Response to chemotherapy is a major parameter-influencing long-term survival of metastatic breast cancer patients

Outcome beyond third-line chemotherapy for metastatic triple-negative breast cancer in the French ESME program

Purpose

Among metastatic breast cancer (MBC) patients, those with a triple-negative breast cancer phenotype (mTNBC) have the worst prognosis, but the benefit of chemotherapy beyond second line on outcome remains uncertain. The purpose of this study was to identify predictive factors of outcome after third- or fourth-line chemotherapy.

Methods

The ESME-MBC database is a French prospective real-life cohort with homogeneous data collection, including patients who initiated first-line treatment for MBC (2008–2016) in 18 cancer centers. After selection of mTNBC cases, we searched for independent predictive factors (Cox proportional-hazards regression models) for overall survival (OS) on third- and fourth-line chemotherapy (OS3, OS4). We built prognostic nomograms based on the main prognostic factors identified.

Results

Of the 22,266 MBC cases in the ESME cohort, 2903 were mTNBC, 1074 (37%) and 598 (20%) of which had received at least 3 or 4 lines of chemotherapy. PFS after first- and second-line chemotherapy (PFS1, PFS2) and number of metastatic sites ≥3 at baseline were identified by multivariate analysis as prognostic factors for both OS3 (HR = 0.76 95%CI[0.66–0.88], HR = 0.55 95%CI[0.46–0.65], HR = 1.36 95%CI[1.14–1.62], respectively), and OS4 (HR = 0.76 95%CI[0.63–0.91], HR = 0.56 95%CI[0.45–0.7], HR = 1.37 95%CI[1.07–1.74]), respectively. In addition, metastasis-free interval was identified as a prognostic factor for OS3 (p = 0.01), while PFS3 influenced OS4 (HR = 0.75 95%CI[0.57–0.98]). Nomograms predicting OS3 and OS4 achieved a C-index of 0.62 and 0.61, respectively.

Conclusion

The duration of each previous PFS is a major prognostic factor for OS in mTNBC patients receiving third- or fourth-line chemotherapy. The clinical utility of nomograms including this information was not demonstrated.

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After 3rd- or 4th-line therapy, PFS remained linear in the majority of women with metastatic triple-negative breast cancer.

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The duration of each previous PFS had an impact on the OS associated with subsequent lines.

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PFS2 was more strongly predictive of outcome than PFS1 for third-line therapy.

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PFS2 and PFS3 had an impact on outcome irrespective of PFS1 for fourth-line therapy.

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The clinical utility of nomograms including duration of each previous PFS to predict OS was not sufficient.

Role of surgery in patients with synchronous metastatic breast cancer: Is there a need for axillary lymph node removal?

INTRODUCTION

About 6% of women with breast cancer present with synchronous metastases. Treatment remains palliative in international recommendations but the impact of loco-regional surgery remains controversial.

OBJECTIVE

We conducted a multicentre, cohort study to evaluate the impact of axillary lymph node (ALN) surgery on overall survival in stage IV breast cancer at diagnosis.

METHODS

Patients presenting with breast cancer and synchronous metastases between 2005 and 2014 were included. Follow up was conducted up to 1st June 2018. The only exclusion criterion was a history of previous malignancies. Breast surgery was defined as lumpectomy or mastectomy. Axillary surgery included full ALN dissection, and sentinel lymph node biopsy (SLNB). If the SLN was invaded on the frozen section, full axillary dissection was performed.

RESULTS

152 patients were included. 71 women had no surgery, 81 had primary site surgery of which 64 (79%) had breast and axillary surgery and 17 (21%) breast surgery only. 5-year overall survival was 59.8% (95% CI=[49.5; 69.5]) for women with breast and axillary surgery, 23.5% (95% CI=[15.6; 33]) for women with breast surgery only and 9.8% (95% CI=[4.7; 17.5]) for women without any surgery, p < 0.001. Combined with breast surgery, axillary surgery significantly added a mean of 33 months to patient overall survival.

CONCLUSION

ALN surgery combined with breast surgery in metastatic breast cancer significantly increased overall survival. Thus surgical indications should not differ from those in women with breast cancer without metastases.

Effects of silver nanoparticles coated with anti-HER2 on irradiation efficiency of SKBR3 breast cancer cells

Breast cancer is the second cause of death in the world. Ionising radiation is a potent mutagen that can cause DNA damage, chromosomes breakage, and cell death. In the present study, radiotherapy and nanoparticle-antibodies (ABs) have been combined to enhance the efficacy of cancer cell treatment. Silver nanoparticles (SNP) were synthesised, coated with anti-HER2, and then characterised with different techniques such as X-ray diffraction, dynamic light scattering, transmission electron microscopy, Fourier transform infrared, and UV-Vis spectroscopy. SKBR3 cells were irradiated with cobalt-60 in the presence of nanoparticle-AB as the drug. Cell viability was measured using the diphenyltetrazolium bromide assay, and the cellular status was assessed by Raman spectroscopy. Irradiation considerably decreased cell viability proportionate to the dose increase and post-irradiation time. The surface-enhanced Raman spectroscopy increased the signal in the presence of SNP. Increasing the dose to 2 Gy increased the irradiation resistance, and higher dose increases (4 and 6 Gy) enhanced the irradiation sensitivity. Moreover, the cellular changes induced by irradiation in the presence of the drug were stable after 48 h. The authors results introduced the combination of the drug with radiation as an effective treatment for cancer and Raman spectroscopy as a suitable tool to diagnose effective irradiation doses.

Urinary Neopterin in Patients with Liver Tumors

Aims and background

Primary and secondary liver tumors are associated with poor prognosis. Neopterin is an indicator of systemic immune activation, and increased neopterin concentrations have been associated with poor prognosis in a wide range of malignant tumors.

Methods

Urinary neopterin was determined by high-performance liquid chromatography in 154 patients with primary and secondary liver tumors. The survival of different groups of patients was compared by log-rank test, and Cox regression was used for multivariate analysis.

Results

Urinary neopterin was significantly increased in patients compared to controls. A statistically significant correlation was observed between urinary neopterin and age of the patients, hemoglobin concentration, mean erythrocyte volume and peripheral blood leukocyte or platelet count. In univariate analysis, urinary neopterin below 214 μmol/mol creatinine, peripheral blood leukocytes below 8 x 109/L, hemoglobin equal to or above 125 g/L, no extrahepatic tumor, stage of liver involvement, and colorectal, breast or ovarian primary were significant prognostic factors for survival. In multivariate analysis, Bengtsson stage, presence of extrahepatic involvement, primary other than colorectal, breast or ovarian carcinoma, peripheral blood leukocyte count and urinary neopterin were independent prognostic factors. Increased urinary neopterin during and at the end of follow-up was also associated with poor prognosis.

Conclusions

Urinary neopterin is increased in patients with liver tumors. Neopterin is an independent prognostic indicator in patients with liver tumors along with Bengtsson stage, presence of extrahepatic disease, primary site and peripheral blood leukocyte count.

Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial

BACKGROUND

The role of locoregional treatment in women with metastatic breast cancer at first presentation is unclear. Preclinical evidence suggests that such treatment might help the growth of metastatic disease, whereas many retrospective analyses in clinical cohorts have suggested a favourable effect of locoregional treatment in these patients. We aimed to compare the effect of locoregional treatment with no treatment on outcome in women with metastatic breast cancer at initial presentation.

METHODS

In this open-label, randomised controlled trial, we recruited previously untreated patients (≤65 years of age with an estimated remaining life expectancy of at least 1 year) presenting with de-novo metastatic breast cancer from Tata Memorial Centre, Mumbai, India. Patients were randomly assigned (1:1) to receive locoregional treatment directed at their primary breast tumour and axillary lymph nodes, or no locoregional treatment, by a computer-generated block randomisation sequence (block size of four). Randomisation was stratified by site of distant metastases, number of metastatic lesions, and hormone receptor status. Patients with resectable primary tumour in the breast that could be treated with endocrine therapy were randomly assigned upfront, whereas those with an unresectable primary tumour were planned for chemotherapy before randomisation. Of the patients who had chemotherapy before randomisation, we randomly assigned patients who had an objective tumour response after six to eight cycles of chemotherapy. The primary endpoint was overall survival analysed by intention to treat. This study is registered with ClinicalTrials.gov, NCT00193778.

FINDINGS

Between Feb 7, 2005, and Jan 18, 2013, of the 716 women presenting with de-novo metastatic breast cancer, we randomly assigned 350 patients: 173 to locoregional treatment and 177 to no locoregional treatment. At data cut-off of Nov 1, 2013, median follow-up was 23 months (IQR 12·2-38·7) with 235 deaths (locoregional treatment n=118, no locoregional treatment n=117). Median overall survival was 19·2 months (95% CI 15·98-22·46) in the locoregional treatment group and 20·5 months (16·96-23·98) in the no-locoregional treatment group (HR 1·04, 95% CI 0·81-1·34; p=0·79), and the corresponding 2-year overall survival was 41·9% (95% CI 33·9-49·7) in the locoregional treatment group and 43·0% (35·2-50·8) in the no locoregional treatment group. The only adverse event noted was wound infection related to surgery in one patient in the locoregional treatment group.

INTERPRETATION

There is no evidence to suggest that locoregional treatment of the primary tumour affects overall survival in patients with metastatic breast cancer at initial presentation who have responded to front-line chemotherapy, and this procedure should not be part of routine practice.

Features of aggressive breast cancer

BACKGROUND

Aggressive breast cancer is a term commonly used in literature to describe breast cancer with a poor prognosis. Identifying and understanding the factors associated with aggressiveness could be helpful to the management of patients with breast cancer. Breast cancer is a heterogeneous disease, both clinically and biologically, which may be responsible for the wide range of survival durations for patients with metastatic disease.

AIM

The goal of this study was to identify the factors most often described in association with aggressive metastatic breast cancer (MBC).

METHODS

A systematic review was performed by querying PubMed from January 1, 2012 to June 1, 2014 for "metastatic breast cancer" ("aggressive" or "poor prognosis" or "high risk"). The level of evidence to support each potential prognostic factor of aggressive MBC was also reviewed.

RESULTS

The identified factors were grouped into 3 principle categories: clinical, biological, and patient related. Because patient-related factors may not be indicative of inherent cancer aggressiveness, this review focused only on clinical and biological factors. The factors with the highest levels of evidence to support associations with survival in metastatic breast cancer were visceral metastases, number of metastatic sites, disease-free interval, presence of CTCs, triple-negative disease, and tumour grade.

CONCLUSION

Identification of these factors and understanding their contribution to the aggressiveness of MBC and disease progression may lead to more personalized treatment in this patient population.

Trends in Survival for Patients with Metastatic Breast Cancer: Is Survival Improving?

Introduction

The treatment of patients with metastatic breast cancer (mBC) is one of the most difficult problems in clinical oncology. Clinical trial results suggest that novel therapies may be having a favorable impact on the survival of mBC patients, but the real impact of new therapies on OS rates has yet to be established. The aim of this outcome study was to evaluate the most reliable parameters to define the long-term result in terms of OS of different treatment strategies for mBC patients in a real-world clinical practice.

Materials and Methods

A retrospective analysis of consecutive patients diagnosed with mBC between February 2001 and December 2008 and treated at our medical oncology unit was performed.

Results

We evaluated 70 female patients. At the last follow-up all patients had died. Median OS was 31.55 months (range, 2.33-100.13). There was no statistically significant difference in OS (p = 0.284) between the period 2001-2004 and the period 2005-2008. We did not find any statistically significant difference in OS even in the transition from one year to the next (p = 0.154).

Conclusions

The results of the current analysis suggest that the OS of women with mBC has not improved in the last years. However, these results should be interpreted with caution, considering the difficulty of determining changes in survival over time. Larger studies are needed to corroborate our findings.

Nanoparticle albumin-bound paclitaxel (nab-paclitaxel) as second-line chemotherapy in HER2-negative, taxane-pretreated metastatic breast cancer patients: prospective evaluation of activity, safety, and quality of life

BACKGROUND

A prospective, multicenter trial was undertaken to assess the activity, safety, and quality of life of nanoparticle albumin-bound paclitaxel (nab-paclitaxel) as second-line chemotherapy in HER2-negative, taxane-pretreated metastatic breast cancer (MBC).

PATIENTS AND METHODS

Fifty-two women with HER2-negative MBC who were candidates for second-line chemotherapy for the metastatic disease were enrolled and treated at three centers in Northern Italy. All patients had previously received taxane-based chemotherapy in the adjuvant or first-line metastatic setting. Single-agent nab-paclitaxel was given at the dose of 260 mg/m(2) as a 30-minute intravenous infusion on day 1 each treatment cycle, which lasted 3 weeks, in the outpatient setting. No steroid or antihistamine premedication was provided. Treatment was stopped for documented disease progression, unacceptable toxicity, or patient refusal.

RESULTS

All of the enrolled patients were evaluable for the study endpoints. The objective response rate was 48% (95% CI, 31.5%-61.3%) and included complete responses from 13.5%. Disease stabilization was obtained in 19 patients and lasted >6 months in 15 of them; the overall clinical benefit rate was 77%. The median time to response was 70 days (range 52-86 days). The median progression-free survival time was 8.9 months (95% CI, 8.0-11.6 months, range 5-21+ months). The median overall survival point has not yet been reached. Toxicities were expected and manageable with good patient compliance and preserved quality of life in patients given long-term treatment.

CONCLUSION

Our results showed that single-agent nab-paclitaxel 260 mg/m(2) every 3 weeks is an effective and well tolerated regimen as second-line chemotherapy in HER2-negative, taxane-pretreated MBC patients, and that it produced interesting values of objective response rate and progression-free survival without the concern of significant toxicity. Specifically, the present study shows that such a regimen is a valid therapeutic option for that 'difficult to treat' patient population represented by women who at the time of disease relapse have already received the most active agents in the adjuvant and/or metastatic setting (ie, conventional taxanes).

[Bevacizumab and taxanes in the first-line treatment of metastatic breast cancer : overall survival and subgroup analyses of the ATHENA study in France]

The international phase IIIb study, ATHENA assessed the combination of bevacizumab/taxane-based chemotherapy in the first-line treatment of HER2 negative metastatic breast cancer (mBC) in real-life setting. Among the 365 patients included in France, median overall survival (OS) is 28.4 months (CI95% 24.8-33.0), with a median time from treatment start to end of study of 36,5 months (25,1-45,4). Exploratory analyses in three sub-groups show that the median OS in long responder patients (not progressing for at least one year; n = 116) is not reached. In responder patients (n = 308), median OS is 33.0 months (CI95% 28.6-37.4) and 12.4 months (CI95% 11.2-17.4) in non-responders (n = 41). In patients with mBC expressing hormone receptors (HR+), treated with first-line hormone therapy before inclusion (n = 87) median OS in is 23.2 months (CI95% 19.6-28.6), and 35.3 months (CI95% 32.2-not reached); P = 0.004 in patients treated first with chemotherapy + bevacizumab (n = 179). The safety analysis in the various sub-groups of grade 3-5 adverse events of particular interest to bevacizumab of this study was comparable to the safety data of randomized phase III studies.

Evaluating the role of nab-paclitaxel (Abraxane) in women with aggressive metastatic breast cancer

Nab-paclitaxel (Abraxane(®)) is an albumin-bound form of paclitaxel that utilizes the natural properties of albumin to improve paclitaxel delivery to the tumor. It is licensed for use in metastatic breast cancer (MBC) at a dose of 260 mg/m(2) Q3W based on its superior therapeutic index versus conventional paclitaxel 175 mg/m(2) Q3W demonstrated in a Phase III study. In a post-hoc analysis, nab-paclitaxel treatment was associated with rapid and dramatic tumor responses in patients with poor prognostic factors (visceral dominant disease, ≥3 metastatic lesions), suggesting it may be a preferred treatment for these patients. Moreover, significant efficacy has been seen with nab-paclitaxel 100 and 150 mg/m(2) QW 3/4, suggesting it may be possible to tailor use of this agent in the future.

Percutaneous cryoablation of liver metastases from breast cancer: initial experience in 17 patients

AIM

To assess the feasibility, safety, and effectiveness of percutaneous cryoablation for the treatment of liver metastases from breast cancer.

MATERIALS AND METHODS

This study included 39 liver metastases in 17 female breast cancer patients who underwent computed tomography (CT)-guided percutaneous cryoablation. The mean age of the cohort was 55 years (range 30-66 years). The tumour response was evaluated by CT performed before treatment, 1 month after treatment, and every 3 months thereafter. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) was used to assess the patients' quality of life before, 1 week, 1 month, and 3 months after cryoablation. The primary endpoints were technique effectiveness, quality of life, and complications.

RESULTS

The technical success rate was 92% with no major complication reported. At the 1-month follow-up, the primary technique effectiveness was 87.1% (34 of 39 tumours). At the 3-months follow-up, local tumour progression was observed in six of 39 lesions (15.4%). The 1-year survival from the time of cryoablation was 70.6%. The quality of life symptoms and functioning scales were preserved in patients alive at 3 months after cryoablation. The global quality of life, mean value of "pain" and "fatigue" between 3 months after cryoablation and prior to treatment showed statistically significant differences, but no clinical significance.

CONCLUSIONS

Cryoablation is a safe and effective ablative therapy, providing a high rate of local tumour control in breast cancer liver metastases.

Cardioprotective interventions for cancer patients receiving anthracyclines

BACKGROUND

Anthracyclines are among the most effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent this cardiotoxicity, different cardioprotective agents have been studied.

OBJECTIVES

The objective of this review was to assess the efficacy of different cardioprotective agents in preventing heart damage in cancer patients treated with anthracyclines.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10), MEDLINE (1966 to November 2010) and EMBASE (1980 to November 2010) databases. In addition, we handsearched reference lists, conference proceedings of the International Society of Paediatric Oncology (SIOP) and American Society of Clinical Oncology (ASCO) meetings (1998 to 2010) and ongoing trials registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which any cardioprotective agent was compared to no additional therapy or placebo in cancer patients (children and adults) receiving anthracyclines.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection, risk of bias assessment and data extraction including adverse effects.

MAIN RESULTS

We identified RCTs for the eight cardioprotective agents N-acetylcysteine, phenethylamines, coenzyme Q10, a combination of vitamins E and C and N-acetylcysteine, L-carnitine, carvedilol, amifostine and dexrazoxane (mostly for adults with advanced breast cancer). All studies had methodological limitations and for the first seven agents there were too few studies to allow pooling of results. None of the individual studies showed a cardioprotective effect. The 10 included studies on dexrazoxane enrolled 1619 patients. The meta-analysis for dexrazoxane showed a statistically significant benefit in favour of dexrazoxane for the occurrence of heart failure (risk ratio (RR) 0.29, 95% CI 0.20 to 0.41). No evidence was found for a difference in response rate or survival between the dexrazoxane and control groups. The results for adverse effects were ambiguous. No significant difference in the occurrence of secondary malignancies was identified.

AUTHORS' CONCLUSIONS

No definitive conclusions can be made about the efficacy of cardioprotective agents for which pooling of results was impossible. Dexrazoxane prevents heart damage and no evidence for a difference in response rate or survival between the dexrazoxane and control groups was identified. The evidence available did not allow us to reach any definite conclusions about adverse effects. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in patients with cancer treated with anthracyclines. However, clinicians should weigh the cardioprotective effect of dexrazoxane against the possible risk of adverse effects for each individual patient.

Usefulness of chemotherapy beyond the second line for metastatic breast cancer: a therapeutic challenge

PURPOSE

Several lines of chemotherapy can be proposed for patients with metastatic breast cancer, but beyond the second line, agreement is lacking concerning the most appropriate therapeutic strategy.

METHODS

We conducted a retrospective analysis of the files of 162 patients, who had received at least 3 lines of chemotherapy (CT3) for metastatic breast cancer during a 5-year period (2000-2004), in order to analyze management practices and search for factors affecting survival from CT3 and predictive factors of non-progressive disease (NPD) after CT3.

RESULTS

Multivariate analysis identified seven factors which had a positive influence on survival from CT3 (SBR grade I, absence of adjuvant hormone therapy, free interval >or=2 years, absence of cerebromeningeal metastasis before CT, unique focus at initiation of CT3, use of polychemotherapy for CT2, and complete response to CT1 or CT2) and two predictive factors of NPD (histology and drug group used for CT3).

CONCLUSIONS

These factors should help determine the appropriate strategy for proposing a third line of chemotherapy.

Development and verification of a prediction model using serum tumor markers to predict the response to chemotherapy of patients with metastatic or recurrent breast cancer

PURPOSE

The aim of this study was to develop a prediction model using serum tumor markers to predict the response to chemotherapy of patients with metastatic or recurrent breast cancer.

METHODS

We retrospectively analyzed a training set of 105 patients with metastatic or recurrent breast cancer. Their chemotherapeutic response had been evaluated according to the World Health Organization (WHO)'s response criteria. Our model for predicting response using carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 15-3, and NCC-ST-439 was determined using the area under the receiver operating characteristic curve (ROC-AUC) and the overall misclassification rate (OMR) in a random cross-validation. The prediction model was then verified in a consecutive set of 64 patients. Their response had been evaluated using the response evaluation criteria in solid tumors (RECIST) criteria.

RESULTS

The best prediction model consisted of the serum CEA, CA15-3, and NCC-ST-439 levels, but the prediction formula varied according to the baseline CA15-3 level (elevated or normal). The overall ROC-AUC and OMR in the training set were 0.83 and 0.19, respectively. The overall ROC-AUC and OMR in the verification set were 0.72 and 0.28, respectively. When the verification set was stratified according to either the objective response or the predicted response, the time-to-progression, but not the overall survival, was significantly different.

CONCLUSION

Our model for predicting the response to first-line chemotherapy of patients with metastatic or recurrent breast cancer may be valid because it predicted the outcome of more than 70% of the patients in an independent verification set.

Cardioprotective interventions for cancer patients receiving anthracyclines

BACKGROUND

Anthracyclines are among the most effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent this cardiotoxicity, different cardioprotective agents have been studied.

OBJECTIVES

The objective of this review was to assess the efficacy of different cardioprotective agents in preventing heart damage in cancer patients treated with anthracyclines.

SEARCH STRATEGY

We searched the databases of the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2007), MEDLINE (1966 to April 2007) and EMBASE (1980 to April 2007). In addition, we handsearched reference lists and conference proceedings of the SIOP and ASCO meetings (1998 to 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which any cardioprotective agent was compared to no additional or placebo therapy in cancer patients (children and adults) receiving anthracyclines.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection, quality assessment and data-extraction including adverse effects.

MAIN RESULTS

We identified RCTs for seven cardioprotective agents: N-acetylcysteine, phenetylamines, coenzyme Q10, combination of vitamins E and C and N-acetylcysteine, L-carnitine, carvedilol and dexrazoxane (mostly adults with advanced breast cancer). All studies had methodological limitations. For the first six agents, there were too few studies to allow pooling of results. None of the individual studies showed a cardioprotective effect. The nine included studies of dexrazoxane enrolled 1403 patients. The meta-analysis of dexrazoxane showed a statistically significant benefit in favour of dexrazoxane for the occurrence of heart failure (Relative Risk (RR) 0.29, 95% CI 0.20 to 0.41). No evidence was found for a difference in response rate or survival between the dexrazoxane and control group. Only for one adverse effect (abnormal white blood cell count at nadir) a difference in favour of the control group was identified.

AUTHORS' CONCLUSIONS

For cardioprotective agents for which pooling was impossible, no definitive conclusions can be made about their efficacy. Dexrazoxane prevents heart damage and no evidence for a difference in response rate or survival between the dexrazoxane and control group was identified. Only for an abnormal white blood cell count at nadir a clearly significant difference in favour of the control group was identified. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in patients with cancer treated with anthracyclines. However, for each individual patient clinicians should weigh the cardioprotective effect of dexrazoxane against the possible risk of adverse effects.

Prognostic significance of changes in CA 15-3 serum levels during chemotherapy in metastatic breast cancer patients

Tumor response to first-line chemotherapy in advanced breast cancer offers prognostic information and may be used as a surrogate marker for evaluating treatment efficacy. With this study we wanted to determine whether changes in circulating serum CA 15-3 levels during chemotherapy provided additional information for prognostic prediction. Serum CA 15-3 was measured at baseline and after 3 and 6 months during anthracycline-based first-line chemotherapy in 526 patients with advanced breast cancer prospectively enrolled in five phase II-III trials. Changes in marker levels were correlated with disease response, time to progression and overall survival. In all, 336 patients attained a disease response. A significant relationship was found between disease response and CA 15-3 variations, although many individual discrepancies were also observed. At the 6-month time point, the median time to progression was 15.3 months in patients with normal marker levels throughout the study, 11.7 months in those with a CA15-3 reduction >25%, 9.6 months in those with elevated baseline CA 15-3 levels which did not change during therapy and 8.6 months in those with increased marker levels (p < 0.001). The median survival was 42.3, 29.7, 28.5, and 24.8 months, respectively (p < 0.002). The prognostic role of changes in CA 15-3 levels was maintained in the patient subset attaining disease response or stabilization to treatment (p < 0.001) and after adjusting for clinical response and major prognostic parameters in the multivariate analysis (p < 0.001). In conclusion, monitoring serum CA 15-3 levels during first-line chemotherapy in advanced breast cancer patients provides prognostic information independently from tumor response.

Extending survival with chemotherapy in metastatic breast cancer

Metastatic breast cancer (MBC) remains essentially incurable, and goals of therapy include the palliation of symptoms, delay of disease progression, and prolongation of overall survival time without negatively impacting quality of life. Anthracycline and taxane-based therapies have traditionally shown the highest degree of activity in MBC. Though numerous randomized clinical trials have shown improvements in overall response rates, few have found clear survival benefits. In recent years, however, there has been a small but growing series of clinical trials demonstrating modest, but meaningful survival advantages in metastatic disease. A common feature in many of these trials has been the use of a taxane, and more recently, a taxane combined with an antimetabolite. In addition, the development of targeted biologic agents active against MBC, such as trastuzumab and bevacizumab, has demonstrated great potential for enhancing the effects of chemotherapy and producing meaningful survival improvements. The role of the taxanes, antimetabolites, and biologics in extending survival in MBC is discussed.

Objective Response to Chemotherapy As a Potential Surrogate End Point of Survival in Metastatic Breast Cancer Patients

Purpose

To assess the validity of objective response to chemotherapy as a surrogate end point for survival in metastatic breast cancer.

Patients and Methods

We carried out a meta-analysis on individual data from 2,126 metastatic breast cancer patients who were enrolled onto 10 randomized trials comparing standard versus intensified epirubicin-containing chemotherapy.

Results

The intensified chemotherapy was associated with a significantly higher tumor response rate compared with standard chemotherapy (pooled odds ratio for nonresponse, 0.60; 95% CI, 0.51 to 0.72). The intensified regimens also led to better (although not significant) survival (pooled odds ratio, 0.94; 95% CI, 0.86 to 1.04; P = .22). Tumor response was a highly significant predictor of survival (P < .0001). When tumor response was introduced in the Cox model, the hazard ratio in favor of experimental treatment changed from 0.94 to 1.005 (95% CI, 0.91 to 1.11; P = .92), indicating that no residual effect of the experimental treatment on survival was present once tumor response was adjusted for. This suggests that the overall survival benefit of intensified epirubicin was a result of the increase in response rate. The median survival time of patients with complete response and partial response was 28.8 months (95% CI, 25.4 to 45.3 months) and 21.3 months (95% CI, 19.2 to 22.4 months), respectively; whereas, the median survival time of patients with no response was 14.6 months (95% CI, 13.9 to 15.4 months).

Conclusion

These results support the hypothesis that the achievement of an objective response to chemotherapy in metastatic breast cancer is associated with a true survival benefit. The potential role of objective response as a surrogate end point for survival in chemotherapy trials of metastatic breast cancer warrants further investigation.

Maintenance Therapy to Suppress Micrometastasis: The New Challenge for Adjuvant Cancer Treatment

The palliative efficacy of cytotoxic drugs is routinely assessed using tumor shrinkage (response) rates shown in clinical trials. Although adjuvant drug therapy has a goal distinct from that of palliative therapy (i.e., to prolong survival by inhibiting progression of micrometastatic disease), it is widely assumed that the adjuvant efficacy of a drug will parallel its response rate ("activity") in advanced stages of the disease. Reconsideration of this assumption seems timely in view of recent developments: the realization that many predictors of short-term tumor response correlate inversely with long-term survival outcomes; the characterization of tumor progression as a discontinuous process that may include dormant phases; the understanding that micrometastasis is therapeutically suppressible by a variety of mechanisms including direct tumor cell kill, cytotoxic disruption of paracrine growth signals from normal tissues, and targeted inhibition of prometastatic pathways; the recognition that tumor dormancy not only blocks the antimetastatic efficacy of cytotoxic drugs but also represents a therapeutic end point for metastasis-suppressive noncytotoxic drugs such as hormone inhibitors; and the insight that optimal adjuvant drug therapy is likely to include both induction and maintenance components. The traditional view of cytoreductive response as a prerequisite for adjuvant drug efficacy thus merits reappraisal, with a view to accelerating incorporation of novel noncytotoxic maintenance therapies into controlled studies.

Cardioprotective interventions for cancer patients receiving anthracyclines

BACKGROUND

Anthracyclines are among the most effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent this cardiotoxicity, different cardioprotective agents have been studied.

OBJECTIVES

The objective of this review was to assess the efficacy of different cardioprotective agents in preventing heart damage in cancer patients treated with anthracyclines.

SEARCH STRATEGY

We searched the databases of CENTRAL (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to August 2002) and EMBASE (1980 to August 2002). In addition, we handsearched reference lists and conference proceedings of the International Society for Paediatric Oncology (SIOP) and the American Society of Clinical Oncology (ASCO) (1998 to 2002).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which any cardioprotective agent was compared to no additional or placebo therapy in cancer patients (children and adults) receiving anthracyclines.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed the study selection, quality assessment and data-extraction including adverse effects.

MAIN RESULTS

We identified RCTs for 5 cardioprotective agents: N-acetylcysteine (1 study; 54 patients), phenetylamines (2 studies; 100 patients), coenzyme Q10 (1 study; 20 patients), combination of vitamin E, vitamin C and N-acetylcysteine (1 study; 14 patients) and dexrazoxane (6 studies; 1013 patients). All studies had methodological limitations. Due to the insufficient number of studies, for the first four mentioned cardioprotective agents pooling of the results was impossible. None of the individual studies showed a cardioprotective effect. The meta-analysis of the dexrazoxane-studies showed a statistically significant benefit in favour of dexrazoxane for the occurrence of heart failure (Relative Risk (RR) = 0.28, 95% Confidence Interval (CI) 0.18 to 0.42, P < 0.00001). No statistically significant difference in response rate between the dexrazoxane and control group was found (RR = 0.88, 95% CI 0.77 to 1.01, P = 0.06), but there was some suggestion that patients treated with dexrazoxane might have a lower anti-tumour response rate. Our meta-analysis of survival showed no significant difference between the dexrazoxane and control group. For adverse effects pooling was impossible. However, no important differences in the occurrence of side effects were found. The majority of the patients included in this meta-analysis were adults with advanced breast cancer.

AUTHORS' CONCLUSIONS

For cardioprotective agents for which pooling was impossible no high quality evidence was available and therefore, no definitive conclusions can be made about their efficacy. Dexrazoxane prevents heart damage, however there was some suggestion that patients treated with dexrazoxane might have a lower anti-tumour response rate. There was no significant difference in survival between the dexrazoxane and control group. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in patients with cancer treated with anthracyclines. However, for each individual patient clinicians should weigh the cardioprotective effect of dexrazoxane against the possible risk of a lower response rate.

Long-term survival of a patient with primarily chemo-resistant metastatic breast cancer treated with medroxyprogesterone acetate

The prognosis of breast cancer patients with liver metastases is extremely poor. Here we present the case of a 66-year-old female breast cancer patient with multiple liver metastases diagnosed 2 years after a radical modified mastectomy followed by adjuvant tamoxifen. At progression, anthracycline-based chemotherapy was administered, but a CT scan following two cycles of FEC (5-fluorouracil, epirubicin, cyclophosphamide) showed progression of the liver metastases. Chemotherapy was therefore switched to medroxyprogesterone acetate (MPA). After 3 months the patient's general status improved, and disease stabilization was observed at the next CT scan. A further 4 months of MPA treatment resulted in complete response of all liver lesions. Treatment with oral MPA was continued for 4 years. At present, 11 years after the diagnosis of metastatic liver involvement, the patient is alive, free of cancer, and fully ambulatory. Despite bulky visceral disease and chemoresistance, hormonal treatment with MPA resulted in a spectacular and long-lasting response.

Tumor Response and Survival End Points in Clinical Trials

Survival has become the gold standard for determining the relative effectiveness of chemotherapy regimens in phase III clinical trials and is measured generally as the median survival. Response could be a surrogate for survival in evaluating clinical trials for chemotherapy, but it has become a controversial measurement parameter because of the quantitative variability in measurement and the fact that differences in response rates are not commonly translated into differences in survival. However, if response is indeed a determinant of survival, the median survival (the point at which 50% of the patients are alive) will not be impacted because response rates (RR) for most advanced cancers are less than 50%. Nonetheless, a survival benefit has been identified for tumors in which response rates are 50% or less in 4 phase III randomized trials; 2 in breast cancer (a high response-rate tumor) also show significant differences in survival. These data would imply that factors other than tumor response could be operative in influencing survival. It is a categorical truth that "responders" live longer than "nonresponders," but the response and survival relationship is complex and both parameters are important in clinical trials.

Initially metastatic breast carcinoma has a distinct disease pattern but an equivalent outcome compared with recurrent metastatic breast carcinoma

BACKGROUND

To date, the clinical features and outcomes of patients with initially metastatic breast carcinoma (IMBC) have not been compared with the corresponding characteristics in patients with recurrent metastatic breast carcinoma (RBC). This issue may be particularly relevant to clinical research, as it may shed light on a potential bias with respect to the selection of patients for clinical trials.

METHODS

A retrospective analysis of the medical records of 1350 patients with breast carcinoma was performed. Outcome variables included overall survival, response rate, and progression-free survival.

RESULTS

One hundred nineteen of 370 patients with metastatic breast carcinoma had IMBC, whereas the remaining 251 had RBC. The median follow-up duration was 39.4 months, and the median overall survival duration was 24 months. With regard to clinical characteristics, patients with IMBC were older than patients with RBC (61.7 years vs. 58.1 years; P < 0.001) and had a higher incidence of lobular carcinoma (15.9% vs. 7.7%; P = 0.018), a greater proportion of T3-4 tumors (58.8% vs. 27.9%; P < 0.001), a higher incidence of bone as the dominant metastatic site (41.2% vs. 21.5%; P < 0.001), a lower incidence of soft tissue as the dominant metastatic site (10.1% vs. 26.7%; P < 0.001), and a similar incidence of the viscera as the dominant metastatic site (48.7% vs. 51.8%; P = 0.78). Median overall survival duration was similar for patients with IMBC (25.1 months) and patients with RBC (23.3 months; P = 0.81). Statistical analyses also revealed nonsignificant differences between patients with IMBC and patients with RBC in terms of response rate (40.7% vs. 35.2%, respectively; P = 0.35) and median progression-free survival duration (10.2 months vs. 9.0 months, respectively; P = 0.58).

CONCLUSIONS

Although patients with IMBC and patients with RBC exhibit distinct histologic and clinical characteristics, similar treatment efficacy results and survival outcomes are observed in these two groups.

Maintaining treatment of locally advanced breast cancer

Locally advanced breast cancer is a specific clinic entity, comprising various degrees of breast cancer local and regional extension. This term is applied to nonmetastatic large primary tumors (including inflammatory breast carcinoma), with or without extensive regional lymph node involvement, with a rapid or slow evolution, and usually with poor prognosis. This clinical presentation of mammary carcinoma is common in developing countries (30% to 60%), but also with a remarkable incidence in developed countries (10% to 20%). During many decades patients were treated with radical surgery or radiation therapy and with their combination, but always with poor results. The inclusion of neoadjuvant chemotherapy in the treatment enabled more favorable treatment results. The mortality from disseminated disease is the main problem in these patients, inducing the question of need for additional postoperative adjuvant systemic therapy. For steroid receptor positive patients hormonotherapy is a convenient choice of maintaining treatment. In endocrine non-responsive tumors, the role of postoperative chemotherapy is doubtful, having in mind preoperative chemotherapy and cumulative toxic effects. New trials including the large number of patients are necessary to obtain the definite answer whether the maintaining chemotherapy is useful but today it seems that additive postoperative treatment is not more efficient than preoperative alone.

Objective response to treatment as a potential surrogate marker of survival in breast cancer

Until recently, objective tumor response to chemotherapy was used as the primary endpoint in phase II trials aimed at assessing the anti-tumor activity of new drugs. However, it was not accepted as a surrogate endpoint of survival for efficacy trials in solid tumors, and it was not believed to be associated with survival benefit. The recent demonstration that objective response is indeed a valid surrogate endpoint of survival in colorectal cancer, together with strong indirect evidence supporting a similar role of response in breast cancer, opens new possibilities for both the design of trials in metastatic breast cancer and the clinical decision in individual patients with the disease.