Optimizing anticancer drug treatment in pregnant cancer patients: pharmacokinetic analysis of gestation-induced changes for doxorubicin, epirubicin, docetaxel and paclitaxel

Position statement on the diagnosis and management of acute leukaemia and aggressive lymphomas in pregnancy

Haematological malignancies affect 12·5 in 100 000 pregnancies. Over the past two decades, the number of haematological malignancies in pregnancy has substantially increased. Life-threatening haematological malignancies in pregnancy, such as acute leukaemia and aggressive lymphomas, pose a unique therapeutic challenge: clinicians must consider both maternal and fetal wellbeing, aiming to deliver optimal curative therapy for the patient and a successful pregnancy outcome. A multidisciplinary approach to disease management is paramount, and there are currently no clinical practice guidelines available. An Australasian working group, including representatives from haematology, obstetric medicine, clinical teratology, radiology, nuclear medicine, maternal-fetal medicine, and a patient representative, was established to develop this position statement, which is based on a combination of current evidence and expert consensus. We provide recommendations for diagnosis and staging, imaging safety in pregnancy, therapy in pregnancy incorporating a multidisciplinary approach, supportive care, oncofertility, and pregnancy and birth management. This Viewpoint was reviewed and endorsed by the councils of the Society of Obstetric Medicine of Australia and New Zealand, the Haematology Society of Australia and New Zealand, and the Haematology in Obstetric and Women's Health Collaborative.

Multidisciplinary Management of Pregnancy-Associated Breast Cancer

Breast cancer during pregnancy is uncommon; however, it is one of the most common malignancies affecting pregnant women. Pregnancy-associated breast cancer (PABC) is a complex entity characterized by unique risk factors, presentation, and pathology. Furthermore, although management generally aims to mirror that for nonpregnant patients, there are distinct aspects of oncologic care delivery specific to PABC. The focus is on optimizing maternal outcomes while maximizing maternal and fetal safety. A multidisciplinary approach is key, and the timing of various treatment modalities is critical. Postdelivery care and counseling are also imperative to address issues such as contraception, breastfeeding, and future fertility. In the present review, we discuss the current knowledge base and the diagnostic and treatment landscape for PABC, including recent literature and practice pattern updates.

Virtual Patient Simulation Using Copula Modeling

Virtual patient simulation is increasingly performed to support model-based optimization of clinical trial designs or individualized dosing strategies. Quantitative pharmacological models typically incorporate individual-level patient characteristics, or covariates, which enable the generation of virtual patient cohorts. The individual-level patient characteristics, or covariates, used as input for such simulations should accurately reflect the values seen in real patient populations. Current methods often make unrealistic assumptions about the correlation between patient's covariates or require direct access to actual data sets with individual-level patient data, which may often be limited by data sharing limitations. We propose and evaluate the use of copulas to address current shortcomings in simulation of patient-associated covariates for virtual patient simulations for model-based dose and trial optimization in clinical pharmacology. Copulas are multivariate distribution functions that can capture joint distributions, including the correlation, of covariate sets. We compare the performance of copulas to alternative simulation strategies, and we demonstrate their utility in several case studies. Our work demonstrates that copulas can reproduce realistic patient characteristics, both in terms of individual covariates and the dependence structure between different covariates, outperforming alternative methods, in particular when aiming to reproduce high-dimensional covariate sets. In conclusion, copulas represent a versatile and generalizable approach for virtual patient simulation which preserve relationships between covariates, and offer an open science strategy to facilitate re-use of patient data sets.

Utility of Physiologically Based Pharmacokinetic Modeling to Investigate the Impact of Physiological Changes of Pregnancy and Cancer on Oncology Drug Pharmacokinetics

BACKGROUND

The treatment of cancer during pregnancy remains challenging with knowledge gaps in drug dosage, safety, and efficacy due to the under-representation of this population in clinical trials. Our aim was to investigate physiological changes reported in both pregnancy and cancer populations into a PBPK modeling framework that allows for a more accurate estimation of PK changes in pregnant patients with cancer.

METHODS

Paclitaxel and docetaxel were selected to validate a population model using clinical data from pregnant patients with cancer. The validated population model was subsequently used to predict the PK of acalabrutinib in pregnant patients with cancer.

RESULTS

The Simcyp pregnancy population model reasonably predicted the PK of docetaxel in pregnant patients with cancer, while a modified model that included a 2.5-fold increase in CYP2C8 abundance, consistent with the increased expression during pregnancy, was needed to reasonably predict the PK of paclitaxel in pregnant patients with cancer. Changes in protein binding levels of patients with cancer had a minimal impact on the predicted clearance of paclitaxel and docetaxel. PBPK modeling predicted approximately 60% lower AUC and Cmax for acalabrutinib in pregnant versus non-pregnant patients with cancer.

CONCLUSIONS

Our results suggest that PBPK modeling is a promising approach to investigate the effects of pregnancy and cancer on the PK of oncology drugs and potentially inform dosing for pregnant patients with cancer. Further evaluation and refinement of the population model are needed for pregnant patients with cancer with additional compounds and clinical PK data.

Semi-physiological Enriched Population Pharmacokinetic Modelling to Predict the Effects of Pregnancy on the Pharmacokinetics of Cytotoxic Drugs

BACKGROUND AND OBJECTIVE

As a result of changes in physiology during pregnancy, the pharmacokinetics (PK) of drugs can be altered. It is unclear whether under- or overexposure occurs in pregnant cancer patients and thus also whether adjustments in dosing regimens are required. Given the severity of the malignant disease and the potentially high impact on both the mother and child, there is a high unmet medical need for adequate and tolerable treatment of this patient population. We aimed to develop and evaluate a semi-physiological enriched model that incorporates physiological changes during pregnancy into available population PK models developed from non-pregnant patient data.

METHODS

Gestational changes in plasma protein levels, renal function, hepatic function, plasma volume, extracellular water and total body water were implemented in existing empirical PK models for docetaxel, paclitaxel, epirubicin and doxorubicin. These models were used to predict PK profiles for pregnant patients, which were compared with observed data obtained from pregnant patients.

RESULTS

The observed PK profiles were well described by the model. For docetaxel, paclitaxel and doxorubicin, an overprediction of the lower concentrations was observed, most likely as a result of a lack of data on the gestational changes in metabolizing enzymes. For paclitaxel, epirubicin and doxorubicin, the semi-physiological enriched model performed better in predicting PK in pregnant patients compared with a model that was not adjusted for pregnancy-induced changes.

CONCLUSION

By incorporating gestational changes into existing population pharmacokinetic models, it is possible to adequately predict plasma concentrations of drugs in pregnant patients which may inform dose adjustments in this population.

Landscape and Regulatory Perspective on Oncology Drugs in Pregnancy

Cancers affecting pregnant women include breast cancer, melanoma, thyroid cancer, cervical cancer, lymphomas, and leukemias. The medical management of cancer during pregnancy with molecularly targeted oncology drugs remains quite challenging, with knowledge gaps about the drugs' safety and efficacy due to exclusion of pregnant women from cancer clinical trials, discontinuation of individuals who become pregnant during clinical trials, and limited information on appropriate dosing of molecularly targeted oncology drugs during pregnancy. Physiological changes occur during pregnancy and may result in alterations in the absorption, distribution, metabolism, and excretion of drugs used in pregnant women. Physiologically based pharmacokinetic modeling that incorporates physiological changes induced by both the cancer disease state and pregnancy has the potential to inform dosing of molecularly targeted oncology drugs for pregnant women, improve our understanding of the pharmacokinetic changes associated with pregnancy in patients with cancer, facilitate the design of potential studies of molecularly targeted oncology drugs in pregnant women to support dosing recommendations, and provide model-informed pharmacokinetic data to support regulatory decision making.

Optimizing Therapeutic Drug Monitoring in Pregnant Women: A Critical Literature Review

BACKGROUND

More than 90% of pregnant women take at least one drug during pregnancy. Drug dose adjustments during pregnancy are sometimes necessary due to various pregnancy-induced physiological alterations frequently associated with lower plasma concentrations. However, the clinical relevance or benefits of therapeutic drug monitoring (TDM) in pregnant women have not been specifically studied. Clinical pharmacokinetic studies in pregnant women are incredibly challenging for many reasons. Despite this, regulatory agencies have made efforts to encourage the inclusion of this population in clinical trials to achieve more information on the pharmacotherapy of pregnant women. This review aims to provide support for TDM recommendations and dose adjustments in pregnant women.

METHODS

The search was conducted after a predetermined strategy on PubMed and Scopus databases using the MeSH term "pregnancy" alongside other terms such as "Pregnancy and dose adjustment," "Pregnancy and therapeutic drug monitoring," "Pregnancy and PBPK," "Pregnancy and pharmacokinetics," and "Pregnancy and physiological changes."

RESULTS

The main information on TDM in pregnant women is available for antiepileptics, antipsychotics, antidepressants, antibiotics, antimalarials, and oncologic and immunosuppressive drugs.

CONCLUSIONS

More data are needed to support informed benefit-risk decision making for the administration of drugs to pregnant women. TDM and/or pharmacokinetic studies could ensure that pregnant women receive an adequate dosage of an active drug. Mechanistic modeling approaches potentially could increase our knowledge about the pharmacotherapy of this special population, and they could be used to better design dosage regimens.

Pregnancy-Associated Breast Cancer: A Diagnostic and Therapeutic Challenge

Pregnancy-associated breast cancer (PABC) is commonly defined as a breast cancer occurring during pregnancy, throughout 1 year postpartum, or during lactation. Despite being a rare circumstance, PABC is one of the most common types of malignancies occurring during pregnancy and lactation, with growing incidence in developed countries, due both to decreasing age at onset of breast cancer and to increasing maternal age. Diagnosis and management of malignancy in the prenatal and postnatal settings are challenging for practitioners, as the structural and functional changes that the breast undergoes may be misleading for both the radiologist and the clinician. Furthermore, safety concerns for the mother and child, as well as psychological aspects in this unique and delicate condition, need to be constantly considered. In this comprehensive review, clinical, diagnostic, and therapeutic aspects of PABC (including surgery, chemotherapy and other systemic treatments, and radiotherapy) are presented and fully discussed, based on medical literature, current international clinical guidelines, and systematic practice.

Population pharmacokinetics of doxorubicin: A systematic review

Because of the high interindividual pharmacokinetic variability, several population pharmacokinetic (PopPK) models of doxorubicin (DOX) were developed to characterize factors influencing such variability. However, significant predictors for DOX pharmacokinetics identified using PopPK models varied across studies. Thus, this review aims to summarize PopPK models of DOX and its metabolites (if any) as well as significant covariates influencing DOX (and its metabolites) pharmacokinetic variability. A systematic search from PubMed, CINAHL Complete, Science Direct, and SCOPUS databases identified 503 studies. Of these, 16 studies met the inclusion criteria and were included in this review. DOX pharmacokinetics was described with two- or three-compartment models. Most studies found a significant increase in DOX clearance with an increase in body surface area from the median value of 1.8 m² . Moreover, this review identified that while a 10-year increase in patient age resulted in a decrease in DOX clearance in adults and the elderly, younger children had lower DOX clearance compared to older children. Further, low DOX exposure was observed in pregnant women, and thus dosage adjustment is required. Concerning model applicability, predictive performance assessment of these published models should be performed before implementing such models in clinical practice.

Weekly Paclitaxel Administered During a Twin Pregnancy for Recurrent Breast Cancer: Case Report and Review of the Literature

Although cancer treatment during single pregnancy has been standardized, how to manage cancer diagnosed during a multiple gestation is still unclear. Chemotherapy during pregnancy has shown to be safe, however, there are reports of increased risks of fetal complications such as intrauterine growth restriction and preterm birth. Also, how to best adjust this to the pharmacokinetic characteristics of a twin gestation has yet to be fully investigated. We report the case of an IVF twin pregnancy with a diagnosis of breast cancer recurrence shortly after conception, and how the pregnancy was managed to obtain optimal obstetric, maternal/oncological, and fetal outcomes.

Outcome of breast cancer patients treated with chemotherapy during pregnancy compared with non-pregnant controls

BACKGROUND

A diagnosis of breast cancer during pregnancy (PrBC) does not impact prognosis if standard treatment is offered. However, caution is warranted as gestational changes in pharmacokinetics may lead to reduced chemotherapy concentration.

METHODS

Survival of PrBC patients treated with chemotherapy during pregnancy was compared to non-pregnant breast cancer patients treated with chemotherapy, diagnosed after 2000, excluding patients older than 45 years or with a postpartum diagnosis. The data was registered in two multicenter registries (the International Network of Cancer, Infertility and Pregnancy and the German Breast Group). Cox proportional hazards regression was used to compare disease-free (DFS) and overall survival (OS) between both groups, adjusting for age, stage, grade, hormone receptor status, human epidermal growth factor 2 status and histology, weighted by propensity scoring to account for the differences in baseline characteristics between pregnant patients and controls.

RESULTS

In total, 662 pregnant and 2081 non-pregnant patients were selected. Pregnant patients were more likely to have stage II breast cancer (60.1% vs 56.1%, p = 0.035), grade 3 tumors (74.0% vs 62.2%, p < 0.001), hormone receptor-negative tumors (48.4% vs 34.0%, p < 0.001) or triple-negative breast cancer (38.9% vs 26.9%, p < 0.001). Median follow-up was 66 months. In multivariable analysis, DFS and OS were comparable for pregnant and non-pregnant patients (DFS: HR 1.02, 95% CI 0.82-1.27, p = 0.83; OS: HR 1.08, 95% CI 0.81-1.45, p = 0.59).

CONCLUSION

Outcome of women with breast cancer treated with chemotherapy during pregnancy is comparable to young non-pregnant women. These results support chemotherapy for PrBC when indicated.

Pregnancy and Cancer: Cellular Biology and Mechanisms Affecting the Placenta

Cancer during pregnancy is rarely studied due to its low incidence (1:1000). However, as a result of different sociocultural and economic changes, women are postponing pregnancy, so the number of pregnant women with cancer has been increasing in recent years. The importance of studying cancer during pregnancy is not only based on maternal and foetal prognosis, but also on the evolutionary mechanisms of the cell biology of trophoblasts and neoplastic cells, which point out similarities between and suggest new fields for the study of cancer. Moreover, the magnitude of how cancer factors can affect trophoblastic cells, and vice versa, in altering the foetus's nutrition and health is still a subject to be understood. In this context, the objective of this narrative review was to show that some researchers point out the importance of supplementing branched-chain amino acids, especially leucine, in experimental models of pregnancy associated with women with cancer. A leucine-rich diet may be an interesting strategy to preserve physiological placenta metabolism for protecting the mother and foetus from the harmful effects of cancer during pregnancy.

Cancer during Pregnancy: A Review of Preclinical and Clinical Transplacental Transfer of Anticancer Agents

The occurrence of cancer during pregnancy is observed in 1 in 1000 pregnancies and is expected to increase given the trend of delaying childbearing. While breast cancer is the most common, the incidence of other cancers, such as cervical, ovarian, and lung cancers as well as hemopathies and melanomas, is also increasing. Thus, cancer occurrence in pregnant women raises questions of management during pregnancy and, especially, assessment of the treatment benefit-risk ratio to ensure optimal management for the mother while ensuring the safety of the fetus. Chemotherapy remains a cornerstone of cancer management. If the use of anticancer agents appears possible during pregnancy, while avoiding the first trimester, the extent of placental transfer of different anticancer agents varies considerably thereafter. Furthermore, the significant physiological pharmacokinetic variations observed in pregnant women may have an impact on the placental transfer of anticancer agents. Given the complexity of predicting placental transfer of anticancer agents, preclinical studies are therefore mandatory. The aim of this review was to provide updated data on in vivo and ex vivo transplacental transfer of anticancer agents used in the management of the most common pregnancy-associated cancers to better manage these highly complex cases.

Maternal and Neonatal Outcome after the Use of G-CSF for Cancer Treatment during Pregnancy

Simple Summary

Treatment of pregnant cancer patients should adhere as much as possible to standard treatment protocols in order to safeguard maternal prognosis. The use of Granulocyte colony-stimulating factor (G-CSF) can be indicated for dose dense chemotherapy in high risk breast cancer patients or for the treatment or prevention of neutropenic fever, which can be an important threat for maternal and fetal survival. However, as evidence is still scarce, physicians are still reluctant to the use of G-CSF during pregnancy. In this series, the International Network of Cancer, Infertility and Pregnancy (INCIP) reports on 42 pregnant patients who received G-CSF during oncological treatment. Reported maternal and neonatal complications are acceptable; however, a continuous evaluation of clinical practice is necessary as the limited data in numbers and follow-up do not allow robust conclusions.

Abstract

Data on the use of Granulocyte colony-stimulating factor (G-CSF) in pregnant cancer patients are scarce. The International Network of Cancer, Infertility and Pregnancy (INCIP) reviewed data of pregnant patients treated with chemotherapy and G-CSF, and their offspring. Among 2083 registered patients, 42 pregnant patients received G-CSF for the following indications: recent chemotherapy induced febrile neutropenia (5; 12%), dose dense chemotherapy (28, 67%), poly chemotherapy (7, 17%), or prevention of neutropenia at delivery (2; 5%). Among 24 women receiving dose dense chemotherapy, three (13%) patients recovered from asymptomatic neutropenia within 5 days. One patient developed pancytopenia following polychemotherapy after which the pregnancy was complicated by chorioamnionitis and intrauterine death. Nineteen singleton livebirths (49%) were born preterm. Sixteen neonates (41%) were admitted to the Neonatal Intensive care Unit (NICU). No neonatal neutropenia occurred. Two neonates had congenital malformations. Out of 21 children in follow-up, there were four children with a motor development delay and two premature infants had a delay in cognitive development. In conclusion, the rate of maternal and neonatal complications are similar to those described in (pregnant) women treated with chemotherapy. Due to small numbers and limited follow-up, rare or delayed effects among offspring exposed to G-CSF in utero cannot be ruled out yet.

Population Pharmacokinetics of Docetaxel, Paclitaxel, Doxorubicin and Epirubicin in Pregnant Women with Cancer: A Study from the International Network of Cancer, Infertility and Pregnancy (INCIP)

BACKGROUND

Based on reassuring short-term foetal and maternal safety data, there is an increasing trend to administer chemotherapy during the second and third trimesters of pregnancy. The pharmacokinetics (PK) of drugs might change as a result of several physiological changes that occur during pregnancy, potentially affecting the efficacy and safety of chemotherapy.

OBJECTIVE

With this analysis, we aimed to quantitatively describe the changes in the PK of docetaxel, paclitaxel, doxorubicin and epirubicin in pregnant women compared with non-pregnant women.

METHODS

PK data from 9, 20, 22 and 16 pregnant cancer patients from the International Network of Cancer, Infertility and Pregnancy (INCIP) were available for docetaxel, paclitaxel, doxorubicin and epirubicin, respectively. These samples were combined with available PK data from non-pregnant patients. Empirical non-linear mixed-effects models were developed, evaluating fixed pregnancy effects and gestational age as covariates.

RESULTS

Overall, 82, 189, 271, and 227 plasma samples were collected from pregnant patients treated with docetaxel, paclitaxel, doxorubicin and epirubicin, respectively. The plasma PK data were adequately described by the respective models for all cytotoxic drugs. Typical increases in central and peripheral volumes of distribution of pregnant women were identified for docetaxel, paclitaxel, doxorubicin and epirubicin. Additionally, docetaxel, doxorubicin and paclitaxel clearance were increased in pregnant patients, resulting in lower exposure in pregnant women compared with non-pregnant patients.

CONCLUSION

Given the interpatient variability, the identified pregnancy-induced changes in PK do not directly warrant dose adjustments for the studied drugs. Nevertheless, these results underscore the need to investigate the efficacy of chemotherapy, when administered during pregnancy.

Maternal survival of patients with pregnancy-associated cancers in Taiwan - A national population-based study

Pregnancy-associated cancer (PAC), defined as cancers diagnosed during pregnancy or the first year after delivery, affects one to two in every 1000 pregnancies. Although PAC is expected to be a growing issue, information about PAC in the Asian population is still scarce. Women with cancer diagnosed at the age of 16-49 years between 2001 and 2015 were selected from the Taiwan Cancer Registry and linked with the National Birth Reporting Database to identify PAC patients. We compared the overall survival of patients with PAC to patients without pregnancy. Among 126,646 female cancer patients of childbearing age, 512 were diagnosed during pregnancy, and 2151 during the first postpartum year. Breast cancer was the most common PAC (N = 755, 28%). Compared with patients without pregnancy in the control group, patients with cancers diagnosed during pregnancy and the first postpartum year generally had more advanced stages (odds ratio 1.35 and 1.36, 95% confidence interval [CI] 1.02-1.77 and 1.18-1.57, respectively). For all cancer types combined and controlled for the stage, age, and year of diagnosis, patients with PAC had similar overall survival with those in the control group, with a hazard ratio (HR) of 1.07 (95% CI 0.80-1.41) for the pregnancy group and HR 1.02 (95% CI 0.88-1.18) for the postpartum group. The diagnosis of breast cancer during the first postpartum year was linked with shorter survival (HR 1.34, 95% CI 1.05-1.72). In contrast, patients with postpartum lymphoma (HR 0.11, 95% CI 0.02-0.79) and cervical cancer (HR 0.40, 95% CI 0.20-0.82) had better prognosis. In general, the diagnosis of cancer during pregnancy or the first postpartum year does not affect the survival of patients with most cancer types. Exceptions include the worse prognosis of postpartum breast cancer and the better outcome of postpartum lymphoma and cervical cancer.

Acute myeloid leukemia during pregnancy: a single institutional experience with 17 patients and literature review

Management of acute myeloid leukemia during pregnancy (P-AML) is a challenging endeavor with limited evidence-based information available. To truly achieve the goal of improving P-AML patients, additional evidence-based research is necessary. We retrospectively reviewed cases of 17 patients diagnosed with P-AML, including seven for acute promyelocytic leukemia (APL) from January 2012 to June 2019. Among the non-APL, 90% patients (9/10) ended pregnancy prior to induction chemotherapy. The median intervals between diagnosis and start of chemotherapy were 5 days (range 1-14 days). Four patients elected to delay chemotherapy by more than one week. Of the seven APL patients, six received all-trans retinoic acid (ATRA) before the diagnostic molecular results. Five patients underwent cesarean sections (CS) and all newborns were alive (four preterm and one full-term deliveries). Overall, approximately 94% of the patients (16/17) are currently alive in remission. To treat P-AML patients in a safer manner, balancing the risk of progressing to advanced disease and proceeding with pregnancy is required. We consider a slight delay (less than 14 days) in the termination of pregnancy may not differ the prognosis to patients with non-APL. For APL, patients will benefit from prompt administration of ATRA for highly suspected cases.

Good news on the active management of pregnant cancer patients

Cancer occurs in approximately 1/1000 to 1/2000 pregnancies and presents complex medical and ethical dilemmas for patients and providers. The most common cancers diagnosed in the gestational period include breast, cervical, melanoma, and lymphomas. The majority of existing evidence regarding the treatment of cancer during pregnancy is derived from experiences with breast cancer. Other cancers often pose unique challenges given the location of the tumors and their traditional mode of treatment with pelvic surgery and radiation. Additionally, many emerging therapies for cancer target mechanisms that are necessary for fetal development, such as angiogenesis, and are contraindicated in pregnant women. Although limitations on the treatment of cancer during pregnancy currently exist, increasing evidence shows that many surgical and systemic therapies can be effective for a mother’s oncologic outcomes without significant detriment to the developing fetus. Traditional perspectives of cancer during gestation may sway providers to encourage pregnancy termination, delays in therapy, or early delivery. However, recent studies and reviews discourage such practices. Although every cancer diagnosis in pregnancy requires an individualized approach and should use the multidisciplinary perspectives of maternal–fetal medicine specialists as well as medical and surgical oncologists, providers should feel empowered to safely employ systemic, surgical, and even reserved cases of radiation therapies for their pregnant patients with cancer. The aim of this review is to highlight some of the recent advances in cancer therapies for common cancer subtypes and encourage providers to use this growing body of evidence to employ treatments with curative intent while continuing to evaluate the long-term effects of these therapies on mothers and their children.

Clinical pharmacokinetics and drug exposure-toxicity correlation study of docetaxel based chemotherapy in Chinese head and neck cancer patients

Background

Area under time-concentration curve (AUC) of docetaxel is related with its toxicity and efficacy. The aim of this study is to investigate the target range of docetaxel AUC in Chinese head and neck cancer (HNC) patients.

Methods

Eligible HNC patients were enrolled and received at least 2 cycles of docetaxel-based chemotherapy. A simplified pharmacokinetic (PK) strategy (2 monitored samples) was developed to simulate docetaxel AUC using the nonlinear mixed-effect modelling program. Preliminary target range of AUC was pre-set as 2.5–3.7 µg·hr/mL according to pooled analysis from 8 previous studies. Fisher exact test was used to analyze the relationship between AUC with neutropenia and efficacy, and to verify the target range.

Results

Thirty-nine eligible patients were enrolled. Grade 3-4 and grade 4 neutropenia rate in 1^st cycle was 64% and 36%, respectively. AUC simulation by simplified PK strategy was acceptable compared to full sampling method from the analysis of archived 300 patients’ data, with −5.67% of mean prediction error (MPE). Median AUC of all patients was 2.58 µg·hr/mL (range from 1.28 to 9.39). A significant correlation (P=0.007) was detected between AUC and body surface area (BSA)-dosage, but BSA contributed only 18.3% of AUC inter-individual variability. Docetaxel AUC was significantly related with the severity (grade 3–4) of neutropenia (correlation of coefficient was 0.452, P=0.004). Fourteen patients (36%) were within the target AUC range. Patients with AUC above the target experienced more severe neutropenia (grade 3–4 rate 100% vs. 56%, P=0.036; grade 4 rate 86% vs. 25%, P=0.005). No significant difference of response rate was found between patients within the target or not.

Conclusions

A simplified samples PK strategy was developed for docetaxel AUC simulation. The target range of docetaxel AUC in Chinese HNC patients was suggested at 2.5–3.7 µg·hr/mL for reduced toxicity without compromising efficacy of docetaxel treatment.

In vitro Transport Ability of ABCC2 (G1249A) Polymorphic Variant Towards Anticancer Drugs

Objective

Multidrug resistance-associated protein 2 (MRP2), encoded by ABCC2 gene, is involved in the efflux of certain anticancer drugs. Here we observed whether the ABCC2 (G1249A) polymorphism impacts the transport abilities of MRP2-dependent paclitaxel, docetaxel, and doxorubicin in recombinant LLC-PK1 cell lines.

Methods

LLC-PK1 cell lines transfected with ABCC2_1249G wild-type and ABCC2_1249A variant alleles were used to evaluate the sensitivity, intracellular accumulation, and transmembrane transport of paclitaxel, docetaxel, and doxorubicin.

Results

The recombinant ABCC2_1249A variant cell line showed higher IC₅₀ values for paclitaxel and doxorubicin than ABCC2_1249G wild-type cell system (p<0.01). Intracellular accumulations of paclitaxel and doxorubicin in cells transfected with ABCC2_1249A variant allele were significantly decreased compared to cells transfected with ABCC2_1249G wild-type allele (p<0.01). The efflux ratios of paclitaxel and doxorubicin across ABCC2_1249A cell line were significantly increased compared with ABCC2_1249G cell system (p<0.01). However, ABCC2 (G1249A) polymorphism had no effect on the transport activity of MRP2-mediated docetaxel.

Conclusion

Our results indicate that ABCC2 (G1249A) polymorphism affects the transport activities of MRP2-dependent paclitaxel and doxorubicin, resulting in greater efflux of these anticancer drugs.

Pregnancy and Cancer: the INCIP Project

PURPOSE OF REVIEW

Cancer diagnosis in young pregnant women challenges oncological decision-making. The International Network on Cancer, Infertility and Pregnancy (INCIP) aims to build on clinical recommendations based on worldwide collaborative research.

RECENT FINDINGS

A pregnancy may complicate diagnostic and therapeutic oncological options, as the unborn child must be protected from potentially hazardous exposures. Pregnant patients should as much as possible be treated as non-pregnant patients, in order to preserve maternal prognosis. Some approaches need adaptations when compared with standard treatment for fetal reasons. Depending on the gestational age, surgery, radiotherapy, and chemotherapy are possible during pregnancy. A multidisciplinary approach is the best guarantee for experience-driven decisions. A setting with a high-risk obstetrical unit is strongly advised to safeguard fetal growth and health. Research wise, the INCIP invests in clinical follow-up of children, as cardiac function, neurodevelopment, cancer occurrence, and fertility theoretically may be affected. Furthermore, parental psychological coping strategies, (epi)genetic alterations, and pathophysiological placental changes secondary to cancer (treatment) are topics of ongoing research. Further international research is needed to provide patients diagnosed with cancer during pregnancy with the best individualized management plan to optimize obstetrical and oncological care.

Diagnosis and Treatment of Breast Cancer in Young Women

OPINION STATEMENT

Despite the increase of breast cancer incidence with age, approximately 7 to 10% ofwomen diagnosed with breast cancer are younger than the age 40. This subgroup ofpatients has different risk factors, tumour biology, clinical outcomes, and specific psy- chosocial issues, such as fertility preservation, family planning, and job reintegration. However, age alone should not be the main consideration when choosing the aggressive- ness of the treatment, as other factors must be considered, including the biologic aggressiveness of the tumour, potential long-term toxicities, and the preferences of the patient. Fertility preservation techniques should be discussed with the patient before starting any cancer treatment. Despite the significant percentage of breast cancer patients younger than age 40, fewclinical studies have specifically investigated disease characteristics and outcomes of this population, and most therapies routinely administered to these younger women were tested in older patients. Moreover, young women who have breast cancer are at a greater risk of sexual and psychological distress, and clinicians should address these issues in order to properly support patients during the long diagnostic and therapeutic journey. Consequently, it is essential to follow diagnostic and treatment guidelines specificallyaddressed to young women. Additional specific procedures should be followed to treat pregnant patients with breast cancer.

Breast Cancer during Pregnancy-Current Paradigms, Paths to Explore

Breast cancer is the most common form of malignancy in pregnant women. The prevalence of pregnancy-associated breast cancer (PABC) is up to 0.04% of pregnancies and is expected to rise in developed countries. PABC represents a unique clinical scenario which requires a delicate balance of risks and benefits for both maternal and fetal well-being. Currently, there is paucity of data regarding the short- and long-term outcomes of in-utero exposure to anti-neoplastic agents. In general, when possible, treatment for PABC should follow the same guidelines as in non-pregnant patients. Surgery, including sentinel lymph node biopsy, is possible during all trimesters of pregnancy. Radiotherapy is contraindicated during pregnancy, although it might be considered in highly selected patients based on risk-benefit assessment. Evidence supports that administration of chemotherapy may be safe during the second and third trimesters, with cessation of treatment three weeks prior to expected delivery. Currently, hormonal therapy and anti-HER2 agents are contraindicated during pregnancy and should be postponed until after delivery. Prematurity is associated with worse neonatal and long-term outcomes, and thus should be avoided. While current data on the long-term effects of anti-neoplastic treatments are reassuring, grade of evidence is lacking, hence additional large prospective studies with long-term follow-up are essential to rule out any treatment-induced adverse effects.

EmDL: Extracting miRNA-Drug Interactions from Literature

The microRNAs (miRNAs), regulators of post-transcriptional processes, have been found to affect the efficacy of drugs by regulating the biological processes in which the target proteins of drugs may be involved. For example, some drugs develop resistance when certain miRNAs are overexpressed. Therefore, identifying miRNAs that affect drug effects can help understand the mechanisms of drug actions and design more efficient drugs. Although some computational approaches have been developed to predict miRNA-drug associations, such associations rarely provide explicit information about which miRNAs and how they affect drug efficacy. On the other hand, there are rich information about which miRNAs affect the efficacy of which drugs in the literature. In this paper, we present a novel text mining approach, named as EmDL (Extracting miRNA-Drug interactions from Literature), to extract the relationships of miRNAs affecting drug efficacy from literature. Benchmarking on the drug-miRNA interactions manually extracted from MEDLINE and PubMed Central, EmDL outperforms traditional text mining approaches as well as other popular methods for predicting drug-miRNA associations. Specifically, EmDL can effectively identify the sentences that describe the relationships of miRNAs affecting drug effects. The drug-miRNA interactome presented here can help understand how miRNAs affect drug effects and provide insights into the mechanisms of drug actions. In addition, with the information about drug-miRNA interactions, more effective drugs or combinatorial strategies can be designed in the future. The data used here can be accessed at http://mtd.comp-sysbio.org/.

Current treatment of lymphoma in pregnancy

Introduction: Lymphoproliferative diseases occurring during pregnancy present the treating physician with unique diagnostic and therapeutic challenges, aiming to achieve maternal cure without impairing fetal health, growth, and survival. Due to the rarity of this complication, there is limited data to guide clinical decision-making, especially regarding the safety of novel emerging therapies. Areas covered: The presented review describes the current practice of treatment for Hodgkin's (HL) and non-Hodgkin's (NHL) lymphoma in the pregnant patient, according to disease stage and trimester of pregnancy. Novel agents for treatment of lymphoma in the setting of pregnancy are discussed. Therapeutic dilemmas and areas of uncertainty are illuminated. Expert opinion: HL and NHL are potentially curable diseases in the pregnant patient with generally good outcomes for the mother and the offspring, when tailoring the treatment according to the individual patient. The complexity of the situation merits shared decision-making with the patient and her family, explicitly outlining the risks and benefits. The pregnant patient is best managed by a multidisciplinary team, familiar with the intricacies of the gestational period, and providing the necessary support and sensitivity. Further studies are needed regarding the safety of novel agents in pregnancy.

Chemotherapy and anti-HER2 therapy in metastatic breast cancer in pregnancy followed by surgical treatment

Between 5% and 10% of women have distant metastases when they receive a breast cancer (BC) diagnosis. Metastatic BC is associated with poor prognosis but advances in systemic treatments have improved survival rates in recent decades.

Debates about local primary tumour management in metastatic stages continue, but multiple studies have shown that primary tumour surgery can be beneficial.

BC is one of the most commonly diagnosed neoplasias during pregnancy. Treatment of pregnant BC patients should follow the standard treatment of young, non-pregnant patients as closely as possible.

We present the case of a young, pregnant patient with metastatic BC with a complete clinical response to chemotherapy followed by surgical treatment.

Management of cancer during pregnancy and current evidence of obstetric, neonatal and pediatric outcome: a review article

The diagnosis of cancer during pregnancy imposes a medical-ethical dilemma in weighing the risks of both mother and child. Increasing awareness of the feasibility of chemotherapy during pregnancy results in more pregnant patients receiving treatment for cancer. Information on obstetric and pediatric outcome of these high-risk pregnancies is greatly needed to guide physicians in patient counseling. In this review we present reported evidence for the incidence, diagnostic options, therapeutic management, obstetric risks, and neonatal outcome when cancer treatment is initiated during pregnancy. Decision-making when a cancer is diagnosed in a pregnant patient should be multidisciplinary, always taking the patient's perspective into account. Cancer treatment during pregnancy is associated with low birth weight and preterm delivery, therefore frequent obstetric follow-up during oncological treatment in a specialized center is mandatory. Short-term clinical, cardiac, and cognitive outcome of children pre-natally exposed to cancer treatment is overall reassuring. Long-term follow-up of children is warranted to define the possible effect of pre-natal cancer treatment on general health, fertility outcome, and the risk of secondary cancers.

Biology, staging, and treatment of breast cancer during pregnancy: reassessing the evidences

Breast cancer is one of the most frequently diagnosed malignancies during pregnancy. Here, we review the management of women with breast cancer during pregnancy (BCP), focusing on biology, diagnosis and staging, local and systemic treatments, obstetric care and long-term follow-up of children with prenatal exposure to anticancer treatments.

Does anthracycline-based chemotherapy in pregnant women with cancer offer safe cardiac and neurodevelopmental outcomes for the developing fetus?

BACKGROUND

Cancer treatment during pregnancy is a growing problem especially now that women delay childbearing. Systemic treatment of these malignancies during pregnancy centers mainly on the anticancer drugs anthracyclines, widely used in treating hematological and breast cancer during pregnancy and sometimes associated with early and late toxicity for the fetus. Owing to concern about their cardiac and neurodevelopmental toxicity more information is needed on which anthracycline to prefer and whether they can safely guarantee a cardiotoxicity-free outcome in the fetus.

DISCUSSION

The major research findings underline anthracycline-induced dose-dependent effects, including cardiotoxicity, many avoidable. Partly because the placenta acts mainly as a barrier, research findings indicate low transplacental anthracycline transfer. Anthracycline-induced teratogenicity depends closely on when patients receive chemotherapy. Anthracycline cardiac toxicity may depend on the association with drugs that inhibit or induce placental P-glycoprotein (P-gp). P-gp-induced drug interactions may alter placental P-gp barrier function and subsequently change fetal exposure. Though many anthracyclines have acceptable safety profiles clinical studies suggest giving idarubicin with special caution. Patients and doctors who care for pregnant women should whenever possible avoid prematurity and hence reduce prematurity-induced medical complications at birth and in the long-term. Information is lacking on long-term anthracycline-induced effects.

CONCLUSION

Pregnant women receiving anthracycline-based chemotherapy should undergo regular, state-of-the-art diagnostic imaging to detect fetal drug-induced cardiac damage early, and allow alternative therapeutic options. Recognizing drug-induced interactions and understanding the most vulnerable fetuses will help in choosing tailored therapy. Future research on placental transport, blood-brain barrier drug passage and pharmacokinetics will improve the way we manage these difficult-to-treat patients and their fetuses.

Acute myeloid leukemia during pregnancy: a systematic review and meta-analysis

Data regarding clinical characteristics, therapy, maternal and fetal outcomes of pregnancy-associated acute myeloid leukemia (PA-AML) are limited. This study (including 138 cases published between 1955 and 2013) provides comprehensive assessment of these clinical parameters and may serve as a platform for developing management recommendations. Most patients (58%) received anthracycline-cytarabine-based regimens (ACBRs), which were associated with significantly increased complete remission (CR: 91%). Yet, the maternal overall survival (OS: ∼30%) was relatively low, probably reflecting reduced application of risk-adapted consolidation and allogeneic stem cell transplantation (allo-SCT). Fetal exposure to ACBRs resulted in a live birth rate of 87%, with complications (16%) diagnosed only in chemotherapy-subjected neonates. This study demonstrates safety and efficacy of ACBRs during pregnancy. Therapy and delivery schedule should allow early referral of high-risk patients to allo-SCT. Generation of a pool of high-quality data on PA-AML could contribute to providing evidence-based therapy and lead to improved maternal and fetal survival.

Management of Hematologic Malignancies: Special Considerations in Pregnant Women

The diagnosis and management of hematologic malignancy during pregnancy is a significant challenge. This is due to both medical and ethical considerations regarding when and how to treat this special sub-group of patients. Recurring uncertainties remain around appropriate imaging techniques, timing and dosage of chemotherapy, and timing of delivery. In this article we examine and summarize current literature in this field to assist physicians in their understanding and management of this patient group. Special attention has been given to diagnostic and staging procedures, risks associated with chemotherapy at different stages of gestation, and chemotherapy-dose adaption during pregnancy. In addition, recommended guidelines for management of lymphoma, leukemia, and planning delivery are discussed. A multidisciplinary team approach is critical for patient care, as is shared decision making with the patient and family.

Anticancer drugs during pregnancy

Although cancer diagnoses during pregnancy are rare, they have been increasing with the rise in maternal age and are now a topic of international concern. In some cases, the administration of chemotherapy is unavoidable, though there is a relative paucity of evidence regarding the administration of anticancer drugs during pregnancy. As more cases have gradually accumulated and further research has been conducted, we are beginning to elucidate the appropriate timing for the administration of chemotherapy, the regimens that can be administered with relative safety, various drug options and the effects of these drugs on both the mother and fetus. However, new challenges have arisen, such as the effects of novel anticancer drugs and the desire to bear children during chemotherapy. In this review, we outline the effects of administering cytotoxic anticancer drugs and molecular targeted drugs to pregnant women on both the mother and fetus, as well as the issues regarding patients who desire to bear children while being treated with anticancer drugs.

Use of anticancer agents in gynecological oncology during pregnancy: a systematic review of maternal pharmacokinetics and transplacental transfer

INTRODUCTION

Cancer affects one in a thousand pregnant women and gynecological cancers are one of the most frequent malignancies. Chemotherapy remains the cornerstone treatment for gynecological cancer. Although all chemotherapeutic agents can cross the placental barrier, the extent of placental transfer varies considerably. Furthermore, the significant physiological variations observed in pregnant women may have an impact on pharmacokinetic parameters. Given the complexity of predicting placental transfer, in vivo and ex vivo studies are essential in this context. In view of the paucity of data on chemotherapy during pregnancy, the objective of the present study was to summarize all the available data on the transplacental transfer of anticancer drugs used to treat gynecological cancers.

AREAS COVERED

In order to evaluate the in vivo and ex vivo transplacental transfer of the anticancer drugs most frequently used in gynecological malignancies, we carried out a comprehensive review of the literature published from 1967 to 2015. Lastly, we summarized recent clinical guidelines on the treatment of gynecological cancers in pregnant patients.

EXPERT OPINION

The preclinical and scarce clinical data must now be extrapolated to define the maternofetal toxicity/efficacy profile and thus guide the physicians to choose anticancer drugs more efficiently in this complex situation.

Effects of prenatal exposure to cancer treatment on neurocognitive development, a review

Due to the increasing incidence of cancer during pregnancy, the need to better understand long-term outcome after prenatal exposure to chemo- and/or radiotherapy has become more urgent. This manuscript focuses on the neurocognitive development after prenatal exposure to cancer treatment. We will review possible pathways for brain damage that could explain the subtle changes in neurocognition and behavior found after in utero exposure to cancer treatment. Contrary to radiation, which has a direct effect on the developing nervous system, chemotherapy has to pass the placental and blood brain barrier to reach the fetal brain. However, there are also indirect effects such as inflammation and oxidative stress. Furthermore, the indirect effects of the cancer itself and its treatment, e.g., poor maternal nutrition and high maternal stress, as well as prematurity, can be related to cognitive impairment. Although the available evidence suggests that cancer treatment can be administered during pregnancy without jeopardizing the fetal chances, larger numbers and longer follow up of these children are needed.

Management of gynecological cancers during pregnancy

The diagnosis of a gynecological malignancy during pregnancy is rare but not uncommon. Cancer treatment during pregnancy is possible, but both maternal and fetal interests need to be respected. Different treatment plans may be justifiable and multidisciplinary treatment is advised. Clinical trials are virtually impossible, and current evidence is mainly based on small case series and expert opinion. Individualization of treatment is necessary and based on tumor type, stage, and gestational age at time of diagnosis. Termination of pregnancy is not necessary in most cases. Surgery and chemotherapy (second trimester and onwards) are possible types of treatment during pregnancy. Radiotherapy of the pelvic area is not compatible with an ongoing pregnancy. This article discusses the current recommendations for the management of gynecological malignancies (cervical, ovarian, and vulvar cancers) during pregnancy.

Towards integrative systems pharmacology models in oncology drug development

Quantitative systems pharmacology (QSP) modeling represents an emerging area of value to further streamline knowledge integration and to better inform decision making processes in drug development. QSP models reside at the interface between systems biology models and pharmacological models, yet their concrete implementation still needs to be established further. This review outlines key modeling techniques in both of these areas and to subsequently discuss challenges and opportunities for further integration, in oncology drug development.

Variation in transplacental transfer of tyrosine kinase inhibitors in the human perfused cotyledon model

BACKGROUND

The use of tyrosine kinase inhibitors (TKis) during pregnancy in humans remains rare, and little data are available on their transplacental passage. Erlotinib and gefitinib are the first-line targeted therapy in case of stage IV nonsmall-cell lung cancer with an EGFR-activating mutation. There are no data available regarding the comparative use of these TKis in pregnant patients. We aimed to compare the transplacental transfer of gefitinib, imatinib and erlotinib, using the ex vivo method of human perfused cotyledon, and to determine the placental accumulation of TKis.

MATERIALS AND METHODS

Term placentas were perfused after delivery with gefitinib, imatinib and erlotinib at targeted maternal concentrations around the steady-state plasma trough concentration (i.e. 500, 1000 and 1500 ng/ml, respectively). Samples from fetal and maternal circulations were collected in order to monitor TKis concentrations. Main transfer parameters such as fetal transfer rate (FTR), clearance index (CI) and placental uptake were assessed.

RESULTS

Mean FTR of gefitinib, imatinib and erlotinib were 16.8%, 10.6% and 31.4%, respectively. Mean CI of gefitinib, imatinib and erlotinib were 0.59, 0.48 and 0.93, respectively. Placental uptake in cotyledon was 0.030% %, 0.010% and 0.003% for gefitinib, imatinib and erlotinib, respectively, corresponding to a mean mass of 27.7 µg for gefitinib, 15.7 µg for imatinib and 6.8 µg for erlotinib.

CONCLUSION

The results suggest that TKis cross the placenta at therapeutic level. Particularly, erlotinib crosses the placenta at a higher rate than gefitinib or imatinib. All of them have a very low placental uptake. These data may suggest that gefitinib should be preferred to erlotinib for the treatment of pregnant woman with lung cancer harboring an EGFR-activating mutation, during the second and third trimesters of pregnancy.

The rights and wrongs of blood-brain barrier permeability studies: a walk through 100 years of history

Careful examination of relevant literature shows that many of the most cherished concepts of the blood-brain barrier are incorrect. These include an almost mythological belief in its immaturity that is unfortunately often equated with absence or at least leakiness in the embryo and fetus. The original concept of a blood-brain barrier is often attributed to Ehrlich; however, he did not accept that permeability of cerebral vessels was different from other organs. Goldmann is often credited with the first experiments showing dye (trypan blue) exclusion from the brain when injected systemically, but not when injected directly into it. Rarely cited are earlier experiments of Bouffard and of Franke who showed methylene blue and trypan red stained all tissues except the brain. The term “blood-brain barrier” “Blut-Hirnschranke” is often attributed to Lewandowsky, but it does not appear in his papers. The first person to use this term seems to be Stern in the early 1920s. Studies in embryos by Stern and colleagues, Weed and Wislocki showed results similar to those in adult animals. These were well-conducted experiments made a century ago, thus the persistence of a belief in barrier immaturity is puzzling. As discussed in this review, evidence for this belief, is of poor experimental quality, often misinterpreted and often not properly cited. The functional state of blood-brain barrier mechanisms in the fetus is an important biological phenomenon with implications for normal brain development. It is also important for clinicians to have proper evidence on which to advise pregnant women who may need to take medications for serious medical conditions. Beliefs in immaturity of the blood-brain barrier have held the field back for decades. Their history illustrates the importance of taking account of all the evidence and assessing its quality, rather than selecting papers that supports a preconceived notion or intuitive belief. This review attempts to right the wrongs. Based on careful translation of original papers, some published a century ago, as well as providing discussion of studies claiming to show barrier immaturity, we hope that readers will have evidence on which to base their own conclusions.

Basic obstetric pharmacology

Pregnancy is associated with a variety of physiological changes that can alter the pharmacokinetics and pharmacodynamics of several drugs. However, limited data exists on the pharmacokinetics and pharmacodynamics of the majority of the medications used in pregnancy. In this article, we first describe basic concepts (drug absorption, bioavailability, distribution, metabolism, elimination, and transport) in pharmacokinetics. Then, we discuss several physiological changes that occur during pregnancy that theoretically affect absorption, distribution, metabolism, and elimination. Further, we provide a brief review of the literature on the clinical pharmacokinetic studies performed in pregnant women in recent years. In general, pregnancy increases the clearance of several drugs and correspondingly decreases drug exposure during pregnancy. Based on current drug exposure measurements during pregnancy, alterations in the dose or dosing regimen of certain drugs are essential during pregnancy. More pharmacological studies in pregnant women are needed to optimize drug therapy in pregnancy.