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Boland PM, Mukherjee S, Imanirad I, Vijayvergia N, Cohen SD, Gupta M, Iyer RV, Bakin A, Wang J, Chatley S, Cahill B, Vadehra D, Attwood K, Hochster HS, Fountzilas C. TAS-102, Irinotecan, and bevacizumab in pre-treated metastatic colorectal cancer (TABAsCO), a phase II clinical trial. Br J Cancer 2024:10.1038/s41416-024-02845-x. [PMID: 39244627 DOI: 10.1038/s41416-024-02845-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 08/17/2024] [Accepted: 08/28/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND The efficacy of FOLFIRI plus an antiangiogenesis biologic agent as 2nd line therapy for metastatic colorectal adenocarcinoma is limited. TAS-102 is a novel oral antimetabolite with a distinct mechanism of action from fluoropyrimidines. We evaluated the antitumour efficacy of TAS-102, irinotecan and bevacizumab in patients with pre-treated, advanced colorectal adenocarcinoma in a multicenter, phase II, single-arm study. METHODS Patients with advanced colorectal adenocarcinoma who had progressed after oxaliplatin and fluoropyrimidine and were eligible for treatment with bevacizumab were treated with irinotecan, bevacizumab, and TAS-102 in 28-day cycles. The primary endpoint was progression-free survival (PFS). RESULTS We enrolled 35 evaluable patients. The study was positive. The median PFS was 7.9 (90% CI 6.2-11.8) months (vs. 6 months in historical control, p = 0.018). The median overall survival was 16.5 (90% CI 9.8-17.5) months. Sixty-seven per cent of patients experienced grade 3 or higher treatment-related adverse events. The most common toxicities were hematological (neutropenia) and gastrointestinal (diarrhoea, nausea, and vomiting). CONCLUSIONS Irinotecan, TAS-102 and bevacizumab is an active 2nd line therapy for patients with metastatic colorectal adenocarcinoma. Neutropenia is common and can affect dose density/intensity mandating use of G-CSF. A randomized study versus standard-of-care therapy is warranted. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT04109924.
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Affiliation(s)
| | - Sarbajit Mukherjee
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Iman Imanirad
- Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, USA
| | | | - Seth D Cohen
- Monmouth Hematology Oncology, RWJBarnanas Health, West Long Branch, NJ, USA
| | - Medhavi Gupta
- Program in Women's Oncology, Women & Infants Hospital, Brown University, Providence, RI, USA
| | - Renuka V Iyer
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Andrei Bakin
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Jianxin Wang
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Sarah Chatley
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Beth Cahill
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Deepak Vadehra
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Kristopher Attwood
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | | | - Christos Fountzilas
- Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA.
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McDonald HG, Kennedy A, Solomon AL, Williams CM, Reagan AM, Cassim E, Harper M, Burke E, Armstrong T, Gosky M, Cavnar M, Pandalai PK, Barry-Hundeyin M, Patel R, Nutalapati S, Moss J, Hull PC, Kolesar J, Pickarski JC, Kim J. Development of a Novel Protocol for Germline Testing in Pancreatic Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-16011-3. [PMID: 39133448 DOI: 10.1245/s10434-024-16011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/25/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Guidelines now recommend universal germline genetic testing (GGT) for all pancreatic ductal adenocarcinoma (PDAC) patients. Testing provides information on actionable pathogenic variants and guides management of patients and family. Since traditional genetic counseling (GC) models are time-intensive and GC resources are sparse, new approaches are needed to comply with guidelines without overwhelming available resources. METHODS A novel protocol was developed for physician-led GGT. Completed test kits were delivered to the GC team, who maintained a prospective database and mailed all orders. If results revealed pathogenic variants for PDAC, patients were offered comprehensive GC, whereas negative and variant of uncertain significance (VUS) test results were reported to patients via brief calls. RESULTS During protocol implementation between January 2020 and December 2022, 310 (81.5%) patients underwent GGT, with a physician compliance rate of 82.6% and patient compliance rate of 98.7%. Of 310 patients tested, 44 (14.2%) patients had detection of pathogenic variants, while 83 (26.8%) patients had VUS. Pathogenic variants included BRCA1/BRCA2/PALB2 (n = 18, 5.8%), ATM (n = 9, 2.9%), CFTR (n = 4, 1.3%), EPCAM/MLH1/MSH2/MSH6/PMS2 (n = 3, 1.0%), and CDKN2A (n = 2, 0.7%). The GC team successfully contacted all patients with pathogenic variants to discuss results and offer comprehensive GC. CONCLUSION Our novel protocol facilitated GGT with excellent compliance despite limited GC resources. This framework for GGT allocates GC resources to those patients who would benefit most from GC. As we continue to expand the program, we seek to implement methods to ensure compliance with cascade testing of high-risk family members.
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Affiliation(s)
- Hannah G McDonald
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Andrew Kennedy
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Angelica L Solomon
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Chelsey M Williams
- Division of Hematology Oncology, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Anna M Reagan
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Emily Cassim
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Megan Harper
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Erin Burke
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Terra Armstrong
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Michael Gosky
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Michael Cavnar
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Prakash K Pandalai
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Mautin Barry-Hundeyin
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Reema Patel
- Division of Hematology Oncology, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Snigdha Nutalapati
- Division of Hematology Oncology, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Jessica Moss
- Division of Hematology Oncology, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Pamela C Hull
- Department of Behavioral Science, University of Kentucky, Lexington, KY, USA
| | - Jill Kolesar
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | | | - Joseph Kim
- Division of Surgical Oncology, Department of Surgery, University of Kentucky, Lexington, KY, USA.
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3
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Tsang ES, Dhawan MS, Pacaud R, Thomas S, Grabowsky J, Wilch L, Karipineni S, Kelley RK, Ko AH, Collisson E, Chapman JS, Ueda S, Bergsland EK, Munster P. Synthetic Lethality Beyond BRCA: A Phase I Study of Rucaparib and Irinotecan in Metastatic Solid Tumors With Homologous Recombination-Deficiency Mutations Beyond BRCA1/2. JCO Precis Oncol 2024; 8:e2300494. [PMID: 38865673 DOI: 10.1200/po.23.00494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/07/2023] [Accepted: 01/09/2024] [Indexed: 06/14/2024] Open
Abstract
PURPOSE Combining poly ADP-ribose polymerase (PARP) and topoisomerase I inhibitors has demonstrated synergistic effects in in vivo models. This phase I trial evaluated rucaparib and irinotecan in metastatic solid tumors with homologous recombination deficiency. METHODS This study enrolled patients in three cohorts to determine the tolerability and preliminary efficacy of (1) rucaparib 400 mg PO twice a day (days 1-7, 15-21) and irinotecan 65 mg/m2 intravenously once every 2 weeks; (2) rucaparib 400 mg PO twice a day (D1-7, 15-21) and irinotecan 100 mg/m2 once every 2 weeks; and (3) rucaparib 400 mg per os twice a day (D1-7) and irinotecan 100 mg/m2 once every 3 weeks. RESULTS Twenty patients were enrolled: 95% with previous platinum, 40% with previous irinotecan, and 20% with previous PARP inhibitor. The maximally tolerated was determined as rucaparib 400 mg twice a day days 1-7 and irinotecan 100 mg/m2 once every 3 weeks. Four dose-limiting toxicities (all grade 3-4 neutropenia) occurred during dose escalation with only neutropenia as other grade 3-4 toxicities (25%; grade 3 [n = 3], grade 4 [n = 2]). Treatment-related grade 1-2 adverse events included neutropenia (45%), diarrhea (45%), nausea (40%), and fatigue (30%). Of 17 patients with evaluable disease, six patients (35%) derived clinical benefit (n = 2 with PR, n = 4 with stable disease for over 6 months). Three patients remained on study >1 year: two with ATM mutations (small bowel carcinoma and pancreatic neuroendocrine tumor) and one patient with a PALB2 mutation (primary peritoneal cancer). CONCLUSION Pulse dosing of rucaparib and once every 3 weeks irinotecan was well tolerated for up to 18 months with durable responses in BRCA-, PALB2-, and ATM-mutated cancers despite progression on previous platinum.
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Affiliation(s)
- Erica S Tsang
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Mallika S Dhawan
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Romain Pacaud
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Scott Thomas
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Jennifer Grabowsky
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Lauren Wilch
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Silpa Karipineni
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Robin Kate Kelley
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Andrew H Ko
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Eric Collisson
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Jocelyn S Chapman
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Stefanie Ueda
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Emily K Bergsland
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Pamela Munster
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
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4
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Wang P, Zhao R, Jin X, Zhou X, Xie X. Veliparib‑Induced Toxicity in Cancer Patients: A Systematic Review and Meta‑Analysis. Cancer Invest 2024:1-14. [PMID: 38588003 DOI: 10.1080/07357907.2024.2338128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/29/2024] [Indexed: 04/10/2024]
Abstract
In this study, we investigate the veliparib‑induced toxicity in cancer patients. Databases were searched for RCTs treated with veliparib. We found veliparib could increase the risk of hematologic and gastrointestinal toxicities. Anemia, neutropenia, thrombocytopenia, and nausea were the most common toxicities. Patients diagnosed with gastrointestinal tumors tend to have a higher risk of high-grade neutropenia; patients in the first-line setting tend to have a higher risk of high-grade anemia and neutropenia than those in the ≥ second line setting. Patients receiving higher dosage of veliparib tend to have a higher risk of all-grade anemia. Veliparib could also increase the risk of insomnia, myalgia, pneumonia, dyspnea, hyponatremia, and fatigue.
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Affiliation(s)
- Peirong Wang
- Internal Medicine of Traditional Chinese Medicine, Chinese Traditional Medicine Hospital of Meishan, China
| | - Ruizhen Zhao
- Internal Medicine of Traditional Chinese Medicine, Chinese Traditional Medicine Hospital of Meishan, China
| | - Xiaohui Jin
- Department of Neurology, Chinese Traditional Medicine Hospital of Meishan, China
| | - Xianhua Zhou
- Internal Medicine of Traditional Chinese Medicine, Chinese Traditional Medicine Hospital of Meishan, China
| | - Xiaolong Xie
- Bone injury of Traditional Chinese Medicine, Chinese Traditional Medicine Hospital of Meishan, Meishan, Sichuan, P.R.China
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Anbil S, Reiss KA. Targeting BRCA and PALB2 in Pancreatic Cancer. Curr Treat Options Oncol 2024; 25:346-363. [PMID: 38311708 DOI: 10.1007/s11864-023-01174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 02/06/2024]
Abstract
OPINION STATEMENT An important subgroup of pancreatic ductal adenocarcinomas (PDACs) harbor pathogenic variants in BRCA1, BRCA2, or PALB2. These tumors are exquisitely sensitive to platinum-based chemotherapy and patients may experience deep and durable responses to this treatment. PARP inhibitors offer potential respite from the cumulative toxicities of chemotherapy as they significantly extend progression-free survival compared to a chemotherapy holiday. Given the lack of proven survival benefit, the decision to use a maintenance PARP inhibitor rather than continue chemotherapy should be individualized. Interestingly, in both published clinical trials of maintenance PARP inhibitors, there is a striking range of interpatient benefit: Even in the platinum-sensitive setting, roughly 25% of tumors appear to be PARP inhibitor refractory (progressive disease within 2 months of starting treatment), 50% sustain moderate benefit (up to 2 years), and 25% are hyper-responsive (more than 2 years of benefit). This finding highlights the need to refine our understanding of which patients will respond to maintenance PARP inhibitors, both by being able to identify biallelic loss and by deepening our knowledge of resistance mechanisms and who develops them. Recent data supports that reversion mutations are common in PARP inhibitor refractory patients, but we have little understanding of the mechanisms that drive delayed resistance and long-term responses. Identifying which patients are more prone to certain mechanisms of resistance and tackling them with specific treatment strategies are areas of active investigation. Additionally, given that PARP inhibitors have limited overall efficacy for most patients, upfront combination strategies are an important future strategy.
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Affiliation(s)
- Sriram Anbil
- Abramson Cancer Center, 10th Floor Perelman Center South, The University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19121, USA
| | - Kim A Reiss
- Abramson Cancer Center, 10th Floor Perelman Center South, The University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19121, USA.
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6
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Tsang ES, Gallinger S. Deciphering the Pathways to PARP Sensitivity in Pancreatic Cancer. Clin Cancer Res 2023; 29:5005-5007. [PMID: 37787975 DOI: 10.1158/1078-0432.ccr-23-2260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
A recent article analyzed paired cell-free DNA among patients with platinum-sensitive BRCA- or PALB2-mutated pancreatic cancer who received maintenance olaparib. Reversion mutations were linked with worse outcomes. These types of paired correlative studies are needed to improve our understanding of drug resistance and guide future clinical trials. See related article by Brown et al., p. 5207.
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Affiliation(s)
- Erica S Tsang
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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7
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Militello AM, Orsi G, Cavaliere A, Niger M, Avallone A, Salvatore L, Tortora G, Rapposelli IG, Giordano G, Noventa S, Giommoni E, Bozzarelli S, Macchini M, Peretti U, Procaccio L, Puccini A, Cascinu S, Montagna C, Milella M, Reni M. Clinical outcomes and response to chemotherapy in a cohort of pancreatic cancer patients with germline variants of unknown significance (VUS) in BRCA1 and BRCA2 genes. Cancer Chemother Pharmacol 2023; 92:501-510. [PMID: 37725113 DOI: 10.1007/s00280-023-04585-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 08/22/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE The clinical outcome and the efficacy of chemotherapy in pancreatic cancer patients with BRCA1/2 Variants of Unknown Significance (VUS) is unknown. We explored the effects of chemotherapy with or without Platinum in non metastatic and metastatic pancreatic cancer patients with BRCA1/2 VUS. METHODS A retrospective analysis of non-metastatic or metastatic pancreatic cancer patients with gBRCA1/2 VUS treated in 13 Italian centers between November 2015 and December 2020 was performed. All patients were assessed for toxicity and RECIST 1.1 response. Metastatic patients were evaluated for survival outcome. RESULTS 30 pancreatic cancer patients with gBRCA1/2 VUS were considered: 20 were M+ and 10 were non-M+. Pl-CT was recommended to 16 patients: 10 M+ (6 FOLFIRINOX and 4 PAXG) and 6 non-M+ (3 FOLFIRINOX and 3 PAXG); 11 patients received Nabpaclitaxel-Gemcitabine (AG; 8 M+) and 3 patients (2 M+) were treated with Gemcitabine (G). The RECIST 1.1 response rate was 27% for AG and 44% for Pl-CT (22% for (m) FOLFIRINOX and 71% PAXG). 1 year Progression-Free Survival was 37.5% for patients treated with AG and 33% in the Pl-CT subgroup. Median Overall Survival (OS) was 23.5 months for patients treated with AG and 14 months for the Pl-CT subgroup. 1 Year and 2 Year OS were numerically better for AG (1 Year OS: 75% vs 60% and 2 Year OS: 50% and 20% in AG and Pl-CT subgroups, respectively) as well. CONCLUSIONS Pl-CT does not seem to be associated with a better outcome compared to AG chemotherapy in PDAC patients with BRCA 1/2 VUS.
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Affiliation(s)
- Anna Maria Militello
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
- Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Orsi
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
- Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Cavaliere
- Department of Oncology, University of Torino, Candiolo, Italy
- Candiolo Cancer Institute, FPO - IRCCS Candiolo, Candiolo, Italy
| | - Monica Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Dei Tumori Di Milano, Milan, Italy
| | - Antonio Avallone
- Biologia Cellulare e Bioterapie, Istituto Nazionale per lo Studio e la Cura dei Tumori ''Fondazione Giovanni Pascale'' - IRCCS, Naples, Italy
| | - Lisa Salvatore
- Unit of Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario, Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giampaolo Tortora
- Unit of Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario, Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ilario Giovanni Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) ''Dino Amadori'', Meldola, Italy
| | - Guido Giordano
- Unit of Medical Oncology and Biomolecular Therapy, Policlinico Riuniti, Foggia, Italy
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Silvia Noventa
- Department of Medical Oncology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Elisa Giommoni
- Medical Oncology Division, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Silvia Bozzarelli
- Department of Medical Oncology and Hematology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marina Macchini
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
- Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Umberto Peretti
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
- Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Letizia Procaccio
- Medical Oncology 1 Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Alberto Puccini
- University of Genoa, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Stefano Cascinu
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
- Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Montagna
- Department of Radiation Oncology and Genomic Instability and Cancer Genetics, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Michele Milella
- Section of Oncology, Department of Medicine, University of Verona School of Medicine and Verona University Hospital Trust, Verona, Italy
| | - Michele Reni
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy.
- Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.
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Petrelli F, Parisi A, Tomasello G, Mini E, Arru M, Russo A, Garrone O, Khakoo S, Ardito R, Ghidini M. Comparison of different second line treatments for metastatic pancreatic cancer: a systematic review and network meta-analysis. BMC Gastroenterol 2023; 23:212. [PMID: 37337148 DOI: 10.1186/s12876-023-02853-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 06/13/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND In metastatic pancreatic ductal adenocarcinoma (mPDAC), first line treatment options usually include combination regimens of folinic acid, 5-fluorouracil (5-FU), irinotecan, and oxaliplatin (FOLFIRINOX or mFOLFIRINOX) or gemcitabine based regimens such as in combination with albumin-bound paclitaxel (GEM + nab-PTX). After progression, multiple regimens including NALIRI + 5-FU and folinic acid, FOLFIRINOX, 5-FU-based oxaliplatin doublets (OFF, FOLFOX, or XELOX), or 5-FU-based monotherapy (FL, capecitabine, or S-1) are considered appropriate by major guidelines. This network meta-analysis (NMA) aimed to compare the efficacy of different treatment strategies tested as second-line regimens for patients with mPDAC after first-line gemcitabine-based systemic treatment. METHODS Randomized phase II and III clinical trials (RCTs) were included if they were published or presented in English. Trials of interest compared two active systemic treatments as second-line regimens until disease progression or unacceptable toxicity. We performed a Bayesian NMA with published hazard ratios (HRs) and 95%confidence intervals (CIs) to evaluate the comparative effectiveness of different second-line therapies for mPDAC. The main outcomes of interest were overall survival (OS) and progression free survival (PFS), secondary endpoints were grade 3-4 toxicities. We calculated the relative ranking of agents for each outcome as their surface under the cumulative ranking (SUCRA). A higher SUCRA score meant a higher ranking for efficacy outcomes. RESULTS A NMA of 9 treatments was performed for OS (n = 2521 patients enrolled). Compared with 5-FU + folinic acid both irinotecan or NALIRI + fluoropyrimidines had a trend to better OS (HR = 0.76, 95%CI 0.21-2.75 and HR = 0.74, 95%CI 0.31-1.85). Fluoropyrimidines + folinic acid + oxaliplatin were no better than the combination without oxaliplatin. The analysis of treatment ranking showed that the combination of NALIRI + 5-FU + folinic acid was most likely to yield the highest OS results (SUCRA = 0.7). Furthermore, the NMA results indicated that with the highest SUCRA score (SUCRA = 0.91), NALIRI + 5-FU + folinic acid may be the optimal choice for improved PFS amongst all regimens studied. CONCLUSIONS According to the NMA results, NALIRI + 5-FU, and folinic acid may represent the best second-line treatment for improved survival outcomes in mPDAC. Further evidence from prospective trials is needed to determine the best treatment option for this group of patients.
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Affiliation(s)
- Fausto Petrelli
- Oncology Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Alessandro Parisi
- Clinica Oncologica e Centro Regionale di Genetica Oncologica, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria delle Marche, Via Conca 71, Ancona, 60126, Italy.
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, 67100, Italy.
| | - Gianluca Tomasello
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
| | - Emanuele Mini
- General Surgery Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Marcella Arru
- General Surgery Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Alessandro Russo
- General Surgery Unit, ASST Bergamo ovest, Treviglio (BG), 24047, Italy
| | - Ornella Garrone
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
| | - Shelize Khakoo
- Department of Medicine, The Royal Marsden Hospital, London, SW3 6JJ, UK
| | - Raffaele Ardito
- Oncological Day Hospital, IRCCS Centro di Riferimento Oncologico Della Basilicata (CROB), Via Padre Pio 1, Rionero in Vulture PZ, 85028, Italy
| | - Michele Ghidini
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, 20122, Italy
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Cecchini M, Walther Z, Wei W, Hafez N, Pilat MJ, Boerner SA, Durecki DE, Eder JP, Schalper KA, Chen AP, LoRusso P. NCI 7977: A Phase I Dose-Escalation Study of Intermittent Oral ABT-888 (Veliparib) plus Intravenous Irinotecan Administered in Patients with Advanced Solid Tumors. CANCER RESEARCH COMMUNICATIONS 2023; 3:1113-1117. [PMID: 37377610 PMCID: PMC10292219 DOI: 10.1158/2767-9764.crc-22-0485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/04/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023]
Abstract
Purpose Veliparib is a PARP inhibitor (PARPi) with activity in BRCA 1/2/PALB2-deficient tumors. Preclinical observations reveal topoisomerase inhibitors like irinotecan are synergistic with PARPi irrespective of homologous recombination deficiency (HRD), potentially expanding the role for PARPi. Experimental Design NCI 7977 was a multicohort phase I clinical trial evaluating the safety and efficacy of multiple dose schedules of veliparib with irinotecan for solid tumors. In the intermittent veliparib cohort, escalating doses of veliparib were given twice daily at dose level (DL) 1 (50 mg) and DL 2 (100 mg) days 1-4 and 8-11 with irinotecan 100 mg/m2 days 3 and 10 in 21-day cycles. Results Fifteen patients enrolled, 8 of 15 (53%) received ≥4 prior systemic treatments. At DL1, 1 of 6 patients experienced a dose-limiting toxicity (DLT) of diarrhea. At DL2, 9 patients were treated, with 3 unevaluable for DLT, and 2 of 6 evaluable patients experienced a DLT of grade 3 neutropenia. Irinotecan 100 mg/m2 and veliparib 50 mg twice daily was the MTD. No objective responses were observed, although 4 patients had progression-free survival >6 months. Conclusions The MTD of intermittent veliparib is 50 mg twice daily days 1-4 and 8-11 with weekly irinotecan 100 mg/m2 days 3 and 10 every 21 days. Multiple patients experienced prolonged stable disease irrespective of HRD and prior irinotecan. However, due to the toxicities with higher dose intermittent veliparib and irinotecan, this schedule was determined too toxic for further development and the arm was closed prematurely. Significance The combination of intermittent veliparib with weekly irinotecan was deemed too toxic for further development. Future PARPi combinations should focus on agents with nonoverlapping toxicities to improve tolerability. The treatment combination showed limited efficacy with prolonged stable disease observed in multiple heavily pretreated patients, but no objective responses were seen.
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Affiliation(s)
- Michael Cecchini
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Zenta Walther
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Wei Wei
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Navid Hafez
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Mary Jo Pilat
- Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Scott A. Boerner
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Diane E. Durecki
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Joseph P. Eder
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Kurt A. Schalper
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Alice P. Chen
- Division of Cancer Treatment and Diagnosis, NCI, Bethesda, Maryland
| | - Patricia LoRusso
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
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10
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Keane F, O’Connor CA, Park W, Seufferlein T, O’Reilly EM. Pancreatic Cancer: BRCA Targeted Therapy and Beyond. Cancers (Basel) 2023; 15:2955. [PMID: 37296917 PMCID: PMC10251879 DOI: 10.3390/cancers15112955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is projected to become the second leading cause of cancer-related death in the US by 2030, despite accounting for only 5% of all cancer diagnoses. Germline gBRCA1/2-mutated PDAC represents a key subgroup with a favorable prognosis, due at least in part to additional approved and guideline-endorsed therapeutic options compared with an unselected PDAC cohort. The relatively recent incorporation of PARP inhibition into the treatment paradigm for such patients has resulted in renewed optimism for a biomarker-based approach to the management of this disease. However, gBRCA1/2 represents a small subgroup of patients with PDAC, and efforts to extend the indication for PARPi beyond BRCA1/2 mutations to patients with PDAC and other genomic alterations associated with deficient DNA damage repair (DDR) are ongoing, with several clinical trials underway. In addition, despite an array of approved therapeutic options for patients with BRCA1/2-associated PDAC, both primary and acquired resistance to platinum-based chemotherapies and PARPi presents a significant challenge in improving long-term outcomes. Herein, we review the current treatment landscape of PDAC for patients with BRCA1/2 and other DDR gene mutations, experimental approaches under investigation or in development, and future directions.
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Affiliation(s)
- Fergus Keane
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (F.K.); (C.A.O.); (W.P.)
- David M. Rubenstein Center for Pancreatic Cancer Research, New York, NY 10065, USA
| | - Catherine A. O’Connor
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (F.K.); (C.A.O.); (W.P.)
- David M. Rubenstein Center for Pancreatic Cancer Research, New York, NY 10065, USA
| | - Wungki Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (F.K.); (C.A.O.); (W.P.)
- David M. Rubenstein Center for Pancreatic Cancer Research, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Thomas Seufferlein
- Department of Internal Medicine, Ulm University Hospital, 89081 Ulm, Germany;
| | - Eileen M. O’Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (F.K.); (C.A.O.); (W.P.)
- David M. Rubenstein Center for Pancreatic Cancer Research, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
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11
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Zhen DB, Safyan RA, Konick EQ, Nguyen R, Prichard CC, Chiorean EG. The role of molecular testing in pancreatic cancer. Therap Adv Gastroenterol 2023; 16:17562848231171456. [PMID: 37197396 PMCID: PMC10184226 DOI: 10.1177/17562848231171456] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/06/2023] [Indexed: 05/19/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDA) is highly aggressive and has few treatment options. To personalize therapy, it is critical to delineate molecular subtypes and understand inter- and intra-tumoral heterogeneity. Germline testing for hereditary genetic abnormalities is recommended for all patients with PDA and somatic molecular testing is recommended for all patients with locally advanced or metastatic disease. KRAS mutations are present in 90% of PDA, while 10% are KRAS wild type and are potentially targetable with epidermal growth factor receptor blockade. KRASG12C inhibitors have shown activity in G12C-mutated cancers, and novel G12D and pan-RAS inhibitors are in clinical trials. DNA damage repair abnormalities, germline or somatic, occur in 5-10% of patients and are likely to benefit from DNA damaging agents and maintenance therapy with poly-ADP ribose polymerase inhibitors. Fewer than 1% of PDA harbor microsatellite instability high status and are susceptible to immune checkpoint blockade. Albeit very rare, occurring in <1% of patients with KRAS wild-type PDAs, BRAF V600E mutations, RET and NTRK fusions are targetable with cancer agnostic Food and Drug Administration-approved therapies. Genetic, epigenetic, and tumor microenvironment targets continue to be identified at an unprecedented pace, enabling PDA patients to be matched to targeted and immune therapeutics, including antibody-drug conjugates, and genetically engineered chimeric antigen receptor or T-cell receptor - T-cell therapies. In this review, we highlight clinically relevant molecular alterations and focus on targeted strategies that can improve patient outcomes through precision medicine.
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Affiliation(s)
- David B. Zhen
- University of Washington School of Medicine, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Rachael A. Safyan
- University of Washington School of Medicine, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Eric Q. Konick
- University of Washington, School of Medicine Seattle, WA, USA
| | - Ryan Nguyen
- University of Washington, School of Medicine Seattle, WA, USA
| | | | - E. Gabriela Chiorean
- University of Washington School of Medicine, Fred Hutchinson Cancer Center, 825 Eastlake Avenue East, LG-465, Seattle, WA 98109, USA Fred Hutchinson
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12
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Fudalej M, Kwaśniewska D, Nurzyński P, Badowska-Kozakiewicz A, Mękal D, Czerw A, Sygit K, Deptała A. New Treatment Options in Metastatic Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15082327. [PMID: 37190255 DOI: 10.3390/cancers15082327] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Abstract
Pancreatic cancer (PC) is the seventh leading cause of cancer death across the world. Poor prognosis of PC is associated with several factors, such as diagnosis at an advanced stage, early distant metastases, and remarkable resistance to most conventional treatment options. The pathogenesis of PC seems to be significantly more complicated than originally assumed, and findings in other solid tumours cannot be extrapolated to this malignancy. To develop effective treatment schemes prolonging patient survival, a multidirectional approach encompassing different aspects of the cancer is needed. Particular directions have been established; however, further studies bringing them all together and connecting the strengths of each therapy are needed. This review summarises the current literature and provides an overview of new or emerging therapeutic strategies for the more effective management of metastatic PC.
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Affiliation(s)
- Marta Fudalej
- Department of Oncology Propaedeutics, Medical University of Warsaw, 01-445 Warsaw, Poland
- Department of Oncology, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | - Daria Kwaśniewska
- Department of Oncology, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | - Paweł Nurzyński
- Department of Oncology, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | | | - Dominika Mękal
- Department of Oncology Propaedeutics, Medical University of Warsaw, 01-445 Warsaw, Poland
| | - Aleksandra Czerw
- Department of Health Economics and Medical Law, Medical University of Warsaw, 01-445 Warsaw, Poland
- Department of Economic and System Analyses, National Institute of Public Health NIH-National Research Institute, 00-791 Warsaw, Poland
| | - Katarzyna Sygit
- Faculty of Health Sciences, Calisia University, 62-800 Kalisz, Poland
| | - Andrzej Deptała
- Department of Oncology Propaedeutics, Medical University of Warsaw, 01-445 Warsaw, Poland
- Department of Oncology, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
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13
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Fuentes-Antrás J, Genta S, Vijenthira A, Siu LL. Antibody-drug conjugates: in search of partners of choice. Trends Cancer 2023; 9:339-354. [PMID: 36746689 DOI: 10.1016/j.trecan.2023.01.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
Antibody-drug conjugates (ADCs) have become a credentialled class of anticancer drugs for both solid and hematological malignancies, with regulatory approvals mainly as single agents. Despite extensive preclinical and clinical efforts to develop rational ADC-based combinations, to date only a limited number have demonstrated survival improvements over standard of care. The most appealing partners for ADCs are those that offer additive or synergistic effects on tumor cells or their microenvironment without unacceptable overlapping toxicities. Coadministration with antiangiogenic compounds, HER2-targeting drugs, DNA-damage response agents and immune checkpoint inhibitors (ICIs) represent active forerunners. Through the identification of targets with tumor-specific expression, improved conjugation technologies, and novel linkers and payloads offering superior therapeutic indices, the next generation of ADCs brings optimism to combinatorial approaches.
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Affiliation(s)
- Jesús Fuentes-Antrás
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sofia Genta
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Abi Vijenthira
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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14
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Second-line therapy in pancreatic ductal adenocarcinoma (PDAC) patients with germline BRCA1-2 pathogenic variants (gBRCA1-2pv). Br J Cancer 2023; 128:877-885. [PMID: 36482190 PMCID: PMC9977912 DOI: 10.1038/s41416-022-02086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) harbouring germline BRCA1-2 pathogenic variants (gBRCA1-2pv) is a distinct nosological entity. Information on second-line therapy (2LT) outcome in this setting is lacking. METHODS Data of gBRCA1-2pv metastatic PDAC patients treated with chemotherapy were collected. A primary analysis of 2LT RECIST response, median progression-free survival (mPFS2) and overall survival (mOS2), was performed. A secondary analysis addressed the impact of timing of platinum introduction on the outcome of patients receiving at least a first-line combination chemotherapy (1LT). RESULTS Eighty-four gBRCA1-2pv metastatic PDAC patients were enrolled. The primary analysis, including 43 patients, highlighted a significant improvement of mPFS2 and a doubled response rate, in the platinum-based 2LT subgroup as compared to the platinum-free (8.8 versus 3.7 months, p = 0.013). Seventy-seven patients were included in the secondary analysis. Median PFS1 of 3- and 4-drug platinum-based 1LT significantly outperformed both platinum-free combinations and platinum-based doublets (11.4 versus 6.4 versus 7.9 months, p = 0.01). Albeit still immature, data on mOS paralleled those on mPFS. CONCLUSIONS This study highlighted the beneficial role of platinum agents in gBRCA1-2pv PDAC patients also in second-line treatment setting. However, our data suggest that early use of 3- and 4-drug platinum-based chemotherapy combinations provides a survival outcome advantage.
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15
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Chen X, Wen Q, Kou L, Xie X, Li J, Li Y. Incidence and risk of hypertension associated with PARP inhibitors in cancer patients: a systematic review and meta-analysis. BMC Cancer 2023; 23:107. [PMID: 36717798 PMCID: PMC9887889 DOI: 10.1186/s12885-023-10571-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/20/2023] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To analyze the incidence and risk of hypertension associated with poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors in cancer patients and provide reference for clinicians. METHODS We used R software to conduct a meta-analysis of phase II/III randomized controlled trials (RCT) on PARP inhibitors for cancer treatment published in PubMed, Embase, Clinical Trials, Cochrane Library and Web of Science from inception to July 29th, 2022. RESULTS We included 32 RCTs with 10,654 participants for this meta-analysis. For total PARP inhibitors, the incidence and risk ratio of all-grade hypertension were 12% and 1.22 (95% CI: 0.91-1.65, P = 0.19, I2 = 81%), and the incidence and risk ratio of grade 3-4 hypertension were 4% and 1.24 (95% CI: 0.74-2.08, P = 0.42, I2 = 68%). Compared with the control group, the niraparib group, olaparib 800 mg/day group, and olaparib plus cediranib group increased the risk of any grade and grade 3-4 hypertension, while the veliparib group and rucaparib group did not increase the risk of any grade and grade 3-4 hypertension, and olaparib 200 mg-600 mg/day group (exclude olaparib plus cediranib regime) reduced the risk of any grade and grade 3-4 hypertension. CONCLUSION Olaparib 200-600 mg/day (excluding olaparib plus cediranib regimen) may be the most suitable PARP inhibitor for cancer patients with high risk of hypertension, followed by veliparib and rucaparib. Niraparib, olaparib 800 mg/day and olaparib combined with cediranib may increase the risk of developing hypertension in cancer patients, clinicians should strengthen the monitoring of blood pressure in cancer patients and give medication in severe cases.
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Affiliation(s)
- Xiu Chen
- grid.488387.8Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China ,grid.410578.f0000 0001 1114 4286School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Qinglian Wen
- grid.488387.8Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Liqiu Kou
- grid.488387.8Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China ,grid.410578.f0000 0001 1114 4286School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Xiaolu Xie
- grid.488387.8Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China ,grid.410578.f0000 0001 1114 4286School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Jun Li
- grid.488387.8Department of Traditional Chinese Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaling Li
- grid.488387.8Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Huffman BM, Basu Mallick A, Horick NK, Wang-Gillam A, Hosein PJ, Morse MA, Beg MS, Murphy JE, Mavroukakis S, Zaki A, Schlechter BL, Sanoff H, Manz C, Wolpin BM, Arlen P, Lacy J, Cleary JM. Effect of a MUC5AC Antibody (NPC-1C) Administered With Second-Line Gemcitabine and Nab-Paclitaxel on the Survival of Patients With Advanced Pancreatic Ductal Adenocarcinoma: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2249720. [PMID: 36602796 PMCID: PMC9856813 DOI: 10.1001/jamanetworkopen.2022.49720] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Treatment options are limited for patients with advanced pancreatic ductal adenocarcinoma (PDAC) beyond first-line 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX), with such individuals commonly being treated with gemcitabine and nab-paclitaxel. OBJECTIVE To determine whether NPC-1C, an antibody directed against MUC5AC, might increase the efficacy of second-line gemcitabine and nab-paclitaxel in patients with advanced PDAC. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized phase II clinical trial enrolled patients with advanced PDAC between April 2014 and March 2017 whose disease had progressed on first-line FOLFIRINOX. Eligible patients had tumors with at least 20 MUC5AC staining by centralized immunohistochemistry review. Statistical analysis was performed from April to May 2022. INTERVENTIONS Patients were randomly assigned to receive gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2) administered intravenously on days 1, 8, and 15 of every 4-week cycle, with or without intravenous NPC-1C 1.5 mg/kg every 2 weeks. MAIN OUTCOMES AND MEASURES The primary end point was overall survival (OS). Secondary end points were progression-free survival (PFS), objective response rate (ORR), and safety. Pretreatment clinical variables were explored with Cox proportional hazards analysis. RESULTS A total of 78 patients (median [range] age, 62 [36-78] years; 32 [41%] women; 9 [12%] Black; 66 [85%] White) received second-line treatment with gemcitabine plus nab-paclitaxel (n = 40) or gemcitabine plus nab-paclitaxel and NPC-1C (n = 38). Median OS was 6.6 months (95% CI, 4.7-8.4 months) with gemcitabine plus nab-paclitaxel vs 5.0 months (95% CI, 3.3-6.5 months; P = .22) with gemcitabine plus nab-paclitaxel and NPC-1C. Median PFS was 2.7 months (95% CI, 1.9-4.1 months) with gemcitabine plus nab-paclitaxel vs 3.4 months (95% CI, 1.9-5.3 months; P = .80) with gemcitabine plus nab-paclitaxel and NPC-1C. The ORR was 3.1% (95% CI, 0.4%-19.7%) in the gemcitabine plus nab-paclitaxel and NPC-1C group and 2.9% (95% CI, 0.4%-18.7%) in the gemcitabine plus nab-paclitaxel group. No differences in toxicity were observed between groups, except that grade 3 or greater anemia occurred more frequently in patients treated with gemcitabine plus nab-paclitaxel and NPC-1C than gemcitabine plus nab-paclitaxel (39% [15 of 38] vs 10% [4 of 40]; P = .003). The frequency of chemotherapy dose reductions was similar in both groups (65% vs 74%; P = .47). Lower performance status, hypoalbuminemia, PDAC diagnosis less than or equal to 18 months before trial enrollment, lymphocyte-to-monocyte ratio less than 2.8, and CA19-9 greater than 2000 IU/mL were independently associated with poorer survival. CONCLUSIONS AND RELEVANCE In this randomized clinical trial of advanced PDAC, NPC-1C did not enhance the efficacy of gemcitabine/nab-paclitaxel. These data provide a benchmark for future trials investigating second-line treatment of PDAC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01834235.
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Affiliation(s)
- Brandon M. Huffman
- Division of Gastrointestinal Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Atrayee Basu Mallick
- Thomas Jefferson University/Sidney Kimmel Cancer Center, Philadelphia, Pennsylvania
| | - Nora K. Horick
- Biostatistics Center, Massachusetts General Hospital, Boston
| | - Andrea Wang-Gillam
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | | | | | - Muhammad Shaalan Beg
- UT Southwestern Medical Center, Dallas, Texas
- Science 37 Inc, Durham, North Carolina
| | - Janet E. Murphy
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston
| | | | | | | | | | - Christopher Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Brian M. Wolpin
- Division of Gastrointestinal Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | | | - Jill Lacy
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - James M. Cleary
- Division of Gastrointestinal Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
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Thein KZ, Thawani R, Kummar S. Combining Poly (ADP-Ribose) Polymerase (PARP) Inhibitors with Chemotherapeutic Agents: Promise and Challenges. Cancer Treat Res 2023; 186:143-170. [PMID: 37978135 DOI: 10.1007/978-3-031-30065-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Better understanding of molecular drivers and dysregulated pathways has furthered the concept of precision oncology and rational drug development. The role of DNA damage response (DDR) pathways has been extensively studied in carcinogenesis and as potential therapeutic targets to improve response to chemotherapy or overcome resistance. Treatment with small molecule inhibitors of PARP has resulted in clinical response and conferred survival benefit to patients with ovarian cancer, BRCA-mutant breast cancer, HRD-deficient prostate cancer and BRCA-mutant pancreatic cancer, leading to US Food and Drug Administration (FDA) approvals. However, the observed clinical benefit with single agent PARP inhibitors is limited to few tumor types within the relevant genetic context. Since DDR pathways are essential for repair of damage caused by cytotoxic agents, PARP inhibitors have been evaluated in combination with various chemotherapeutic agents to broaden the therapeutic application of this class of drugs. In this chapter, we discuss the combination of PARP inhibitors with different chemotherapeutics agents, clinical experience to date, lessons learnt, and future directions for this approach.
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Affiliation(s)
- Kyaw Zin Thein
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV, USA
| | - Rajat Thawani
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV, USA
| | - Shivaani Kummar
- DeArmond Endowed Chair of Cancer Research, Division of Hematology and Medical Oncology, Clinical and Translational Research, Knight Cancer Institute (KCI), Center for Experimental Therapeutics (KCI), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, OC14HO, Portland, OR, 97239, USA.
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Emerging Role of Targeted Therapy in Metastatic Pancreatic Adenocarcinoma. Cancers (Basel) 2022; 14:cancers14246223. [PMID: 36551707 PMCID: PMC9776746 DOI: 10.3390/cancers14246223] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
The aggressive biology of pancreatic ductal adenocarcinoma (PDAC), along with its limited sensitivity to many systemic therapies, presents a major challenge in the management of patients with metastatic PDAC. Over the past decade, the incorporation of combinatorial cytotoxic chemotherapy regimens has improved patient outcomes. Despite these advances, resistance to cytotoxic chemotherapy inevitably occurs, and there is a great need for effective therapies. A major focus of research has been to identify molecularly defined subpopulations of patients with PDAC who may benefit from targeted therapies that are matched to their molecular profile. Recent successes include the demonstration of the efficacy of maintenance PARP inhibition in PDAC tumors harboring deleterious BRCA1, BRCA2, and PALB2 alterations. In addition, while therapeutic targeting of KRAS was long thought to be infeasible, emerging data on the efficacy of KRAS G12C inhibitors have increased optimism about next-generation KRAS-directed therapies in PDAC. Meanwhile, KRAS wild-type PDAC encompasses a unique molecular subpopulation of PDAC that is enriched for targetable genetic alterations, such as oncogenic BRAF alterations, mismatch repair deficiency, and FGFR2, ALK, NTRK, ROS1, NRG1, and RET rearrangements. As more molecularly targeted therapies are developed, precision medicine has the potential to revolutionize the treatment of patients with metastatic PDAC.
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Gössling GCL, Zhen DB, Pillarisetty VG, Chiorean EG. Combination immunotherapy for pancreatic cancer: challenges and future considerations. Expert Rev Clin Immunol 2022; 18:1173-1186. [PMID: 36045547 DOI: 10.1080/1744666x.2022.2120471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Immune checkpoint inhibitors (ICI) have not yielded significant efficacy in pancreatic ductal adenocarcinoma (PDA), despite the role of the innate and adaptive immune systems on progression and survival. However, recently identified pathways have identified new targets and generated promising clinical investigations into promoting an effective immune-mediated antitumor response in PDA. AREAS COVERED : We review biological mechanisms associated with immunotherapy resistance and outline strategies for therapeutic combinations with established and novel therapies in PDA. EXPERT OPINION : Pancreatic cancers rarely benefits from treatment with ICI due to an immunosuppressive tumor microenvironment (TME). New understandings of factors associated with the suppressive TME, include low and poor quality neoantigens, constrained effector T cells infiltration, and the presence of a dense, suppressive myeloid cell population. These findings have been translated into new clinical investigations evaluating novel therapies in combination with ICI and/or standard systemic chemotherapy and radiotherapy. The epithelial, immune, and stromal compartments are intricately related in PDA, and the framework for successful targeting of this disease requires a comprehensive and personalized approach.
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Affiliation(s)
| | - David B Zhen
- University of Washington School of Medicine, Seattle, WA, USA.,Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Venu G Pillarisetty
- University of Washington School of Medicine, Seattle, WA, USA.,Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - E Gabriela Chiorean
- University of Washington School of Medicine, Seattle, WA, USA.,Fred Hutchinson Cancer Center, Seattle, WA, USA
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The disruption of the CCDC6 – PP4 axis induces a BRCAness like phenotype and sensitivity to PARP inhibitors in high-grade serous ovarian carcinoma. J Exp Clin Cancer Res 2022; 41:245. [PMID: 35964058 PMCID: PMC9375931 DOI: 10.1186/s13046-022-02459-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Treatment with PARP inhibitors (PARPi) is primarily effective against high-grade serous ovarian cancers (HGSOC) with BRCA1/2 mutations or other deficiencies in homologous recombination (HR) repair mechanisms. However, resistance to PARPi frequently develops, mostly as a result of BRCA1/2 reversion mutations. The tumour suppressor CCDC6 is involved in HR repair by regulating the PP4c phosphatase activity on γH2AX. In this work, we reported that in ovarian cancer cells, a physical or functional loss of CCDC6 results synthetic lethal with the PARP-inhibitors drugs, by affecting the HR repair. We also unravelled a role for CCDC6 as predictive marker of PARPi sensitivity in ovarian cancer, and the impact of CCDC6 downregulation in overcoming PARPi resistance in these tumours. Methods A panel of HGSOC cell lines (either BRCA-wild type or mutant) were treated with PARPi after CCDC6 was attenuated by silencing or by inhibiting USP7, a CCDC6-deubiquitinating enzyme, and the effects on cell survival were assessed. At the cellular and molecular levels, the processes underlying the CCDC6-dependent modification of drugs’ sensitivity were examined. Patient-derived xenografts (PDXs) were immunostained for CCDC6, and the expression of the protein was analysed statistically after digital or visual means. Results HGSOC cells acquired PARPi sensitivity after CCDC6 depletion. Notably, CCDC6 downregulation restored the PARPi sensitivity in newly generated or spontaneously resistant cells containing either wild type- or mutant-BRCA2. When in an un-phosphorylated state, the CCDC6 residue threonine 427 is crucial for effective CCDC6-PP4 complex formation and PP4 sequestration, which maintains high γH2AX levels and effective HR. Remarkably, the PP4-dependent control of HR repair is influenced by the CCDC6 constitutively phosphorylated mutant T427D or by the CCDC6 loss, favouring PARPi sensitivity. As a result, the PP4 regulatory component PP4R3α showed to be essential for both the activity of the PP4 complex and the CCDC6 dependent PARPi sensitivity. It's interesting to note that immunohistochemistry revealed an intense CCDC6 protein staining in olaparib-resistant HGSOC cells and PDXs. Conclusions Our findings suggest that the physical loss or the functional impairment of CCDC6 enhances the PP4c complex activity, which causes BRCAness and PARPi sensitivity in HGSOC cells. Moreover, CCDC6 downregulation might overcome PARPi resistance in HGSOCs, thus supporting the potential of targeting CCDC6 by USP7 inhibitors to tackle PARPi resistance. Supplementary Information The online version contains supplementary material available at 10.1186/s13046-022-02459-2.
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Yin C, Alqahtani A, Noel MS. The Next Frontier in Pancreatic Cancer: Targeting the Tumor Immune Milieu and Molecular Pathways. Cancers (Basel) 2022; 14:2619. [PMID: 35681599 PMCID: PMC9179513 DOI: 10.3390/cancers14112619] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/13/2022] [Accepted: 05/19/2022] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with abysmal prognosis. It is currently the third most common cause of cancer-related mortality, despite being the 11th most common cancer. Chemotherapy is standard of care in all stages of pancreatic cancer, yet survival, particularly in the advanced stages, often remains under one year. We are turning to immunotherapies and targeted therapies in PDAC in order to directly attack the core features that make PDAC notoriously resistant to chemotherapy. While the initial studies of these agents in PDAC have generally been disappointing, we find optimism in recent preclinical and early clinical research. We find that despite the immunosuppressive effects of the PDAC tumor microenvironment, new strategies, such as combining immune checkpoint inhibitors with vaccine therapy or chemokine receptor antagonists, help elicit strong immune responses. We also expand on principles of DNA homologous recombination repair and highlight opportunities to use agents, such as PARP inhibitors, that exploit deficiencies in DNA repair pathways. Lastly, we describe advances in direct targeting of driver mutations and metabolic pathways and highlight some technological achievements such as novel KRAS inhibitors.
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Affiliation(s)
| | | | - Marcus S. Noel
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA; (C.Y.); (A.A.)
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22
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Martorana F, Da Silva LA, Sessa C, Colombo I. Everything Comes with a Price: The Toxicity Profile of DNA-Damage Response Targeting Agents. Cancers (Basel) 2022; 14:cancers14040953. [PMID: 35205700 PMCID: PMC8870347 DOI: 10.3390/cancers14040953] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary DNA damage induces genome instability, which may elicit cancer development. Defects in the DNA repair machinery further enhance cancer predisposition, but can also be exploited as a therapeutic target. Indeed, targeted agents against specific components of DNA repair, such as PARP inhibitors, are employed in various tumor types, while others, such as ATR, CHK1 or WEE1 inhibitors, are in clinical development. Even though these molecules have proven to be effective in different settings, they display several on- and off-target toxicities, shared by the whole pharmacological class or are drug specific. Among these effects, hematological and gastrointestinal toxicities are the most common, while others are less frequent but potentially life-threatening (e.g., myelodysplastic syndromes). Particular caution is needed in the case of combinatorial therapeutic approaches, which are currently being developed in clinical trials. In any case, it is necessary to recognize and properly manage adverse events of these drugs. This review provides a comprehensive overview on the safety profile of DDR-targeting agents, including indications for their management in clinical practice. Abstract Targeting the inherent vulnerability of cancer cells with an impaired DNA Damage Repair (DDR) machinery, Poly-ADP-Ribose-Polymerase (PARP) inhibitors have yielded significant results in several tumor types, eventually entering clinical practice for the treatment of ovarian, breast, pancreatic and prostate cancer. More recently, inhibitors of other key components of DNA repair, such as ATR, CHK1 and WEE1, have been developed and are currently under investigation in clinical trials. The inhibition of DDR inevitably induces on-target and off-target adverse events. Hematological and gastrointestinal toxicities as well as fatigue are common with all DDR-targeting agents, while other adverse events are drug specific, such as hypertension with niraparib and transaminase elevation with rucaparib. Cases of pneumonitis and secondary hematological malignancies have been reported with PARP inhibitors and, despite being overly rare, they deserve particular attention due to their severity. Safety also represents a crucial issue for the development of combination regimens incorporating DDR-targeting agents with other treatments, such as chemotherapy, anti-angiogenics or immunotherapy. As such, overlapping and cumulative toxicities should be considered, especially when more than two classes of drugs are combined. Here, we review the safety profile of DDR-targeting agents when used as single agents or in combination and we provide principles of toxicity management.
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Affiliation(s)
- Federica Martorana
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy;
| | - Leandro Apolinario Da Silva
- Service of Medical Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, 6500 Bellinzona, Switzerland; (L.A.D.S.); (C.S.)
| | - Cristiana Sessa
- Service of Medical Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, 6500 Bellinzona, Switzerland; (L.A.D.S.); (C.S.)
| | - Ilaria Colombo
- Service of Medical Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, 6500 Bellinzona, Switzerland; (L.A.D.S.); (C.S.)
- Correspondence: ; Tel.: +41-91-811-8194
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Yap TA, Hamilton E, Bauer T, Dumbrava EE, Jeselsohn R, Enke A, Hurley S, Lin KK, Habeck J, Giordano H, Shapiro GI. Phase Ib SEASTAR Study: Combining Rucaparib and Sacituzumab Govitecan in Patients With Cancer With or Without Mutations in Homologous Recombination Repair Genes. JCO Precis Oncol 2022; 6:e2100456. [PMID: 35138920 PMCID: PMC8865521 DOI: 10.1200/po.21.00456] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/19/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Timothy A. Yap
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erika Hamilton
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN
| | - Todd Bauer
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN
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