern attitude towards EBC therapy. We were unable to find any evidence supporting the use of pCR as a desired therapeutic goal because NAST (reinforced by pCR) was never demonstrated to be superior to AST in any context.
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Affiliation(s)
- Nebojsa Ivanovic
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
- Department of Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Bjelica
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
| | - Barbara Loboda
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
| | - Masan Bogdanovski
- Faculty of Philosophy, Department of Philosophy, University of Belgrade, Belgrade, Serbia
| | - Natasa Colakovic
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
- Department of Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Simona Petricevic
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
| | - Milan Gojgic
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
| | - Ognjen Zecic
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
| | - Katarina Zecic
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Darko Zdravkovic
- Department of Surgical Oncology, University Hospital Medical Center (UHMC) “Bezanijska kosa”, Belgrade, Serbia
- Department of Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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10
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Squifflet P, Saad ED, Loibl S, van Mackelenbergh MT, Untch M, Rastogi P, Gianni L, Schneeweiss A, Conte P, Piccart M, Bonnefoi H, Jackisch C, Nekljudova V, Tang G, Valagussa P, Neate C, Gelber R, Poncet C, Heinzmann D, Denkert C, Geyer CE, Cortes J, Guarneri V, de Azambuja E, Cameron D, Ismael G, Wolmark N, Cortazar P, Buyse M. Re-Evaluation of Pathologic Complete Response as a Surrogate for Event-Free and Overall Survival in Human Epidermal Growth Factor Receptor 2-Positive, Early Breast Cancer Treated With Neoadjuvant Therapy Including Anti-Human Epidermal Growth Factor Receptor 2 Therapy. J Clin Oncol 2023; 41:2988-2997. [PMID: 36977286 DOI: 10.1200/jco.22.02363] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/16/2022] [Accepted: 02/09/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE Pathologic complete response (pCR) has prognostic importance and is frequently used as a primary end point, but doubts remain about its validity as a surrogate for event-free survival (EFS) and overall survival (OS) in human epidermal growth factor receptor 2 (HER2)-positive, early breast cancer. METHODS We obtained individual-patient data from randomized trials of neoadjuvant anti-HER2 therapy that enrolled at least 100 patients, had data for pCR, EFS, and OS, and a median follow-up of at least 3 years. We quantified the patient-level association between pCR (defined as ypT0/Tis ypN0) and both EFS and OS using odds ratios (ORs, with ORs >1.00 indicating a benefit from achieving a pCR). We quantified the trial-level association between treatment effects on pCR and on EFS and OS using R2 (with values above 0.75 considered as indicating strong associations). RESULTS Eleven of 15 eligible trials had data for analysis (3,980 patients, with a median follow-up of 62 months). Considering all trials, we found strong patient-level associations, with ORs of 2.64 (95% CI, 2.20 to 3.07) for EFS and 3.15 (95% CI, 2.38 to 3.91) for OS; however, trial-level associations were weak, with an unadjusted R2 of 0.23 (95% CI, 0 to 0.66) for EFS and 0.02 (95% CI, 0 to 0.17) for OS. We found qualitatively similar results when grouping trials according to different clinical questions, when analyzing only patients with hormone receptor-negative disease, and when using a more stringent definition of pCR (ypT0 ypN0). CONCLUSION Although pCR may be useful for patient management, it cannot be considered as a surrogate for EFS or OS in neoadjuvant trials of HER2-positive, operable breast cancer.
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Affiliation(s)
- Pierre Squifflet
- International Drug Development Institute (IDDI), Louvain-la-Neuve, Belgium
| | - Everardo D Saad
- International Drug Development Institute (IDDI), Louvain-la-Neuve, Belgium
| | | | | | | | | | - Luca Gianni
- San Raffaele Scientific Institute, Milan, Italy
| | | | - Pierfranco Conte
- Department of Surgery, Oncology and Gastroenterology, University of Padova and Medical Oncology 2, Istituto Oncologico Veneto IOV-IRCCS, Padova, Italy
| | - Martine Piccart
- Institut Jules Bordet and Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Hervé Bonnefoi
- Institut Bergonié and Université de Bordeaux INSERM U916, Bordeaux, France
| | | | | | - Gong Tang
- University of Pittsburgh, Pittsburgh, PA
| | | | - Colin Neate
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Richard Gelber
- Dana-Farber Cancer Institute, Harvard Medical School, Harvard TH Chan School of Public Health and Frontier Science and Technology Research Foundation, Boston, MA
| | - Coralie Poncet
- European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Dominik Heinzmann
- Product Development-Oncology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Carsten Denkert
- Institut für Pathologie, Philipps-Universität Marburg und Universitätsklinikum Marburg, Marburg, Germany
| | | | - Javier Cortes
- IOB Institute of Oncology, Quiron Group, Madrid & Barcelona and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Valentina Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova and Medical Oncology 2, Istituto Oncologico Veneto IOV-IRCCS, Padova, Italy
| | - Evandro de Azambuja
- Institut Jules Bordet and Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - David Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh and NHS Lothian, Edinburgh, United Kingdom
| | | | | | | | - Marc Buyse
- International Drug Development Institute (IDDI), Louvain-la-Neuve, Belgium
- Data Science Institute, I-BioStat, Hasselt University, Hasselt, Belgium
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11
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Gogate A, Ranjan S, Kumar A, Bhandari H, Papademetriou E, Kim I, Potluri R. Correlation between pathologic complete response, event-free survival/disease-free survival and overall survival in neoadjuvant and/or adjuvant HR+/HER2-breast cancer. Front Oncol 2023; 13:1119102. [PMID: 37205193 PMCID: PMC10185900 DOI: 10.3389/fonc.2023.1119102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
Purpose The study's purpose was to evaluate the correlation between overall survival (OS) and its potential surrogate endpoints: pathologic complete response (pCR) and event-free survival (EFS)/disease-free survival (DFS) in neoadjuvant and/or adjuvant HR+/HER2- breast cancer. Methods Systematic search was performed in MEDLINE, EMBASE, Cochrane Library databases and other relevant sources to identify literature that have reported outcomes of interest in the target setting. The strength of correlation of EFS/DFS with OS, pCR with OS, and pCR with EFS/DFS was measured using Pearson's correlation coefficient (r) based on weighted regression analysis. For Surrogate Endpoint-True Endpoint pairs where correlation was found to be moderate, surrogate threshold effect (STE) was estimated using a mixed-effects model. Sensitivity analyses were conducted on the scale and weights used and removing outlier data. Results Moderate correlation was observed of relative measures [log(HR)] of EFS/DFS and OS (r = 0.91; 95% CI: 0.83, 0.96, p < 0.0001). STE for HREFS/DFS was estimated to be 0.73. Association between EFS/DFS at 1, 2 and 3 years with OS at 4- and 5-year landmarks was moderate. Relative treatment effects of pCR and EFS/DFS were not strongly associated (r: 0.24; 95% CI: -0.63, 0.84, p = 0.6028). Correlation between pCR and OS was either not evaluated due to inadequate sample size (relative outcomes) or weak (absolute outcomes). Results obtained in the sensitivity analyses were similar to base scenario. Conclusion EFS/DFS were moderately correlated with OS in this trial-level analysis. They may be considered as valid surrogates for OS in HR+/HER2- breast cancer.
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Affiliation(s)
- Anagha Gogate
- WWHEOR, Bristol Myers Squibb, Princeton, NJ, United States
- *Correspondence: Anagha Gogate,
| | | | - Amit Kumar
- HEOR, SmartAnalyst India Pvt. Ltd., Gurgaon, India
| | | | | | - Inkyu Kim
- WWHEOR, Bristol Myers Squibb, Princeton, NJ, United States
| | - Ravi Potluri
- HEOR, SmartAnalyst Inc., New York, NY, United States
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12
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Mittal A, Tamimi F, Molto C, Meti N, Al-Showbaki L, Wilson BE, Amir E. Three-year disease-free survival in randomized trials of neoadjuvant chemotherapy and HER2-targeted therapy in breast cancer: A meta-analysis. Crit Rev Oncol Hematol 2023; 181:103880. [PMID: 36435297 DOI: 10.1016/j.critrevonc.2022.103880] [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: 03/30/2022] [Revised: 10/26/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Outcomes for breast cancer patients with residual disease (RD) after neoadjuvant chemotherapy (NACT) and HER2-targeted therapy may be better than anticipated leading to a smaller absolute benefit of adjuvant trastuzumab emtansine (T-DM1). Therefore, accurate estimates of 3-year disease-free survival (DFS) can aid in treatment planning. METHODS We reviewed randomized trials of NACT and HER2-targeted therapy in breast cancer (excluding T-DM1) and calculated mean 3-year DFS weighted by study sample size. Meta-regression comprising linear regression weighted by sample size (mixed-effects) was performed to explore associations between 3-year DFS and year of accrual and trial-level patient, disease, and treatment factors. Data were reported quantitatively irrespective of statistical significance. RESULTS Eleven studies (N = 3581) were included in the primary analysis. The mean 3-year DFS for patients with RD was 79.7% (95% CI 77.4-80.9). This was higher for trials completing accrual after 2010 [83% (95% CI 79.3-86.3)] and for those receiving dual HER2 targeted therapy [83.4% (95% CI 79.2-87.7]. Better outcomes for ER positivity, later accrual and dual Her-2 targeted therapy were confirmed in meta-regression. Negative quantitative significance was observed for larger clinical tumor size and nodal involvement. CONCLUSIONS The 3-year DFS for patients with RD has improved over time possibly due to dual HER2 targeted therapy. This will reduce the absolute benefit of adjuvant T-DM1 in this group of patients.
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Affiliation(s)
- Abhenil Mittal
- Division of Medical Oncology and Haematology, Department of Medicine, Princess Margaret Cancer Center, University of Toronto, ON, Canada
| | - Faris Tamimi
- Division of Medical Oncology and Haematology, Department of Medicine, Princess Margaret Cancer Center, University of Toronto, ON, Canada
| | - Consolacion Molto
- Division of Medical Oncology and Haematology, Department of Medicine, Princess Margaret Cancer Center, University of Toronto, ON, Canada
| | - Nicholas Meti
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Laith Al-Showbaki
- Division of Hematology and Medical Oncology, Department of Medicine, University Hospital and School of Medicine, University of Jordan, Amman, Jordan
| | - Brooke E Wilson
- Collaboration for Cancer Outcomes, Research and Evaluation, South West Clinical School, University of New South Wales, Liverpool, NSW, Australia; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Eitan Amir
- Division of Medical Oncology and Haematology, Department of Medicine, Princess Margaret Cancer Center, University of Toronto, ON, Canada.
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13
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Impact of adjuvant trastuzumab treatment on fatigue, emotional status and quality of personal and work life of patients with localised breast cancer: results of the ‘HER-ception’ study. Support Care Cancer 2023; 31:38. [DOI: 10.1007/s00520-022-07512-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022]
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14
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Liu Y, Zheng L, Cai X, Zhang X, Ye Y. Cardiotoxicity from neoadjuvant targeted treatment for breast cancer prior to surgery. Front Cardiovasc Med 2023; 10:1078135. [PMID: 36910540 PMCID: PMC9992214 DOI: 10.3389/fcvm.2023.1078135] [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: 10/24/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Cancer treatment has been gradually shifting from non-specific cytotoxic agents to molecularly targeted drugs. Breast cancer (BC), a malignant tumor with one of the highest incidence worldwide, has seen a rapid development in terms of targeted therapies, leading to a radical change in the treatment paradigm. However, the use of targeted drugs is accompanied by an increasing rate of deaths due to non-tumor-related causes in BC patients, with cardiovascular complications as the most common cause. Cardiovascular toxicity during antitumor therapy has become a high-risk factor for survival in BC patients. Targeted drug-induced cardiotoxicity exerts a wide range of effects on cardiac structure and function, including conduction disturbances, QT interval prolongation, impaired myocardial contractility, myocardial fibrosis, and hypertrophy, resulting in various clinical manifestations, e.g., arrhythmias, cardiomyopathy, heart failure, and even sudden death. In adult patients, the incidence of antitumor targeted drug-induced cardiotoxicity can reach 50%, and current preclinical evaluation tools are often insufficiently effective in predicting clinical cardiotoxicity. Herein, we reviewed the current status of the occurrence, causative mechanisms, monitoring methods, and progress in the prevention and treatment of cardiotoxicity associated with preoperative neoadjuvant targeted therapy for BC. It supplements the absence of relevant review on the latest research progress of preoperative neoadjuvant targeted therapy for cardiotoxicity, with a view to providing more reference for clinical treatment of BC patients.
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Affiliation(s)
- Yihua Liu
- Department of Breast Surgery, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Li Zheng
- Department of Breast Surgery, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xingjuan Cai
- Department of Breast Surgery, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaojun Zhang
- Department of Breast Surgery, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yang Ye
- Department of Traditional Chinese Medicine, Peking University Third Hospital, Beijing, China
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15
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Viscardi G, Vitiello F, Servetto A, Gristina V, Pizzutilo EG, Canciello MA, Medusa PM, Salomone F, Di Guida G, Mollica M, Aronne L, Scaramuzzi R, Napolitano F, Battiloro C, Caputo F, Gilli M, Totaro G, Curcio C, Rocco D, Montesarchio V. Moving Immune Checkpoint Inhibitors to Early Non-Small Cell Lung Cancer: A Narrative Review. Cancers (Basel) 2022; 14:cancers14235810. [PMID: 36497292 PMCID: PMC9735901 DOI: 10.3390/cancers14235810] [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: 10/25/2022] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 11/29/2022] Open
Abstract
Lung cancer is the leading cause of cancer-related death worldwide. Since prognosis of early-stage non-small cell lung cancer (NSCLC) remains dismal for common relapses after curative surgery, considerable efforts are currently focused on bringing immunotherapy into neoadjuvant and adjuvant settings. Previously, perioperative chemotherapy showed only a modest but significative improvement in overall survival. The presence of broad tumor neoantigens load at primary tumor prior to surgery as well as the known immunosuppressive status following resection represent the main rationale for immunotherapy in early disease. Several trials have been conducted in recent years, leading to atezolizumab and nivolumab approval in the adjuvant and neoadjuvant setting, respectively, and perioperative immunotherapy in NSCLC remains a field of active clinical and preclinical investigation. Unanswered questions in perioperative therapy in NSCLC include the optimal sequence and timing of chemotherapy and immunotherapy, the potential of combination strategies, the role of predictive biomarkers for patient selection and the choice of useful endpoints in clinical investigation.
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Affiliation(s)
- Giuseppe Viscardi
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, Via Sergio Pansini 5, 80131 Naples, Italy
- Correspondence:
| | - Fabiana Vitiello
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Alberto Servetto
- Medical Oncology, Department of Clinical Medicine and Surgery, Università degli Studi di Napoli “Federico II”, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Valerio Gristina
- Medical Oncology, Department of Surgical, Oncological and Oral Sciences, Università degli Studi di Palermo, Via Liborio Giuffrè 5, 90127 Palermo, Italy
| | - Elio Gregory Pizzutilo
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy
- Departmento of Oncology and Hematology, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Maria Anna Canciello
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Paola Maria Medusa
- Pneumology Unit, Università degli Studi della Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Fabio Salomone
- Medical Oncology, Department of Clinical Medicine and Surgery, Università degli Studi di Napoli “Federico II”, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Gaetano Di Guida
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, Via Sergio Pansini 5, 80131 Naples, Italy
| | - Mariano Mollica
- Respiratory Pathophysiology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Luigi Aronne
- Pneumology Unit, Università degli Studi della Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Roberto Scaramuzzi
- Thoracic Surgery, Department of General and Specialistic Surgery, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Filomena Napolitano
- Thoracic Surgery, Department of General and Specialistic Surgery, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Ciro Battiloro
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Francesca Caputo
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Marina Gilli
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Giuseppe Totaro
- Radiotherapy Unit, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Via Mariano Semmola, 80131 Naples, Italy
| | - Carlo Curcio
- Thoracic Surgery, Department of General and Specialistic Surgery, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Danilo Rocco
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Vincenzo Montesarchio
- Medical Oncology, Department of Pneumology and Oncology, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy
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16
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Surrogacy analysis of intermediate end-points for overall survival in randomized controlled trials of rhabdomyosarcoma. Sci Rep 2022; 12:19381. [PMID: 36371419 PMCID: PMC9653385 DOI: 10.1038/s41598-022-23944-w] [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: 06/12/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Treatment of malignant tumors, such as rhabdomyosarcoma (RMS), can improve overall survival (OS). It is time-consuming and expensive for patients to obtain benefits from randomized controlled trials (RCTs) with OS as the primary end-point. Therefore, another surrogate end-point is necessary; however, there is no report on the surrogacy analysis of RMS. In this study, we performed a systematic review of RCTs, involving patients with newly diagnosed RMS, and 11 RCTs were identified. We performed a meta-analysis to assess the surrogacy of intermediate end-points for OS. The correlations between surrogate end-points and OS were investigated using Spearman's rank correlation coefficient (ρ). The coefficient of determination (R2) was employed to measure the strength of the association. A total of 5183 patients were randomly allocated to 34 treatment groups. A marginal correlation (R2 = 0.281, ρ = 0.445) between the hazard ratios (HRs) for event-free survival (EFS) and OS was observed. In patients with localized RMS, the EFS HR had a weaker correlation with OS HR in the sensitivity analysis than that in the primary analysis. Overall, the surrogacy of EFS for OS cannot be confirmed.
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17
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Omidvari A, Salehi A, Sepahvand M, Omidvari S, Mohammadianpanah M. Long-Term Oncologic Outcome of Breast Cancer in Southern Iran: A Retrospective Cohort Study. Asian Pac J Cancer Prev 2022; 23:3877-3884. [PMID: 36444601 PMCID: PMC9930976 DOI: 10.31557/apjcp.2022.23.11.3877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/09/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Breast cancer remains the most frequent and lethal cancer among women worldwide. This study aimed to investigate the characteristics, prognostic factors and outcome of breast cancer patient treated and followed-up in Shiraz, southern Iran from 2000 to 2005. METHODS In this retrospective study, 1,024 patients with breast cancer who were treated in Namazi hospital of Shiraz University of Medical Sciences between 2000 and 2005 were included. Survival analysis was performed to determine potential factors influencing disease free-and overall survival in these patients. RESULTS Median age of the patients at diagnosis was 47 (range 19-83) years. Median follow-up for surviving patients was 68 months. The majority of patients presented at stage II (42%) and stage III (41%). Additionally, most (61%) patients had positive axillary node. The 5-, 10- and 15-year overall survival rates were 83.8%, 61.5% and 56.6% respectively. On multivariate analysis for overall survival, histologic type, Tumor stage, node stage, disease stage, M stage, hormone receptor status, adjuvant radiotherapy, and chemotherapy regimen remained independent prognostic factor for overall survival. CONCLUSION in this study, the poor long-term oncologic outcome of the patients with breast cancer may be due to the higher rate of locally advanced disease; as well as the lack of modern systemic therapies in the study period.
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Affiliation(s)
- Ali Omidvari
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Alireza Salehi
- Department of MPH, School of Medicine Shiraz University of Medical Sciences Shiraz, Iran.
| | - Mahsa Sepahvand
- Department of MPH, School of Medicine Shiraz University of Medical Sciences Shiraz, Iran.
| | - Shapour Omidvari
- Department of MPH, School of Medicine Shiraz University of Medical Sciences Shiraz, Iran.
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18
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Hansen CW, Vogsen M, Kodahl AR. Management and outcomes after neoadjuvant treatment for locally advanced breast cancer in older versus younger women. Acta Oncol 2022; 61:1362-1368. [DOI: 10.1080/0284186x.2022.2137844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
| | - Marianne Vogsen
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Annette Raskov Kodahl
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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19
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Zhao J, Zhao H, Jia T, Yang S, Wang X. Combination of Changes in CEA and CA199 Concentration After Neoadjuvant Chemoradiotherapy Could Predict the Prognosis of Stage II/III Rectal Cancer Patients Receiving Neoadjuvant Chemoradiotherapy Followed by Total Mesorectal Excision. Cancer Manag Res 2022; 14:2933-2944. [PMID: 36200095 PMCID: PMC9529229 DOI: 10.2147/cmar.s377784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Previous studies have shown that the levels of serum tumor markers CEA and CA19-9 were related to chemoradiotherapy. Therefore, it has been assumed that dynamic monitoring of these markers could predict the prognosis of stage II/III rectal cancer (RC). Therefore, this study proposed to evaluate the prognostic value of changes in serum tumor biomarkers for stage II/III RC patients undergoing neoadjuvant chemoradiotherapy (NCRT) followed by total mesorectal excision (TME). Methods A total of 217 patients with stage II/III RC receiving NCRT followed by TME were retrospectively analyzed. Serum CEA and CA199 levels were measured within one week before NCRT and one week before TME. The optimal cut-off points of ∆CEA% and ∆CA199% for prognosis prediction were calculated by receiver operating characteristics (ROC) analysis. Independent prognostic predictors were identified by univariate and multivariate Cox regression analyses. To avoid the efficiency of ∆CEA% and ∆CA199% on serum tumor biomarker change (STBC) score, two models including and excluding ∆CEA% and ∆CA199% were established separately in multivariate analysis. Results The optimal cut-off point for ∆CEA% and ∆CA199% were −30.29% and 20.30%, respectively. Univariate analysis showed that ∆CEA%, ∆CA199%, STBC score, ypT staging and yN staging could predict OS. ypT staging and STBC score could predict DFS. In multivariate analysis, only ∆CA199% (HR = 0.468, 95% CI: 0.220–0.994, p = 0.048), ypT staging (HR = 0.420, 95% CI: 0.182–0.970, p = 0.042), and STBC score (HR = 0.204, 95% CI: 0.078–0.532, p = 0.001) were independently related to OS; and STBC score (HR = 0.412, 95% CI: 0.216–0.785, p=0.007) and ypT staging (HR = 0.421, 95% CI: 0.224–0.792, p = 0.007) were independently related to DFS. Conclusion We established a combined STBC score to predict the prognosis of stage II/III RC patients receiving NCRT followed by TME. The predictive value of the combined score was stronger than a single marker alone and even stronger than several pathological indicators.
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Affiliation(s)
- Jieyi Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- West China Medical School, Sichuan University, Chengdu, People’s Republic of China
| | - Huamin Zhao
- West China Medical School, Sichuan University, Chengdu, People’s Republic of China
| | - Tingting Jia
- West China Medical School, Sichuan University, Chengdu, People’s Republic of China
| | - Shiru Yang
- West China Medical School, Sichuan University, Chengdu, People’s Republic of China
| | - Xiaoyu Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
- West China Medical School, Sichuan University, Chengdu, People’s Republic of China
- Correspondence: Xiaoyu Wang, Tel +86 18980605160, Email
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20
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Corso G, D'Ecclesiis O, Magnoni F, Mazzotta E, Conforti F, Veronesi P, Sajjadi E, Venetis K, Fusco N, Gandini S. Metaplastic breast cancers and triple-negative breast cancers of no special type: are they prognostically different? A systematic review and meta-analysis. Eur J Cancer Prev 2022; 31:459-466. [PMID: 35088973 DOI: 10.1097/cej.0000000000000733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Metaplastic breast cancer (MBC) and triple-negative (TN) BC of no special type are often confounded with each other in terms of survival and prognosis. In this systematic study and meta-analysis, we evaluated the prognosis of each of these two different diagnoses. METHODS We conducted a systematic literature search and review using the MOOSE guidelines, through PUBMED database, the Ovid MEDLINE database, and the ISI Web of Science Citation Index Expanded (SCI Expanded). Overall survival (OS) and disease-free survival (DFS) were the main outcomes considered. RESULTS Our review eventually selected six independent studies, with a total of more than 59 519 patients. MBC was found to associate with worse OS compared to TNBC of no special type, with a significant 40% increased risk of death [summary hazard ratio (SHR) = 1.40, 95% confidence interval (CI): 1.30-1.50]. We found neither heterogeneity ( I2 = 0%) nor evidence of publication bias ( P = 0.82 and P = 0.49 by Begg's and Egger's test, respectively) between studies. No statistically significant difference was found between MBC and TNBC of no special type in terms of DFS (SHR = 1.17, 95% CI: 0.80-1.71). CONCLUSION This study demonstrates that TNBC of no special type and MBC have comparable DFS, although the latter presents a significantly worse prognosis in terms of OS. Despite DFS being similar in both subtypes, this did not result in significant OS benefits, with MBC score being the worse of the two diseases.
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Affiliation(s)
- Giovanni Corso
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, Milan
- Department of Oncology and Hemato-Oncology, University of Milan, Milan
| | - Oriana D'Ecclesiis
- Division of Experimental Oncology, European Institute of Oncology (IEO), IRCCS, Milan
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, Milan
| | - Erica Mazzotta
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, Milan
| | - Fabio Conforti
- Division of Medical Oncology for Melanoma, Sarcoma, and Rare Tumors, European Institute of Oncology (IEO), IRCCS, Milan
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, Milan
- Department of Oncology and Hemato-Oncology, University of Milan, Milan
| | - Elham Sajjadi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan
- Biobank for Translational Medicine (B4MED) Unit, Division of Pathology, European Institute of Oncology (IEO), IRCCS, Milan, Italy
| | - Konstantinos Venetis
- Department of Oncology and Hemato-Oncology, University of Milan, Milan
- Biobank for Translational Medicine (B4MED) Unit, Division of Pathology, European Institute of Oncology (IEO), IRCCS, Milan, Italy
| | - Nicola Fusco
- Department of Oncology and Hemato-Oncology, University of Milan, Milan
- Biobank for Translational Medicine (B4MED) Unit, Division of Pathology, European Institute of Oncology (IEO), IRCCS, Milan, Italy
| | - Sara Gandini
- Division of Experimental Oncology, European Institute of Oncology (IEO), IRCCS, Milan
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21
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Implications of Oncology Trial Design and Uncertainties in Efficacy-Safety Data on Health Technology Assessments. Curr Oncol 2022; 29:5774-5791. [PMID: 36005193 PMCID: PMC9406873 DOI: 10.3390/curroncol29080455] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Advances in cancer medicines have resulted in tangible health impacts, but the magnitude of benefits of approved cancer medicines could vary greatly. Health Technology Assessment (HTA) is a multidisciplinary process used to inform resource allocation through a systematic value assessment of health technology. This paper reviews the challenges in conducting HTA for cancer medicines arising from oncology trial designs and uncertainties of safety-efficacy data. Methods: Multiple databases (PubMed, Scopus and Google Scholar) and grey literature (public health agencies and governmental reports) were searched to inform this policy narrative review. Results: A lack of robust efficacy-safety data from clinical trials and other relevant sources of evidence has made HTA for cancer medicines challenging. The approval of cancer medicines through expedited pathways has increased in recent years, in which surrogate endpoints or biomarkers for patient selection have been widely used. Using these surrogate endpoints has created uncertainties in translating surrogate measures into patient-centric clinically (survival and quality of life) and economically (cost-effectiveness and budget impact) meaningful outcomes, with potential effects on diverting scarce health resources to low-value or detrimental interventions. Potential solutions include policy harmonization between regulatory and HTA authorities, commitment to generating robust post-marketing efficacy-safety data, managing uncertainties through risk-sharing agreements, and using value frameworks. Conclusion: A lack of robust efficacy-safety data is a central problem for conducting HTA of cancer medicines, potentially resulting in misinformed resource allocation.
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22
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Shao Y, Yu Y, Luo Z, Guan H, Zhu F, He Y, Chen Q, Liu C, Nie B, Liu H. Clinical, Pathological Complete Response, and Prognosis Characteristics of HER2-Low Breast Cancer in the Neoadjuvant Chemotherapy Setting: A Retrospective Analysis. Ann Surg Oncol 2022; 29:8026-8034. [PMID: 35933542 DOI: 10.1245/s10434-022-12369-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The present study was conducted to evaluate the clinical, pathological response, and prognosis characteristics of human epidermal growth factor receptor 2 (HER2)-low breast cancer in the neoadjuvant chemotherapy setting. METHODS Patients with HER2-negative breast cancer who received neoadjuvant chemotherapy from January 2017 to December 2019 were retrospectively analyzed. HER2-negative breast cancer was divided into two groups: HER2-zero (defined as immunohistochemistry [IHC] 0) and HER2-low (defined as IHC 1+, or IHC 2+ and fluorescence in-situ hybridization-negative. RESULTS Overall, 314 patients with HER2-negative breast cancer were analyzed. The proportion of HER2-low patients with hormone receptor (HR)-positive disease was higher than in triple-negative breast cancer (TNBC; 75.3% vs. 63.2%, p = 0.032). In HR-positive breast cancer, HER2-low tumors presented less nodal involvement (p = 0.023) and earlier clinical stage (p = 0.015) compared with HER2-zero tumors; however, in TNBC, HER2-low patients had a later clinical stage (p = 0.028). With the pathological complete response (pCR) defined as ypTis/0ypN0, there was no difference in pCR rates among the entire cohort, HR-positive disease, and TNBC. However, with the pCR defined as ypT0ypN0, the pCR rate in HER2-low breast cancer was significantly lower than HER2-zero breast cancer in the entire cohort (24.3% vs. 36.4%, p = 0.032) and the HR-positive subgroup (18.7% vs. 32.1%, p = 0.035), but not for TNBC. Multivariate analysis demonstrated that HER2 status (low vs. zero) was an independent predictive factor for pCR (p = 0.013) in HR-positive breast cancer. There were no statistically significant differences in 3-year disease-free survival and overall survival between HER2-low and HER2-zero breast cancer among the entire cohort, HR-positive disease, and TNBC. CONCLUSIONS HER2-low breast cancer exhibits specific clinical features and different response to treatment associated with HR status in the neoadjuvant chemotherapy setting.
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Affiliation(s)
- Yingbo Shao
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Yang Yu
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Zhifen Luo
- Department of Medical Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Medical Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Huijuan Guan
- Department of Pathology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Pathology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Fangyuan Zhu
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Yaning He
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Qi Chen
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Chaojun Liu
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Bing Nie
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Hui Liu
- Department of Breast Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China. .,Department of Breast Oncology, Henan Provincial People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China.
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23
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Son SY, Hur H, Hyung WJ, Park YK, Lee HJ, An JY, Kim W, Kim HI, Kim HH, Ryu SW, Kim MC, Kong SH, Cho GS, Kim JJ, Park DJ, Ryu KW, Kim YW, Kim JW, Lee JH, Yang HK, Han SU. Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer: 5-Year Outcomes of the KLASS-02 Randomized Clinical Trial. JAMA Surg 2022; 157:879-886. [PMID: 35857305 PMCID: PMC9301593 DOI: 10.1001/jamasurg.2022.2749] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Question What is the oncologic safety profile of laparoscopic distal gastrectomy for the treatment of clinically advanced gastric cancer in terms of 5-year survival? Findings In this randomized clinical trial of 1050 patients, in patients who underwent laparoscopic or open distal gastrectomy, the 5-year overall survival rates (88.9% vs 88.7%) and relapse-free survival rates (79.5% vs 81.1%) did not differ significantly. The late complication rate was significantly lower in the laparoscopic group than in the open group (6.5% vs 11.0%). Meaning The 5-year follow-up results of the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 trial support the rationale for laparoscopic surgery in patients with locally advanced gastric cancer. Importance The long-term safety of laparoscopic distal gastrectomy for locally advanced gastric cancer (AGC) remains uncertain given the lack of 5-year follow-up results. Objective To compare the 5-year follow-up results in patients with clinically AGC enrolled in the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 randomized clinical trial who underwent laparoscopic or open distal gastrectomy. Design, Setting, and Participants The KLASS-02, a multicenter randomized clinical trial, showed that laparoscopic surgery was noninferior to open surgery for patients with locally AGC. The present study assessed the 5-year follow-up results, including 5-year overall survival (OS) and relapse-free survival (RFS) rates and long-term complications, in patients enrolled in KLASS-02. From November 21, 2011, to April 29, 2015, patients aged 20 to 80 years diagnosed preoperatively with locally AGC were enrolled. Final follow-up was on June 15, 2021. Data were analyzed June 24 to September 9, 2021. Interventions Patients were treated with R0 resection either by laparoscopic gastrectomy or open gastrectomy as the full analysis set of the KLASS-02 trial. Main Outcomes and Measures Five-year OS and RFS rates, recurrence patterns, and long-term surgical complications were evaluated. Results This study enrolled a total of 1050 patients. A total of 974 patients were treated with R0 resection; 492 (50.5%) in the laparoscopic gastrectomy group (mean [SD] age, 59.8 [11.0] years; 351 men [71.3%]) and 482 (49.5%) in the open gastrectomy group (mean [SD] age, 59.4 [11.5] years; 335 men [69.5%]). In patients who underwent laparoscopic and open distal gastrectomy, the 5-year OS (88.9% vs 88.7%) and RFS (79.5% vs 81.1%) rates did not differ significantly. The most common types of recurrence were peritoneal carcinomatosis (73 of 173 [42.1%]), hematogenous metastases (36 of 173 [20.8%]), and locoregional recurrence (23 of 173 [13.2%]), with no between-group differences in types of recurrence at each cancer stage. The correlation between 3-year RFS and 5-year OS at the individual level was highest in patients with stage III gastric cancer (ρ = 0.720). The late complication rate was significantly lower in the laparoscopic than in the open surgery group (32 of 492 [6.5%] vs 53 of 482 [11.0%]). The most common type of complication in both groups was intestinal obstruction (13 of 492 [2.6%] vs 24 of 482 [5.0%]). Conclusions and Relevance The 5-year outcomes of the KLASS-02 trial support the 3-year results, which is the noninferiority of laparoscopic surgery compared with open gastrectomy for locally AGC. The laparoscopic approach can be recommended in patients with locally AGC to achieve the benefit of low incidence of late complications. Trial Registration ClinicalTrials.gov Identifier: NCT01456598
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Affiliation(s)
- Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Kyu Park
- Department of Surgery, Chonnam National University Hwasun Hospital, Gwangju, South Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Ji Yeong An
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wook Kim
- Department of Surgery, Yeouido St Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seung Wan Ryu
- Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Min-Chan Kim
- Department of Surgery, Dong-A University Hospital, Korea, Busan, South Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Gyu Seok Cho
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Jin-Jo Kim
- Department of Surgery, Incheon St Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, South Korea
| | - Young Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, South Korea
| | - Jong Won Kim
- Department of Surgery, Chung-Ang University Hospital, Seoul, South Korea
| | - Joo-Ho Lee
- Department of Surgery, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
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Yazdani A, Haghighat S. Determining Prognostic Factors of Disease-Free Survival in Breast Cancer Using Censored Quantile Regression. BREAST CANCER: BASIC AND CLINICAL RESEARCH 2022; 16:11782234221108058. [PMID: 35795199 PMCID: PMC9251962 DOI: 10.1177/11782234221108058] [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: 11/13/2021] [Accepted: 06/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background The analysis of disease-free survival and related factors leads to a better understanding of the patient's condition and recurrence-related characteristics and provides a basis for more appropriate treatment guidance. In this study, we aimed to investigate the role of prognostic factors on disease-free survival in breast cancer with a quantile regression model. Methods This retrospective study was conducted by reviewing data obtained from 2056 breast cancer patients. Age at diagnosis and education status, tumor size, lymph node ratio, tumor grade, estrogen receptor and progesterone receptor, type of surgery, use of radiotherapy, chemotherapy, and hormone therapy were the prognosis factors considered in this study. A quantile regression model was used to investigate prognostic factors of disease-free survival in breast cancer. Results Disease recurrence was verified in 251 (13.9%) women, and 39 (0.02%) women died before experience recurrence. The 10th percentile of disease-free survival for patients with the hormone therapy was 23.85 months greater than patients who did not receive this treatment (P value < .001). In the examination of the tumor size, the 10th and 20th percentiles of disease-free survival for patients with tumor size > 5 cm were 31.06 and 27 months less than patients with the tumor size < 2 cm, respectively (P value = .006 and .021, respectively). Compared with grade 1 tumors, the 10th and 20th percentiles of disease-free survival for patients with grade 3 tumors decreased 30.11 and 38.32 months, respectively (P value < .001 and .038, respectively). The 10th and 20th percentiles of disease-free survival decreased 28.16 and 45.32 months with a 1 unit increase in lymph node ratio, respectively (P value = .032 and .032, respectively). Conclusions Among the prognostic factors, tumor size, grade, and lymph node ratio showed a close relationship with disease-free survival in breast cancer. The findings indicated that developing public screening and educational programs through the health care system with more emphasis on low-educated women is needed among Iranian women.
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Affiliation(s)
- Akram Yazdani
- Department of Biostatistics and Epidemiology, School of Public Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Shahpar Haghighat
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
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25
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Sanaat Z, Vaez Gharamaleki J, Vaez Gharamaleki Y, Dolatkhah R. The analysis of breast cancer survival in East Azerbaijan province of Iran; prognostic impact of chemotherapy and hormone therapy protocols. Cancer Treat Res Commun 2022; 32:100578. [PMID: 35609449 DOI: 10.1016/j.ctarc.2022.100578] [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: 02/19/2022] [Revised: 05/08/2022] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The global cancer pattern indicated that there were about 2.3 million newly diagnosed breast cancer cases in 2020 worldwide, and was the most common cancer incident in the world. The aim of the study was to assess the prognostic impact of various treatment modalities and cancer-specific overall and disease-free survival rates. METHODS One, 5-, 10-, and 15 -years survival rates were calculated; furthermore, overall survival (OS) and disease free survival (DFS) rates were obtained using Kaplan Meier method. To assess the effects of different treatment methods and all clinico-pathological variables with OS and DFS, cox-regression method was used to achieve adjusted hazard ratios of mortality and recurrence rates. RESULTS During the study period, 504 primary breast cancer cases were evaluated, with mean age of 49.69(± 10.68) years. The one, 5-, 10-, and 15- year survival rates were 98.21%, 87.39%, 68.17% and, 60.60%, respectively. Tamoxifen + GnRh Agonist and Tamoxifen protocols decreased the hazard of relapse 46% and 84%, respectively. The best one-year OS was obtained for patients treated with Tamoxifen with an aromatase inhibitor (AI) for about 100% overall survival rate. The breast cancer mortality rate was lower than relapse rate in the first and 5thyears of disease, but 10- and 15- year mortality were higher than 10- and 15 -year relapse rates. CONCLUSION Our results revealed better overall survival and disease- free survival among primary breast cancer patients in East Azerbaijan; consequently, this underscores establishing and using better chemotherapy and hormone therapy protocols and sufficient follow-ups.
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Affiliation(s)
- Zohreh Sanaat
- Medical Hematologist and Oncologist, Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jalil Vaez Gharamaleki
- Medical Hematology and Oncology, Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yosra Vaez Gharamaleki
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Roya Dolatkhah
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Trapani D, Franzoi MA, Burstein HJ, Carey LA, Delaloge S, Harbeck N, Hayes DF, Kalinsky K, Pusztai L, Regan MM, Sestak I, Spanic T, Sparano J, Jezdic S, Cherny N, Curigliano G, Andre F. Risk-adapted modulation through de-intensification of cancer treatments: an ESMO classification. Ann Oncol 2022; 33:702-712. [PMID: 35550723 DOI: 10.1016/j.annonc.2022.03.273] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The landscape of clinical trials testing risk-adapted modulations of cancer treatments is complex. Multiple trial designs, endpoints, and thresholds for non-inferiority have been used; however, no consensus or convention has ever been agreed to categorise biomarkers useful to inform the treatment intensity modulation of cancer treatments. METHODS An expert subgroup under the European Society for Medical Oncology (ESMO) Precision Medicine Working Group shaped an international collaborative project to develop a classification system for biomarkers used in the cancer treatment de-intensification, based on a tiered approach. A group of disease-oriented clinical, translational, methodology and public health experts, and patients' representatives provided an analysis of the status quo, and scanned the horizon of ongoing clinical trials. The classification was developed through multiple rounds of expert revisions and inputs. RESULTS The working group agreed on a univocal definition of treatment de-intensification. Evidence of reduction in the dose-density, intensity, or cumulative dose, including intermittent schedules or shorter treatment duration or deletion of segment(s) of the standard regimens, compound(s), or treatment modality must be demonstrated, to define a treatment de-intensification. De-intensified regimens must also portend a positive impact on toxicity, quality of life, health system burden, or financial toxicity. ESMO classification categorises the biomarkers for treatment modulation in three tiers, based on the level of evidence. Tier A includes biomarkers validated in prospective, randomised, non-inferiority clinical trials. The working group agreed that in non-inferiority clinical trials, boundaries are highly dependent upon the disease scenario and endpoint being studied and that the absolute differences in the outcomes are the most relevant measures, rather than relative differences. Biomarkers tested in single-arm studies with a threshold of non-inferiority are classified as Tier B. Tier C is when the validation occurs in prospective-retrospective quality cohort investigations. CONCLUSIONS ESMO classification for the risk-guided intensity modulation of cancer treatments provides a set of evidence-based criteria to categorise biomarkers deemed to inform de-intensification of cancer treatments, in risk-defined patients. The classification aims at harmonising definitions on this matter, therefore offering a common language for all the relevant stakeholders, including clinicians, patients, decision-makers, and for clinical trials.
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Affiliation(s)
- D Trapani
- New Drugs Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Medical Oncology, Dana-Farber Cancer Center, Boston, USA
| | - M A Franzoi
- INSERM Unit 981 - Molecular Predictors and New Targets in Oncology, PRISM Center for Precision Medicine, Gustave Roussy, Villejuif, France
| | - H J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Center, Boston, USA
| | - L A Carey
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - S Delaloge
- Breast Cancer Unit, Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - N Harbeck
- Breast Center, Department of Obstetrics & Gynecology and Comprehensive Cancer Center Munich, LMU University Hospital, Munich, Germany
| | - D F Hayes
- University of Michigan Rogel Cancer Center, Ann Arbor, USA
| | - K Kalinsky
- Department of Hematology and Medical Oncology, Winship Cancer Institute at Emory University, Atlanta, USA
| | - L Pusztai
- Yale Cancer Center Genetics and Genomics Program, Yale Cancer Center, Yale School of Medicine, New Haven, USA
| | - M M Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - I Sestak
- Wolfson Institute of Preventive Medicine - Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - T Spanic
- ESMO Patient Advocates Working Group, Ljubljana, Slovenia
| | - J Sparano
- Division of Hematology/Oncology, Icahn School of Medicine at Mt. Sinai, Tisch Cancer Institute, New York, USA
| | - S Jezdic
- Scientific and Medical Division, European Society for Medical Oncology, Lugano, Switzerland
| | - N Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan, European Institute of Oncology, IRCCS, Milan, Italy.
| | - F Andre
- INSERM Unit 981 - Molecular Predictors and New Targets in Oncology, PRISM Center for Precision Medicine, Gustave Roussy, Villejuif, France.
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Wilson BE, Desnoyers A, Al-Showbaki L, Nadler MB, Amir E. A retrospective analysis of changes in distant and breast cancer related disease-free survival events in adjuvant breast cancer trials over time. Sci Rep 2022; 12:6352. [PMID: 35428842 PMCID: PMC9012825 DOI: 10.1038/s41598-022-09949-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/14/2022] [Indexed: 11/09/2022] Open
Abstract
Disease-free survival (DFS) comprises both breast cancer and non-breast cancer events. DFS has not been validated as a surrogate endpoint for overall survival (OS) in most breast cancer subtypes. We assessed changes to the type of events contributing to DFS over time. We identified adjuvant studies in breast cancer (BC) from 2000 to 2020 where the endpoint was DFS. We examined change in distant DFS events and the BC-related DFS using univariable and multivariable linear regression. Data were reported quantitatively using the Burnand criteria irrespective of statistical significance. We included 84 studies (88 cohorts), comprising 212,191 participants, 41,604 DFS events and 23,205 distant DFS events. The DFS event rate/100 participants/year has declined modestly over time (ß - 0.34, p = 0.001). Start year was negatively associated with distant DFS events (ß - 0.58, p < 0.0001); however, the effect was lost after adjusting for follow-up time (ß - 0.18, p = 0.096). The average number of BC-related events/100 participants/year also declined over time (ß - 0.28, p = 0.009). In multivariable analysis, start year and ER expression were quantitatively associated with distant DFS events and BC-related DFS events. DFS events have declined over time driven by a reduction in BC related events. As DFS events are increasingly defined by non-BC events, there will be limited surrogacy between DFS and OS.
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Affiliation(s)
- Brooke E Wilson
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, 700 University Ave, 700U, 7W305, Toronto, ON, M5G 2M9, Canada. .,University of New South Wales, Kensington, NSW, Australia.
| | - Alexandra Desnoyers
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, 700 University Ave, 700U, 7W305, Toronto, ON, M5G 2M9, Canada
| | - Laith Al-Showbaki
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, 700 University Ave, 700U, 7W305, Toronto, ON, M5G 2M9, Canada
| | - Michelle B Nadler
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, 700 University Ave, 700U, 7W305, Toronto, ON, M5G 2M9, Canada
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, 700 University Ave, 700U, 7W305, Toronto, ON, M5G 2M9, Canada
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Buyse M, Saad ED, Burzykowski T, Regan MM, Sweeney CS. Surrogacy Beyond Prognosis: The Importance of “Trial-Level” Surrogacy. Oncologist 2022; 27:266-271. [PMID: 35380717 PMCID: PMC8982389 DOI: 10.1093/oncolo/oyac006] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 11/05/2021] [Indexed: 11/14/2022] Open
Abstract
Many candidate surrogate endpoints are currently assessed using a 2-level statistical approach, which consists in checking whether (1) the potential surrogate is associated with the final endpoint in individual patients and (2) the effect of treatment on the surrogate can be used to reliably predict the effect of treatment on the final endpoint. In some situations, condition (1) is fulfilled but condition (2) is not. We use concepts of causal inference to explain this apparently paradoxical situation, illustrating this review with 2 contrasting examples in operable breast cancer: the example of pathological complete response (pCR) and that of disease-free survival (DFS). In a previous meta-analysis, pCR has been shown to be a strong and independent prognostic factor for event-free survival (EFS) and overall survival (OS) after neoadjuvant treatment of operable breast cancer. Yet, in randomized trials, the effects of experimental treatments on pCR have not translated into predictable effects on EFS or OS, making pCR an “individual-level” surrogate, but not a “trial-level” surrogate. In contrast, DFS has been shown to be an acceptable surrogate for OS at both the individual and trial levels in early, HER2-positive breast cancer. The distinction between the prognostic and predictive roles of a tentative surrogate, not always made in the literature, avoids unnecessary confusion and allows better understanding of what it takes to validate a surrogate endpoint that is truly able to replace a final endpoint.
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Affiliation(s)
- Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve, Belgium
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), Hasselt University, Hasselt, Belgium
| | - Everardo D Saad
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Tomasz Burzykowski
- International Drug Development Institute, Louvain-la-Neuve, Belgium
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), Hasselt University, Hasselt, Belgium
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Gunasekara ADM, Anothaisintawee T, Youngkong S, Ha NT, McKay GJ, Attia J, Thakkinstian A. Neoadjuvant Treatment with HER2-Targeted Therapies in HER2-Positive Breast Cancer: A Systematic Review and Network Meta-Analysis. Cancers (Basel) 2022; 14:cancers14030523. [PMID: 35158791 PMCID: PMC8833584 DOI: 10.3390/cancers14030523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/14/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Human epidermal growth factor receptor 2 (HER2)-positive breast cancer causes more aggressive progression of disease and poorer outcomes for patients. HER2-targeted medicines used as neoadjuvant systemic therapy could improve clinical outcomes in early-stage or locally advanced breast cancer patients. The purpose of this systematic review and network meta-analysis was to identify the neoadjuvant anti-HER2 therapy with the best balance between efficacy and safety. We found that trastuzumab emtansine + pertuzumab + chemotherapy had a high pathologic complete response with a low risk of adverse events compared to other neoadjuvant anti-HER2 regimens, while the pertuzumab + trastuzumab + chemotherapy regimen showed the highest disease-free survival. However, further trial data on neoadjuvant regimens with trastuzumab emtansine are needed to confirm these findings. Abstract This systematic review aimed to identify neoadjuvant anti-human epidermal growth factor receptor 2 (HER2) therapies with the best balance between efficacy and safety. Methods: A network meta-analysis was applied to estimate the risk ratios along with 95% confidence intervals (CIs) for pathological complete response (pCR) and serious adverse events (SAE). A mixed-effect parametric survival analysis was conducted to assess the disease-free survival (DFS) between treatments. Results: Twenty-one RCTs with eleven regimens of neoadjuvant anti-HER2 therapy (i.e., trastuzumab + chemotherapy (TC), lapatinib + chemotherapy (LC), pertuzumab + chemotherapy (PC), pertuzumab + trastuzumab (PT), trastuzumab emtansine + pertuzumab (T-DM1P), pertuzumab + trastuzumab + chemotherapy (PTC), lapatinib + trastuzumab + chemotherapy (LTC), trastuzumab emtansine + lapatinib + chemotherapy (T-DM1LC), trastuzumab emtansine + pertuzumab + chemotherapy(T-DM1PC), PTC followed by T-DM1P (PTC_T-DM1P), and trastuzumab emtansine (T-DM1)) and chemotherapy alone were included. When compared to TC, only PTC had a significantly higher DFS with a hazard ratio (95% CI) of 0.54 (0.32–0.91). The surface under the cumulative ranking curve (SUCRA) suggested that T-DM1LC (91.9%) was ranked first in achieving pCR, followed by the PTC_T-DM1P (90.5%), PTC (74.8%), and T-DM1PC (73.5%) regimens. For SAEs, LTC, LC, and T-DM1LC presented with the highest risks (SUCRA = 10.7%, 16.8%, and 20.8%), while PT (99.2%), T-DM1P (88%), and T-DM1 (83.9%) were the safest regimens. The T-DM1PC (73.5% vs. 71.6%), T-DM1 (70.5% vs. 83.9%), and PTC_T-DM1P (90.5% vs. 47.3%) regimens offered the optimal balance between pCR and SAE. Conclusions: The T-DM1PC, T-DM1, and PTC_T-DM1P regimens had the optimal balance between efficacy and safety, while DFS was highest for the PTC regimen. However, these results were based on a small number of studies, and additional RCTs assessing the efficacy of regimens with T-DM1 are still needed to confirm these findings.
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Affiliation(s)
- Agampodi Danushi M. Gunasekara
- Mahidol University Health Technology Assessment Graduate Program (MUHTA), Mahidol University, Bangkok 10400, Thailand; (A.D.M.G.); (N.T.H.); (A.T.)
- Department of Paraclinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Ratmalana, Colombo 10390, Sri Lanka
| | - Thunyarat Anothaisintawee
- Mahidol University Health Technology Assessment Graduate Program (MUHTA), Mahidol University, Bangkok 10400, Thailand; (A.D.M.G.); (N.T.H.); (A.T.)
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Correspondence: (T.A.); (S.Y.); Tel.: +66-2-201-1406 (T.A.)
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment Graduate Program (MUHTA), Mahidol University, Bangkok 10400, Thailand; (A.D.M.G.); (N.T.H.); (A.T.)
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
- Correspondence: (T.A.); (S.Y.); Tel.: +66-2-201-1406 (T.A.)
| | - Nguyen T. Ha
- Mahidol University Health Technology Assessment Graduate Program (MUHTA), Mahidol University, Bangkok 10400, Thailand; (A.D.M.G.); (N.T.H.); (A.T.)
- School of Medicine, Vietnam National University, Ho Chi Minh City 700000, Vietnam
| | - Gareth J. McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast BT12 6BA, UK;
| | - John Attia
- School of Medicine and Public Health, College of Health and Wellbeing, University of Newcastle, Newcastle, NSW 2308, Australia;
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment Graduate Program (MUHTA), Mahidol University, Bangkok 10400, Thailand; (A.D.M.G.); (N.T.H.); (A.T.)
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Bychkov D, Joensuu H, Nordling S, Tiulpin A, Kücükel H, Lundin M, Sihto H, Isola J, Lehtimäki T, Kellokumpu-Lehtinen PL, Smitten K, Lundin J, Linder N. Outcome and biomarker supervised deep learning for survival prediction in two multicenter breast cancer series. J Pathol Inform 2022; 13:9. [PMID: 35136676 PMCID: PMC8794033 DOI: 10.4103/jpi.jpi_29_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/10/2021] [Accepted: 06/20/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Prediction of clinical outcomes for individual cancer patients is an important step in the disease diagnosis and subsequently guides the treatment and patient counseling. In this work, we develop and evaluate a joint outcome and biomarker supervised (estrogen receptor expression and ERBB2 expression and gene amplification) multitask deep learning model for prediction of outcome in breast cancer patients in two nation-wide multicenter studies in Finland (the FinProg and FinHer studies). Our approach combines deep learning with expert knowledge to provide more accurate, robust, and integrated prediction of breast cancer outcomes. Materials and Methods: Using deep learning, we trained convolutional neural networks (CNNs) with digitized tissue microarray (TMA) samples of primary hematoxylin-eosin-stained breast cancer specimens from 693 patients in the FinProg series as input and breast cancer-specific survival as the endpoint. The trained algorithms were tested on 354 TMA patient samples in the same series. An independent set of whole-slide (WS) tumor samples from 674 patients in another multicenter study (FinHer) was used to validate and verify the generalization of the outcome prediction based on CNN models by Cox survival regression and concordance index (c-index). Visual cancer tissue characterization, i.e., number of mitoses, tubules, nuclear pleomorphism, tumor-infiltrating lymphocytes, and necrosis was performed on TMA samples in the FinProg test set by a pathologist and combined with deep learning-based outcome prediction in a multitask algorithm. Results: The multitask algorithm achieved a hazard ratio (HR) of 2.0 (95% confidence interval [CI] 1.30–3.00), P < 0.001, c-index of 0.59 on the 354 test set of FinProg patients, and an HR of 1.7 (95% CI 1.2–2.6), P = 0.003, c-index 0.57 on the WS tumor samples from 674 patients in the independent FinHer series. The multitask CNN remained a statistically independent predictor of survival in both test sets when adjusted for histological grade, tumor size, and axillary lymph node status in a multivariate Cox analyses. An improved accuracy (c-index 0.66) was achieved when deep learning was combined with the tissue characteristics assessed visually by a pathologist. Conclusions: A multitask deep learning algorithm supervised by both patient outcome and biomarker status learned features in basic tissue morphology predictive of survival in a nationwide, multicenter series of patients with breast cancer. The algorithms generalized to another independent multicenter patient series and whole-slide breast cancer samples and provide prognostic information complementary to that of a comprehensive series of established prognostic factors.
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Conforti F, Pala L, Sala I, Oriecuia C, De Pas T, Specchia C, Graffeo R, Pagan E, Queirolo P, Pennacchioli E, Colleoni M, Viale G, Bagnardi V, Gelber RD. Evaluation of pathological complete response as surrogate endpoint in neoadjuvant randomised clinical trials of early stage breast cancer: systematic review and meta-analysis. BMJ 2021; 375:e066381. [PMID: 34933868 PMCID: PMC8689398 DOI: 10.1136/bmj-2021-066381] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate pathological complete response as a surrogate endpoint for disease-free survival and overall survival in regulatory neoadjuvant trials of early stage breast cancer. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and Scopus to 1 December 2020. ELIGIBILITY CRITERIA FOR STUDY SELECTION Randomised clinical trials that tested neoadjuvant chemotherapy given alone or combined with other treatments, including anti-human epidermal growth factor 2 (anti-HER2) drugs, targeted treatments, antivascular agents, bisphosphonates, and immune checkpoint inhibitors. DATA EXTRACTION AND SYNTHESIS Trial level associations between the surrogate endpoint pathological complete response and disease-free survival and overall survival. METHODS A weighted regression analysis was performed on log transformed treatment effect estimates (hazard ratio for disease-free survival and overall survival and relative risk for pathological complete response), and the coefficient of determination (R2) was used to quantify the association. The secondary objective was to explore heterogeneity of results in preplanned subgroups analysis, stratifying trials according treatment type in the experimental arm, definition used for pathological complete response (breast and lymph nodes v breast only), and biological features of the disease (HER2 positive or triple negative breast cancer). The surrogate threshold effect was also evaluated, indicating the minimum value of the relative risk for pathological complete response necessary to confidently predict a non-null effect on hazard ratio for disease-free survival or overall survival. RESULTS 54 randomised clinical trials comprising a total of 32 611 patients were included in the analysis. A weak association was observed between the log(relative risk) for pathological complete response and log(hazard ratio) for both disease-free survival (R2=0.14, 95% confidence interval 0.00 to 0.29) and overall survival (R2 =0.08, 0.00 to 0.22). Similar results were found across all subgroups evaluated, independently of the definition used for pathological complete response, treatment type in the experimental arm, and biological features of the disease. The surrogate threshold effect was 5.19 for disease-free survival but was not estimable for overall survival. Consistent results were confirmed in three sensitivity analyses: excluding small trials (<200 patients enrolled), excluding trials with short median follow-up (<24 months), and replacing the relative risk for pathological complete response with the absolute difference of pathological complete response rates between treatment arms. CONCLUSION A lack of surrogacy of pathological complete response was identified at trial level for both disease-free survival and overall survival. The findings suggest that pathological complete response should not be used as primary endpoint in regulatory neoadjuvant trials of early stage breast cancer.
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Affiliation(s)
- Fabio Conforti
- Division of Melanoma, Sarcomas and Rare Tumors, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Laura Pala
- Division of Melanoma, Sarcomas and Rare Tumors, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Isabella Sala
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Chiara Oriecuia
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Tommaso De Pas
- Division of Melanoma, Sarcomas and Rare Tumors, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Rossella Graffeo
- Breast Unit of Southern Switzerland, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Eleonora Pagan
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Paola Queirolo
- Division of Melanoma, Sarcomas and Rare Tumors, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Elisabetta Pennacchioli
- Division of Melanoma, Sarcomas and Rare Tumors, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Viale
- Department of Pathology, IEO, European Institute of Oncology, IRCCS, Milan, Italy
- University of Milan, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Richard D Gelber
- Medical School, Harvard T H Chan School of Public Health, and Frontier Science and Technology Research Foundation, Boston, MA, USA
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Gion M, Pérez-García JM, Llombart-Cussac A, Sampayo-Cordero M, Cortés J, Malfettone A. Surrogate endpoints for early-stage breast cancer: a review of the state of the art, controversies, and future prospects. Ther Adv Med Oncol 2021; 13:17588359211059587. [PMID: 34868353 PMCID: PMC8640314 DOI: 10.1177/17588359211059587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/25/2021] [Indexed: 01/07/2023] Open
Abstract
Drug approval for early-stage breast cancer (EBC) has been historically granted in the context of registration trials based on adequate outcomes such as disease-free survival and overall survival. Improvements in long-term outcomes have made it more difficult to demonstrate the clinical benefit of a new cancer drug in large, randomized, comparative clinical trials. Therefore, the use of surrogate endpoints rather than traditional measures allows for cancer drug trials to proceed with smaller sample sizes and shorter follow-up periods, which reduces drug development time. Among surrogate endpoints for breast cancer, the increase in pathological complete response (pCR) rates was considered appropriate for accelerated drug approval. The association between pCR and long-term outcomes was strongest in patients with aggressive tumor subtypes, such as triple-negative and human epidermal growth factor receptor 2 (HER2)-positive/hormone receptor-negative breast cancers. Whereas in hormone receptor-positive/HER2-negative EBC, the most accepted surrogate markers for endocrine therapy-based trials include changes in Ki67 and the preoperative endocrine prognostic index. Beyond the classic endpoints, further prognostic tools are required to provide EBC patients with individualized and effective therapies, and the neoadjuvant setting provides an excellent platform for drug development and biomarker discovery. Nowadays, the availability of multigene signatures is offering a standardized quantitative and reproducible tool to potentiate the efficacy of standard treatment for high-risk patients and develop de-escalated treatments for patients at lower risk of relapse. In this article, we first evaluate the surrogacies used for long-term outcomes and the underlying evidence supporting the use of each surrogate endpoint for the accelerated or regular drug approval process in EBC. Next, we provide an overview of the most recent studies and innovative strategies in a (neo)adjuvant setting as a platform to accelerate new drug approval. Finally, we highlight some clinical trials aimed at tailoring systemic treatment of EBC using prognosis-related factors or early biomarkers of drug sensitivity or resistance.
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Affiliation(s)
- María Gion
- University Hospital Ramon y Cajal, Madrid, Spain
| | - José Manuel Pérez-García
- International Breast Cancer Center (IBCC), Quironsalud Group, Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| | - Antonio Llombart-Cussac
- Hospital Arnau de Vilanova, Valencia, Spain
- Universidad Catolica de Valencia San Vicente Martir, Valencia, Spain
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| | - Miguel Sampayo-Cordero
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| | - Javier Cortés
- International Breast Cancer Center (IBCC), Quironsalud Group, Carrer de Vilana, 12, 08022 Barcelona, SpainVall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Andrea Malfettone
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
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The Importance of Disease-Free Survival as a Clinical Trial Endpoint: A Qualitative Study Among Canadian Survivors of Lung Cancer. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 15:307-316. [PMID: 34643935 DOI: 10.1007/s40271-021-00552-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In lung cancer trials, overall survival is a well-validated and widely used endpoint; yet, in the context of adjuvant or curative intent treatments, disease-free survival (DFS) may be a better indicator of transformative patient outcomes. Although use of DFS is growing, patient perceptions of its relevance have not been established. OBJECTIVE We aimed to understand the importance of DFS as a trial endpoint, from the perspective of survivors of lung cancer. METHODS Web-based qualitative interviews were conducted with Canadian survivors of stage Ib-IIIa lung cancer. Participants described their experiences of cancer diagnosis and treatment, including their treatment goals and priorities. Participants then provided their perspectives on DFS and overall survival, and how well each aligned with their treatment priorities. Thematic analysis was used to explore patterns in responses. RESULTS Among the 18 participants (mean age, 64 years), 83% were female, most (89%) had received surgery, and 56% received chemotherapy. Most participants viewed DFS as an intrinsically meaningful treatment outcome, for reasons such as alignment with treatment goals, and the perception that DFS would help maintain a high quality of life. One individual was interested in DFS only as a potential surrogate for overall survival. Participants desired access to new treatments that improve DFS and emphasized this within the context of promoting patient agency in treatment decision making. CONCLUSIONS These findings suggest DFS is a meaningful endpoint from the perspective of survivors of lung cancer; and may help inform decisions regarding regulatory approval and reimbursement of new treatments based on DFS data.
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Krishnatreya M. Nothing is permanent except for change: Disease-free survival in cancer, time to change? J Cancer Res Ther 2021; 17:1132-1133. [PMID: 34528578 DOI: 10.4103/jcrt.jcrt_318_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Manigreeva Krishnatreya
- Department of Cancer Registry and Epidemiology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
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Zhang Y, Liu M, Yang H, Wang S. Physicians’ Perception of the Evidence in Relation to Primary Endpoints of Clinical Trials on Breast Cancer. Breast Care (Basel) 2021; 17:180-187. [DOI: 10.1159/000518260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 06/21/2021] [Indexed: 11/19/2022] Open
Abstract
<b><i>Objective:</i></b> To investigate physicians’ perception of the evidence of clinical trials on breast cancer. <b><i>Methods:</i></b> A survey was conducted by the Chinese Society of Breast Surgeons. We investigated the physicians’ perception of meaningful endpoints, appropriate follow-up duration, and clinically acceptable benefit through online questionnaires. <b><i>Results:</i></b> Among 278 validated questionnaires, the majority of the questions had no consistent answer. For local treatment, 30.6, 28.8, and 28.4% of participants regarded locoregional recurrence (LRR), disease-free survival (DFS), and overall survival (OS) as the most meaningful endpoint, respectively, 47.5% believed that 5-year follow-up can alter clinical practice, and 34.5% thought it should be >10 years. In the adjuvant setting, 45.7, 38.5, and 12.9% regarded DFS, OS, and LRR as the most meaningful endpoint, respectively, 52.5% thought that 10-year follow-up was solid, while 37.4% thought that 5-year follow-up was enough. In the advanced setting, 49.6, 24.1, and 23.7% considered progression-free survival, quality of life, and OS the most meaningful endpoint, respectively, and 39.6 and 28.8% considered that a follow-up of 1 year and 3 years, respectively, was meaningful. Similarly, the clinically acceptable absolute difference was inconsistent. <b><i>Conclusion:</i></b> Most Chinese oncologists advocated that surrogate endpoints could be used in certain circumstances, though OS was the most reliable one in breast cancer studies. Doctors’ perceptions of follow-up time and magnitude of benefit vary widely, reflecting the fact that there are many unanswered questions about supporting the use of new cancer treatments; a common understanding needs to be reached, such as a very consensual surrogate endpoint and a meaningful sufficiently large therapeutic benefit.
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Botelho CH, Estevez-Diz MDP, Campolina AG. Cost-effectiveness analysis of trastuzumab for early breast cancer in Brazil. Expert Rev Pharmacoecon Outcomes Res 2021; 22:63-72. [PMID: 34319216 DOI: 10.1080/14737167.2021.1909478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Adjuvant chemotherapy with trastuzumab for HER2 positive breast cancers has brought considerable benefits to disease-free survival and overall survival.Objective: To conduct a cost-effectiveness analysis of the treatment of patients with early and locally advanced HER2 positive breast cancer, within the scope of the Brazilian public health system, comparing adjuvant chemotherapy with and without trastuzumab, for 1 year of treatment.Methods: A 4-state Markov model was developed to estimate strategy costs and outcomes.Results: Based on the proposed model, we verified an incremental benefit of trastuzumab therapy compared to treatment without trastuzumab with 0.84 quality-adjusted life years (QALY) and 1.16 life years gained (LYG). The use of adjuvant chemotherapy with trastuzumab has an ICER of US$19,599.26 for each quality-adjusted life year and US$14,180.68 for each life year gained in relation to chemotherapy without trastuzumab.Conclusion: In Brazil, adjuvant chemotherapy with trastuzumab may be considered cost-effective only if a cost-effectiveness threshold is stipulated with the value starting at three times the Brazilian GDP per capita for QALY or two times the Brazilian GDP per capita for LYG, from health system perspective.
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Affiliation(s)
- Carlos Henrique Botelho
- Department of Radiology and Oncology, Cancer Institute of the State of Sao Paulo/Faculty of Medicine at the University of Sao Paulo, Sao Paulo, Brazil
| | - Maria Del Pilar Estevez-Diz
- Department of Radiology and Oncology, Cancer Institute of the State of Sao Paulo/Faculty of Medicine at the University of Sao Paulo, Sao Paulo, Brazil
| | - Alessandro Gonçalves Campolina
- Center for Translational Research in Oncology, Cancer Institute of the State of Sao Paulo/Faculty of Medicine of the University of Sao Paulo, São Paulo, Brazil
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Anti-HER2 antibody prolongs overall survival disproportionally more than progression-free survival in HER2-Positive metastatic breast cancer patients. Breast 2021; 59:211-220. [PMID: 34298300 PMCID: PMC8321956 DOI: 10.1016/j.breast.2021.07.006] [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: 04/26/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 12/01/2022] Open
Abstract
Background This meta-analysis aimed to test the hypothesis that the HER2-positive metastatic breast cancer (mBC) patients treated with anti-HER2 antibodies in trial intervention arms have a greater prolongation of overall survival (OS) than of progression-free survival (PFS) and this extra-prolongation of median survival time in OS relates specifically to the anti-HER2 antibody. Methods The NCBI/Pubmed and Cochrane databases were searched systematically for HER2-positive or mBC trials published in English during January 1999–November 2017. Treatment arms with shorter PFS were considered as the “control” arm, whereas those with longer PFS as the “test” arm. The between-treatment drug differences were grouped into nine categories. Groups with or without anti-HER2 antibodies were pooled respectively for comparisons. The interrelationships between PFS and OS hazard ratios (HRs) and median survival time differences were investigated by conducting fixed-effects and mixed-effects linear meta-regression analyses. Results Twenty-eight trials (10,928 patients) from 438 articles were collected, and four with missing data were excluded in meta-regression analysis. Overall median PFS (HR = 0.73, 95% CI: 0.68–0.78) and median OS (HR = 0.82, 95% CI: 0.77–0.87) weakly favored the longer PFS arm with a weak correlation between the PFS and OS HRs. However, the between-treatment drug difference was anti-HER2 antibody, the absolute increment in median OS time was double that of median PFS time (p < 0.001) and linearly correlated, which was not found with any non-anti-HER2 antibody drug differences. Conclusions Anti-HER2 antibody in patients with HER2-positive mBC prolonged OS more than PFS and mandates further investigation. Our study dissected the overall survival benefit over progression-free survival in HER-2 positive metastatic breast cancer treated with anti-HER2 antibody by meta-analysis. Use of anti-HER2 antibodies, but not other anticancer drugs, to treat HER2-positive metastatic breast cancer independently predicted the OS compared with PFS. The design of future clinical trials should consider anti-HER2 antibodies carefully in the treatment armamentarium for HER2-positive metastatic breast cancer.
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Methods and Designs of Modern Breast Cancer Confirmatory Trials. Cancers (Basel) 2021; 13:cancers13112757. [PMID: 34199352 PMCID: PMC8199547 DOI: 10.3390/cancers13112757] [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: 04/11/2021] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The benefit–risk assessments of new drugs for breast cancer (BC) face several challenges, as all stakeholders do not agree on the evidence bar required for market authorization, and by the fragmentation of breast cancer diagnosis. In this study, we describe the methods and designs of breast cancer confirmatory trials published between 2001 and 2020. We found that the quality of the evidence supporting new breast cancer drugs was improving over time, but that patient-relevant endpoints such as survival and quality of life remained unfrequently used as primary endpoints. Abstract Background: The benefit–risk assessments of new drugs for breast cancer (BC) face several challenges, as all stakeholders do not agree on the evidence bar required for market authorization, and by the fragmentation of breast cancer diagnosis. The aim of this study was to describe the changes in methods and designs of breast cancer confirmatory trials. Methods: All phase III randomized trials published between 2001 and 2020 and assessing systemic BC therapies were included. Trials’ main characteristics, endpoints, and statistical methods were collected using a standardized data extraction form. Results: A total of 347 randomized controlled trials (RCTs) met the inclusion criteria. While most older trials (79%) included all subtypes of breast cancer, most recent trials populations were limited to one large intrinsic BC subgroup (69%). The use of gatekeeping testing strategies increased dramatically from 9% to 71%. The use of overall survival (OS) as an endpoint in the trials increased over time, but its use as a primary endpoint remained infrequent. The inclusion of OS testing in a hierarchical sequence in case of positive testing of a tumor-centered or composite endpoint appeared to have become the new standard. Conclusion: Our findings indicate some improvements in the quality of the evidence-base supporting new breast cancer drugs. The rigorous assessment of patient-relevant endpoints has increased over time, but this improvement is mainly related to the analysis of OS as a secondary endpoint analyzed in a hierarchical sequence.
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Nebhan CA, Johnson DB. Pembrolizumab in the adjuvant treatment of melanoma: efficacy and safety. Expert Rev Anticancer Ther 2021; 21:583-590. [PMID: 33504219 PMCID: PMC8238788 DOI: 10.1080/14737140.2021.1882856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
Introduction: Regional or distant metastases from melanoma may be surgically resected but remain at high-risk of recurrence. Over the last few years, several treatments have been approved to mitigate this risk. These include anti-PD-1 agents, specifically pembrolizumab and nivolumab.Areas covered: Herein, we will discuss the landscape of pembrolizumab safety and efficacy used in the adjuvant setting for high-risk, resected melanoma. We place this in context with other available adjuvant therapies, and discuss subgroup analyses.Expert opinion: Anti-PD-1 therapy with either pembrolizumab or nivolumab has become a standard of care for patients with resected stage III or IV melanoma. In our practice, we generally offer these agents (which have comparable safety and efficacy profiles) to patients with resected stage IIIb-IV melanoma regardless of BRAF mutation status.
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Affiliation(s)
- Caroline A. Nebhan
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center
| | - Douglas B. Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center
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40
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Geybels M, Wolthers BO, Kreiner FF, Rasmussen S, Bauer R. Surrogate endpoint evaluation using data from one large global randomized controlled trial. BMC Med Inform Decis Mak 2021; 21:164. [PMID: 34016120 PMCID: PMC8139150 DOI: 10.1186/s12911-021-01516-8] [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: 12/29/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Robust identification of surrogate endpoints can help accelerate the development of pharmacotherapies for diseases traditionally evaluated using true endpoints associated with prolonged follow-up. The meta-analysis-based surrogate endpoint evaluation (SEE) integrates data from multiple, usually smaller, trials to statistically confirm a surrogate endpoint as a robust proxy for the true endpoint. To test the applicability of SEE when only a single, larger trial is available, we analysed the cardiovascular (CV) survival endpoint from the large multinational trial LEADER (9340 subjects) that confirmed the CV safety of a diabetes drug (liraglutide). We evaluated if using country as a trial unit adequately facilitated the meta-analysis and calculation of R2 by country group. METHODS Data were grouped by country, ensuring at least 30 CV deaths (497 in total) in each of the nine resulting by-country groups. In a two-step SEE on the grouped dataset, we first fitted the group-specific Cox proportional hazard models; next, on the trial-level, we regressed the estimated hazard ratio (HR; liraglutide vs placebo) of the true endpoints (CV death: 497 events, or all-cause death: 828 events) on the HR of the surrogate endpoint (major CV adverse event [MACE]: 1302 events) and derived the group-specific R2 and its 95% confidence interval (CI). RESULTS Group-level surrogacy of MACE was supported for CV death but not for all-cause death, with [Formula: see text] values of 0.85 [0.63;1.00]95% CI and 0.23 [0.00;0.67]95% CI, respectively. Sensitivity analyses using different grouping approaches (e.g. grouping by region) corroborated the robustness of the conclusions as well as the appropriateness of the data-grouping approaches. CONCLUSIONS We derived a specific grouping approach to successfully apply SEE on data from a single trial. This may allow for the statistically robust identification and validation of surrogate endpoints based on the abundance of large monolithic outcome trials conducted as part of drug development programmes in, for example, diabetes.
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Affiliation(s)
- Milan Geybels
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
| | | | | | - Søren Rasmussen
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
| | - Robert Bauer
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
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Delgado A, Guddati AK. Clinical endpoints in oncology - a primer. Am J Cancer Res 2021; 11:1121-1131. [PMID: 33948349 PMCID: PMC8085844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/17/2021] [Indexed: 06/12/2023] Open
Abstract
Clinical endpoints are essential for assessing the safety and efficacy of new cancer therapies. They are used by oncologists to help guide clinical decision making. While overall survival (OS) has frequently been regarded as the "gold standard" primary clinical endpoint, it's utility is constrained by several disadvantages. The time-consuming nature of trials using OS has led to a recent push to explore surrogate clinical endpoints and their potential to serve as primary clinical endpoints in lieu of OS. Additionally, it is becoming evident that other endpoints add valuable information about quality of life and treatment failure as their use is becoming increasingly prevalent in oncology clinical trials. Without a doubt, the use of clinical endpoints will continue to expand and evolve as new cancer therapies are developed and novel treatments, including immunotherapy, draw interest. This review explores the roles of primary and surrogate clinical endpoints as well as the benefits and drawbacks of each specific endpoint. In addition, it directly compares the unique features of each suggesting some of the specific uses each one fulfills.
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Affiliation(s)
- Amanda Delgado
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University GA 30912, Augusta
| | - Achuta Kumar Guddati
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University GA 30912, Augusta
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Harbeck N, Schneeweiss A, Thuss-Patience P, Miller K, Garbe C, Griesinger F, Eberhardt WEE, Klussmann JP, Wollenberg B, Grimm MO, Zander T, Lüftner D. Neoadjuvant and adjuvant end-points in health technology assessment in oncology. Eur J Cancer 2021; 147:40-50. [PMID: 33611103 DOI: 10.1016/j.ejca.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 11/26/2022]
Abstract
Health technology assessment (HTA) of clinical and economic value of a new intervention is an integral step in providing the access of patients to innovative cancer care and treatment. Overall survival (OS) is the preferred criterion for demonstrating the therapeutic efficacy in HTA given its direct clinical and patient relevance. However, with often long life expectancy of patients with early cancer, analysis of OS becomes less practical. Partially due to this reason, pathological complete response (pCR) and time-to-event end-points like disease-free survival are frequently incorporated into the pivotal clinical trials in the neoadjuvant and adjuvant settings. However, there exists a discrepancy between different national HTA bodies regarding the acknowledgement of patient relevance of these end-points. In this article, we analysed the perspectives of patients on different aspects of end-points used in clinical trials in early cancer. Gathered evidence strongly suggests that complete tumour eradication and reduced risk of recurrence provide important psychological benefits thus signifying that pCR and time-to-event end-points are directly relevant to patients. Additionally, we reviewed opinions on patient relevance of neoadjuvant and adjuvant therapy end-points adopted by HTA bodies during the recent evaluations. We found that improvements in end-points used in the adjuvant setting were commonly considered as valuable to patients. In contrast, opinions on patient relevance of neoadjuvant therapy end-points varied between the national HTA bodies. Universal acknowledgement of patient relevance of therapeutic end-points for early cancer by HTA bodies is necessary to balance the inequality in uptake of innovative therapies into national healthcare systems.
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Affiliation(s)
- Nadia Harbeck
- Breast Center, Department of Obstetrics and Gynecology and Comprehensive Cancer Center, University of Munich (LMU), 81377 Munich, Germany
| | - Andreas Schneeweiss
- National Center for Tumor Diseases, Division of Gynecologic Oncology, University Hospital and German Cancer Research Center, 69120 Heidelberg, Germany
| | - Peter Thuss-Patience
- Department of Hematology, Oncology and Tumor Immunology, Campus Virchow-Klinikum, Charité University Hospital Berlin, 12203 Berlin, Germany
| | - Kurt Miller
- Department of Urology, Charité University Hospital Berlin, 12203 Berlin, Germany
| | - Claus Garbe
- Center for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Frank Griesinger
- Department of Hematology and Oncology, Pius-Hospital, University Department Internal Medicine-Oncology, University of Oldenburg, 26121 Oldenburg, Germany
| | - Wilfried E E Eberhardt
- Department of Medical Oncology, West German Cancer Centre, Ruhrlandklinik, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Jens P Klussmann
- Department of Otolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, 50937 Cologne, Germany
| | - Barbara Wollenberg
- Department of Otolaryngology, Head and Neck Surgery, University Hospital MRI, Technical University Munich, 81675 Munich, Germany
| | - Marc-Oliver Grimm
- Department of Urology, Jena University Hospital, 07747 Jena, Germany
| | - Thomas Zander
- Department of Internal Medicine I, University Hospital Cologne, 50924 Cologne, Germany
| | - Diana Lüftner
- Department of Hematology, Oncology and Tumour Immunology, Charité Campus Benjamin Franklin, University Medicine Berlin, 12200 Berlin, Germany.
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Stewart P, Blanchette P, Shah PS, Ye XY, Boldt RG, Fernandes R, Vandenberg T, Raphael J. Do all patients with HER2 positive breast cancer require one year of adjuvant trastuzumab? A systematic review and meta-analysis. Breast 2020; 54:203-210. [PMID: 33130486 PMCID: PMC7599130 DOI: 10.1016/j.breast.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/03/2023] Open
Abstract
One year of adjuvant trastuzumab is considered the standard treatment for patients with HER2 positive breast cancer. However, a shorter duration of trastuzumab may be associated with reduced costs and side effects. Results from randomized trials with diverse non-inferiority margins comparing one year to a shorter duration of adjuvant trastuzumab are not consistent and have not been systematically reviewed using a non-inferiority meta-analysis approach. We conducted a systematic review and meta-analysis of randomized trials to assess whether a shorter duration of adjuvant trastuzumab was non-inferior to one year of treatment or not. The non-inferiority margin for the meta-analysis was pre-defined as the median of the margins of all the trials included. Data of 11,376 patients from 5 trials were analyzed. Non-inferiority margins in included studies varied from 1.15 to 1.53 with median of 1.29 for HR of DFS. A shorter duration of trastuzumab was non-inferior to one year of therapy for DFS (HR 1.13, 95%CI 1.03-1.24) but inconclusive for OS (HR 1.14, 95%CI 1.00-1.30). In a subgroup analysis for DFS outcome, shorter therapy was non-inferior in patients with ER positive disease (HR 1.10, 95%CI 0.95-1.28) and those with sequential therapy (HR 0.97, 95%CI 0.75-1.27) and when the duration of treatment was 6 months (HR 1.09, 95%CI 0.98-1.22). Although a shorter duration of adjuvant trastuzumab was non-inferior to one year of therapy for DFS in patients with HER2 positive breast cancer based on our HR margin of 1.29, any benefit of a shorter duration comes at a loss of efficacy with an increase in absolute risk up to 3.9% for 5 year DFS. Whether the potential increased risk is clinically acceptable for the benefits of a shorter duration remains debatable.
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Affiliation(s)
- Paul Stewart
- Department of Oncology, Division of Medical Oncology, The University of Western Ontario, London, ON, Canada.
| | - Phillip Blanchette
- Department of Oncology, Division of Medical Oncology, The University of Western Ontario, London, ON, Canada
| | - Prakesh S Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Xiang Y Ye
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - R Gabriel Boldt
- London Regional Cancer Program, London Health Sciences Centre, London, ON, Canada
| | - Ricardo Fernandes
- Department of Oncology, Division of Medical Oncology, The University of Western Ontario, London, ON, Canada
| | - Ted Vandenberg
- Department of Oncology, Division of Medical Oncology, The University of Western Ontario, London, ON, Canada
| | - Jacques Raphael
- Department of Oncology, Division of Medical Oncology, The University of Western Ontario, London, ON, Canada
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Steuer CE, Ramalingam SS. EGFR tyrosine kinase inhibitors (TKIs) for adjuvant therapy of early-stage non-small cell lung cancer (NSCLC): ready for the clinic? Transl Lung Cancer Res 2020; 9:1720-1723. [PMID: 33209593 PMCID: PMC7653125 DOI: 10.21037/tlcr-2020-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Conor E Steuer
- Department of Hematology & Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Suresh S Ramalingam
- Department of Hematology & Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
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Tailored duration of adjuvant trastuzumab for human epidermal growth factor receptor 2-positive breast cancer. NPJ Precis Oncol 2020; 4:23. [PMID: 32802960 PMCID: PMC7406512 DOI: 10.1038/s41698-020-00128-1] [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: 02/23/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022] Open
Abstract
We assumed that the effect of adjuvant trastuzumab on survival is mediated by the treatment time and we conducted this trial-level meta-regression to determine the appropriate length of treatment. Twelve adjuvant trastuzumab trials (from January 2000 to June 2019, consisting of 20,271 patients) were included. We considered 12-month trastuzumab treatment as the standard. The primary study endpoint was disease-free survival (DFS). By quantifying the relationship between shortened treatment time (month) and altered recurrence risk (expressed as hazard ratio), we found the regression coefficient β was 0.05 (95% confidence interval: 0.02–0.08, P = 0.002), indicating the recurrence risk would increase 5.1% for each month that treatment was shortened. Accordingly, 3, 6, and 9-month reductions in treatment time resulted in 16%, 35%, and 57% increases in recurrence risk, respectively. We revealed a significant linear association between shortened treatment time of trastuzumab and recurrence risk. The clinical duration of adjuvant trastuzumab should be tailored.
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Huang M, O’Shaughnessy J, Zhao J, Haiderali A, Cortes J, Ramsey S, Briggs A, Karantza V, Aktan G, Qi CZ, Gu C, Xie J, Yuan M, Cook J, Untch M, Schmid P, Fasching PA. Evaluation of Pathologic Complete Response as a Surrogate for Long-Term Survival Outcomes in Triple-Negative Breast Cancer. J Natl Compr Canc Netw 2020; 18:1096-1104. [DOI: 10.6004/jnccn.2020.7550] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/18/2020] [Indexed: 11/17/2022]
Abstract
Background: Pathologic complete response (pCR) is a common efficacy endpoint in neoadjuvant therapy trials for triple-negative breast cancer (TNBC). Previous studies have shown that pCR is strongly associated with improved long-term survival outcomes, including event-free survival (EFS) and overall survival (OS). However, the trial-level associations between treatment effect on pCR and long-term survival outcomes are not well established. This study sought to evaluate these associations by incorporating more recent clinical trials in TNBC. Methods: A literature review identified published randomized controlled trials (RCTs) of neoadjuvant therapy for TNBC that reported results for both pCR and EFS/OS. Meta-regression models were performed to evaluate the association of treatment effect on pCR and EFS/OS. Sensitivity analyses were conducted to assess the impact of divergent study designs. Results: Ten comparisons from 8 RCTs (N=2,478 patients) were identified from the literature review. The log (odds ratio) of pCR was a significant predictor of the log (hazard ratio) of EFS (P=.003), with a coefficient of determination of 0.68 (95% CI, 0.41–0.95). There was a weaker association between pCR and OS (P=.18), with a coefficient of determination of 0.24 (95% CI, 0.01–0.77). Consistent results were found in the exploratory analysis and sensitivity analyses. Conclusions: This is the first study that has shown a trial-level association between pCR and survival outcomes in TNBC. By incorporating the most up-to-date RCTs, this study showed a significant trial-level association between pCR and EFS. A positive association between pCR and OS was also recorded.
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Affiliation(s)
- Min Huang
- 1Merck & Co., Inc., Kenilworth, New Jersey
| | - Joyce O’Shaughnessy
- 2Baylor University Medical Center, Texas Oncology, and U.S. Oncology, Dallas, Texas
| | - Jing Zhao
- 1Merck & Co., Inc., Kenilworth, New Jersey
| | | | - Javier Cortes
- 3IOB Institute of Oncology, Quironsalud Group, Madrid and Barcelona, Spain
- 4Vall d’Hebron Institute of Oncology, Barcelona, Spain
| | - Scott Ramsey
- 5Fred Hutchinson Cancer Research Center, and University of Washington, Seattle, Washington
| | - Andrew Briggs
- 6London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Chenyang Gu
- 8Analysis Group, Inc., Los Angeles, California
| | - Jipan Xie
- 8Analysis Group, Inc., Los Angeles, California
| | - Muhan Yuan
- 7Analysis Group, Inc., Boston, Massachusetts
| | - John Cook
- 9Complete HEOR Solutions, North Wales, Pennsylvania
| | - Michael Untch
- 10Department of Gynecology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Peter Schmid
- 11Barts Cancer Institute, Queen Mary University of London, London, United Kingdom; and
| | - Peter A. Fasching
- 12Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Abstract
The discovery of the HER2 molecules has embarked a series of investigations on the efficacy and safety of different types of anti-HER2 therapies for treating breast cancer, with the clinical pathway requiring a more detailed, more precise, and more dynamics therapeutic approaches due to the heterogeneity of the disease. As the "do more" and "do less" approaches are becoming more important to personalize treatment for early HER2-positive breast cancer, recent advances aim at tackling the advanced stage of the disease by using novel therapeutic agents and combination strategies. There are also important points of consideration on prognosis and choice of therapies, including HER2 gene copy number, HER2 heterogeneity, tissue biomarkers, blood-based biomarkers, and HER2 mutation and its treatment. Altogether, these could potentially play a vital role in the journey of HER2-positive breast cancer patient to achieve greater survival benefit and potentially a cure for the disease.
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Affiliation(s)
- Louis W C Chow
- UNIMED Medical Institute, Hong Kong, China; Organisation for Oncology and Translational Research, Hong Kong, China.
| | - Erich F Lie
- Organisation for Oncology and Translational Research, Hong Kong, China
| | - Masakazu Toi
- Organisation for Oncology and Translational Research, Hong Kong, China; Department of Breast Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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48
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Gyawali B, Hey SP, Kesselheim AS. Evaluating the evidence behind the surrogate measures included in the FDA's table of surrogate endpoints as supporting approval of cancer drugs. EClinicalMedicine 2020; 21:100332. [PMID: 32382717 PMCID: PMC7201012 DOI: 10.1016/j.eclinm.2020.100332] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In July 2018, the FDA first published a table listing all surrogate measures that it has used, and may accept for future use, in regulatory approval. However, the strength of surrogacy for those measures was not formally assessed. Using the case example of breast cancer, we aimed to evaluate the strength of correlation of surrogate measures listed in the FDA's Table with overall survival. METHODS This cross-sectional study of the FDA's Table of Surrogate Endpoints was conducted in May 2019. All surrogate measures listed in the FDA table as appropriate for accelerated or regular approval for breast cancer were extracted. We identified studies evaluating the correlation of treatment benefit in the surrogate with treatment benefit in overall survival and extracted results from the correlation analysis. FINDINGS Five surrogate endpoints were listed for breast cancer in the FDA website: pathological complete response rates (pCR), event-free survival (EFS), disease-free survival (DFS), objective response rates (ORR), and progression-free survival (PFS), of which pCR was listed as appropriate only for accelerated approval, while the rest were considered appropriate for accelerated or regular approval. No correlation study evaluated the correlation of treatment effects on EFS with that on OS. The results from correlation studies evaluating pCR, DFS, ORR, and PFS suggest that the treatment effects on none of these surrogate measures were strongly correlated with treatment effects on OS (r<0.85 or R2 < 0.7, except for DFS in HER2 positive early breast cancer (R2 = 0.75). INTERPRETATION Using breast cancer as an example, we evaluated the underlying evidence for the surrogate endpoints for solid tumors listed in the FDA's Table of Surrogate Endpoints and found weak or missing correlations of treatment effects on these surrogates with treatment effects on OS . Surrogate measures should be predictive of clinical benefit to be useful in supporting regular FDA approval. FUNDING Work on this project was funded by the Arnold Ventures. Dr. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Affiliation(s)
- Bishal Gyawali
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Department of Oncology, Department of Public Health Sciences and Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
- Corresponding author.
| | - Spencer P. Hey
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, US
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, US
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49
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Contextualizing pertuzumab approval in the treatment of HER2-positive breast cancer patients. Cancer Treat Rev 2019; 83:101944. [PMID: 31830538 DOI: 10.1016/j.ctrv.2019.101944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 12/17/2022]
Abstract
The use of adjuvant pertuzumab in HER2-positive early-stage breast cancer has recently been approved by the EMA on the basis of data from the APHINITY trial. Accordingly, we have produced this opinion article with the aim of putting the study data in perspective against other add-on therapeutic strategies, to clarify methodological or statistical doubts about the study, and to define the population of high-risk patients with hormone receptor-negative breast cancer that we agree, in general, should be treated. With this approval, physicians must be well prepared to place the APHINITY study data in context. It is now up to each country to ratify the EMA-approved indications and to agree on reimbursement, and doctors must optimize their use based on knowledge and discussion with patients.
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50
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D'Hondt V, Canon JL, Roca L, Levy C, Pierga JY, Le Du F, Campone M, Desmoulins I, Goncalves A, Debled M, Rios M, Ferrero JM, Serin D, Hardy-Bessard AC, Piot G, Brain E, Dohollou N, Orfeuvre H, Lemonnier J, Roché H, Delaloge S, Dalenc F. UCBG 2-04: Long-term results of the PACS 04 trial evaluating adjuvant epirubicin plus docetaxel in node-positive breast cancer and trastuzumab in the human epidermal growth factor receptor 2-positive subgroup. Eur J Cancer 2019; 122:91-100. [PMID: 31634648 DOI: 10.1016/j.ejca.2019.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE We conducted a double-randomised phase III trial to evaluate a concomitant taxane-anthracycline regimen in node-positive breast cancer and the efficacy of trastuzumab in the human epidermal growth factor receptor 2 (HER2)-positive subpopulation. METHODS A total of 3010 patients with node-positive breast cancer were randomly assigned to receive 6 cycles of 500 mg/m2 of fluorouracil, 100 mg/m2 of epirubicin and 500 mg/m2 of cyclophosphamide (FEC) or 75 mg/m2 of epirubicin and 75 mg/m2 of docetaxel (ED). Patients with HER2-positive tumours were secondary randomly assigned to either trastuzumab or observation. The primary end-point was disease-free survival (DFS) in the two chemotherapy arms. RESULTS After a 115-month median follow-up, DFS was not significantly better in the ED arm (DFS: 70%, 95% confidence interval [CI]: 67-72) than in the FEC arm (DFS: 68%, 95% CI: 65-70; hazard ratio [HR] = 0.88, 95% CI: 0.77-1.01; p = 0.064). The OS was not different between FEC (OS: 80%, 95% CI: 78-83) and ED (OS: 81%, 95% CI: 79-83); HR = 0.97, 95% CI: 0.81-1.16; p = 0.729). ED appeared more toxic. In the 528 HER2-positive subset, there was trend for a higher DFS, in the intention-to-treat population, in the trastuzumab arm (DFS: 68%, 95% CI: 61-74) than in the observation arm (DFS: 60%, 95% CI: 54-66; HR = 0.77, 95% CI: 0.57-1.03; p = 0.079). In the per-protocol population, DFS was significantly higher in the trastuzumab arm (DFS: 70%, 95% CI: 63-76) than in the observation arm (DFS: 59%, 95% CI: 53-65; HR = 0.69, 95% CI: 0.51-0.94; p = 0.0156). The OS was not different between these 2 arms. CONCLUSION This study did not show superiority of the concomitant anthracycline-taxane arm which was more toxic in high-risk node-positive breast cancer patients. Long-term results of the HER2-positive subpopulation are in line with those of the other adjuvant trastuzumab trials but quantitatively less pronounced mostly because of lack of power.
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Affiliation(s)
- Véronique D'Hondt
- Medical Oncology Department, Institut du Cancer, IRCM, INSERM, Univ Montpellier, France.
| | - Jean-Luc Canon
- Medical Oncology Department, Clinique Notre Dame, Charleroi, Belgium
| | - Lise Roca
- Biometrics Unit, Institut du Cancer, Montpellier, France
| | - Christelle Levy
- Medical Oncology Department, Centre François Baclesse, Caen, France
| | - Jean-Yves Pierga
- Medical Oncology Department, Institut Curie & St Cloud, Université Paris Descartes, Paris, France
| | - Fanny Le Du
- Medical Oncology Department, Centre Eugène Marquis, Rennes, France
| | - Mario Campone
- Medical Oncology Department, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | | | - Anthony Goncalves
- Medical Oncology Department, Institut Paoli-Calmettes, Marseille, France
| | - Marc Debled
- Medical Oncology Department, Institut Bergonié, Bordeaux, France
| | - Maria Rios
- Medical Oncology Department, Institut de Cancérologie de Lorraine - Alexis Vautrin, Vandoeuvre-Les-Nancy, France
| | - Jean-Marc Ferrero
- Medical Oncology Department, Centre Antoine Lacassagne, Nice, France
| | - Daniel Serin
- Medical Oncology Department, Institut Sainte-Catherine, Avignon, France
| | - Anne-Claire Hardy-Bessard
- Medical Oncology Department, Centre Armoricain de Radiothérapie, d'Imagerie et d'Oncologie, Plérin, France
| | - Gilles Piot
- Medical Oncology Department, Centre-Médico Chirurgical Les Ormeaux, Le Havre, France
| | - Etienne Brain
- Medical Oncology Department, Institut Curie, Centre René Huguenin, Saint-Cloud, France
| | - Nadine Dohollou
- Medical Oncology Department, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - Hubert Orfeuvre
- Medical Oncology Department, CH - Hôpital de Fleyriat, Bourg-en-Bresse, France
| | | | - Henri Roché
- Medical Oncology Department, IUCT Claudius Regaud, Toulouse, France
| | | | - Florence Dalenc
- Medical Oncology Department, IUCT Claudius Regaud, Toulouse, France
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