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Doxycycline-Induced Changes in Circulating MMP or TIMP2 Levels Are Not Associated with Skeletal-Related Event-Free or Overall Survival in Patients with Bone Metastases from Breast Cancer. Cancers (Basel) 2023; 15:cancers15030571. [PMID: 36765529 PMCID: PMC9913061 DOI: 10.3390/cancers15030571] [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: 12/08/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023] Open
Abstract
Doxycycline is often used as a promoter of inducible gene expression in preclinical models; however, it can also have direct effects on tumor growth and survival. This is due in part to its ability to inhibit cell invasion and regulate matrix metalloproteinase (MMP) expression. Given that doxycycline is also osteotropic, a clinical study to assess its effects on modulation of tumor progression or prevention of skeletal-related events (SRE) in patients with bone metastases from breast cancer (the Achilles trial) was undertaken. Patients received 100 mg of oral doxycycline twice daily for 12 weeks, with serum obtained at baseline and 4, 8 and 12 weeks post-initiation of doxycycline treatment. Exploratory analysis of the effects of doxycycline on circulating levels of MMP or tissue inhibitor of matrix metalloproteinase 2 (TIMP2) was performed in enrolled patients. Statistically significant associations were observed between MMP2, MMP9 and TIMP2 at baseline with significant associations maintained between absolute levels and changes in levels of MMP2 and TIMP2 at weeks 4-12 post initiation of doxycycline. Treatment with doxycycline generally resulted in decreases in MMP2 and MMP9 levels with concurrent upregulation of TIMP2 at 12 weeks post-initiation of doxycycline treatment. Despite this, we observed no association with the levels of any of these factors with either SRE-free or overall survival in this patient cohort. In summary, despite observing hypothesized effects of doxycycline administration on surrogate markers of its anti-tumor activity, measures of circulating levels of these biomarkers were not prognostic in this patient population.
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Alzahrani M, Stober C, Liu M, Awan A, Ng TL, Pond G, Alshamsan B, Vandermeer L, Clemons M. Symptomatic skeletal-related events in patients receiving longer term bone-modifying agents for bone metastases from breast and castration resistant prostate cancers. Support Care Cancer 2022; 30:3977-3984. [DOI: 10.1007/s00520-021-06714-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022]
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Saunders D, Liu M, Vandermeer L, Alzahrani MJ, Hutton B, Clemons M. The Rethinking Clinical Trials (REaCT) Program. A Canadian-Led Pragmatic Trials Program: Strategies for Integrating Knowledge Users into Trial Design. Curr Oncol 2021; 28:3959-3977. [PMID: 34677255 PMCID: PMC8534460 DOI: 10.3390/curroncol28050337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
We reviewed patient and health care provider (HCP) surveys performed through the REaCT program. The REaCT team has performed 15 patient surveys (2298 respondents) and 13 HCP surveys (1033 respondents) that have addressed a broad range of topics in breast cancer management. Over time, the proportion of surveys distributed by paper/regular mail has fallen, with electronic distribution now the norm. For the patient surveys, the median duration of the surveys was 3 months (IQR 2.5-7 months) and the median response rate was 84% (IQR 80-91.7%). For the HCP surveys, the median survey duration was 3 months (IQR 1.75-4 months), and the median response rate, where available, was 28% (IQR 21.2-49%). The survey data have so far led to: 10 systematic reviews, 6 peer-reviewed grant applications and 19 clinical trials. Knowledge users should be an essential component of clinical research. The REaCT program has integrated surveys as a standard step of their trials process. The COVID-19 pandemic and reduced face-to-face interactions with patients in the clinic as well as the continued importance of social media highlight the need for alternative means of distributing and responding to surveys.
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Affiliation(s)
- Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
| | - Michelle Liu
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
| | - Mashari Jemaan Alzahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada;
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada;
| | - Mark Clemons
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada;
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McGee S, Alzahrani M, Vandermeer L, Cole K, Larocque G, Awan A, Hutton B, Pond G, Saunders D, Clemons M. Adjuvant bisphosphonate use in patients with early stage breast cancer: a physician survey. Breast Cancer Res Treat 2021; 187:477-486. [PMID: 33755864 PMCID: PMC7985746 DOI: 10.1007/s10549-021-06147-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
Purpose Despite the increasing use of adjuvant bone-modifying agents (BMAs) such as zoledronate and clodronate in the treatment of patients with early stage breast cancer (EBC), little is known about real world practice patterns. A physician survey was performed to address this deficit and determine interest in clinical trials of alternative strategies for BMA administration. Methods Canadian oncologists treating patients with EBC were surveyed via an anonymized online survey. The survey collected information on: physician demographics, knowledge and interpretation of adjuvant bisphosphonate guidelines, and real world prescribing practices. Questions also determined thoughts around the design of future adjuvant BMA trials. Results Of 127 surveyed physicians, 53 eligible invitees responded (response rate 42%). The majority of physicians are offering high-risk postmenopausal patients adjuvant BMAs. The most common BMA regimen was adjuvant zoledronate (45/53, 85%) every 6 months for 3 years. Concerns around toxicities and repeated visits to the cancer centre were perceived as the greatest barriers to adjuvant bisphosphonate use. Respondents were interested in future trials of de-escalation of BMAs comparing a single infusion of zoledronate vs. 6-monthly zoledronate for 3 years. The most favoured primary endpoints for such a trial included disease recurrence and fragility fracture rates. Conclusion Questions around optimal use of adjuvant bisphosphonates in patients with EBC still exist. There is interest among physicians in performing trials of de-escalation of these agents. The results of this survey will assist in designing pragmatic clinical trials to address this question. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06147-1.
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Affiliation(s)
- Sharon McGee
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Mashari Alzahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Katherine Cole
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada
| | - Gail Larocque
- The Ottawa Hospital Cancer Program, The Ottawa Hospital, Ottawa, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Gregory Pond
- Department of Oncology, Juravinski Cancer Centre and McMaster University, Hamilton, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, Canada. .,Cancer Therapeutics Program, Ottawa Hospital Research, and University of Ottawa, Ottawa, Canada.
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McGee S, AlZahrani M, Stober C, Ng TL, Cole K, Larocque G, Awan A, Sehdev S, Hilton J, Vandermeer L, Hutton B, Pond G, Saunders D, Clemons M. Adjuvant bisphosphonate use in patients with early stage breast cancer: Patient perspectives on treatment acceptability and potential de-escalation. J Bone Oncol 2021; 27:100351. [PMID: 33680749 PMCID: PMC7930351 DOI: 10.1016/j.jbo.2021.100351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 11/30/2022] Open
Abstract
Background Despite the increasing use of adjuvant bisphosphonates for early stage breast cancer (EBC), little is known about the patient experience with such treatments. A patient survey was performed to identify current prescribing practices, perceptions around the role of treatment, the impact of treatment on patients' quality of life, and future trial designs. Methods EBC patients who had either completed or were currently receiving adjuvant bisphosphonates were sent an anonymized survey. The survey collected information on patient and disease characteristics, bisphosphonate scheduling, compliance, and tolerance. Questions also assessed patient interest in trials of de-escalated bisphosphonate therapy. Results A total of 255 patients were contacted, with 164 eligible respondents (eligible response rate 164/255, 64.3%). Median patient age was 52 years (range 28 to 82 years). The majority (111/163, 68.1%) were postmenopausal at the time of diagnosis, 23.3% (38/163) were premenopausal, and 7.4% (12/163) were perimenopausal. Most patients (78%) had received chemotherapy. Zoledronate was the most commonly used bisphosphonate (92%), with the majority receiving treatment every 6 months for 3 years (73%). While 66% (107/161) of respondents had experienced side effects with treatment, most had, or expected to, complete treatment (154/163, 94%). Provided there was no detriment in breast cancer outcomes, there was strong interest in future studies of de-escalating adjuvant bisphosphonate therapy. Conclusion While most patients tolerate their treatment, there is interest in performing trials of de-escalation of these agents.
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Affiliation(s)
- Sharon McGee
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mashari AlZahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Terry L Ng
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katherine Cole
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Gail Larocque
- The Ottawa Hospital Cancer Program, The Ottawa Hospital, Ottawa, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sandeep Sehdev
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Gregory Pond
- Department of Oncology, Juravinski Cancer Centre and McMaster University, Hamilton, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada.,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Luo Q, Men P, Liu Z, Zhai S, Jiang M. Is De-escalated Bisphosphonates Therapy a Suitable Alternative to Standard Dosing in Malignant Tumor Patients With Bone Metastases: A Systematic Review and Meta-Analysis. Front Oncol 2019; 9:774. [PMID: 31475116 PMCID: PMC6702312 DOI: 10.3389/fonc.2019.00774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have preliminarily identified the non-inferior efficacy for reducing skeletal-related event (SRE) rates between de-escalated (Q12w) and standard (Q3-4w) bone-targeting agents therapy in malignant tumor patients with bone metastases. In this study, we aim to make further efforts to analyze whether the de-escalated bisphosphonates (BPs) strategy is a suitable option by comprehensively retrieving and synthesizing state-of-the-art evidence. Methods: An extensive electronic search for randomized controlled trials (RCTs) comparing a BPs standard strategy with the de-escalated one in patients with bone metastases was performed up to June 2018. Outcomes of interest were general and found individual types of SRE, skeletal morbidity rate (SMR), bone pain, bone turnover biomarkers and adverse events (AEs). Continuous and dichotomous outcomes were summarized by the weighted mean difference (WMD) and risk ratio (RR), respectively, with 95% confidence intervals (CIs). Results: A total of eight studies, representing six unique trials (involving 3114 patients), were included. Pooled results indicated comparable efficacy on general SRE (RR 0.99, 95% CI 0.87-1.12; P = 0.86; I 2 = 0%) and SMR (WMD 0.00, 95% CI -0.02 -0.03; P = 0.81; I 2 = 0%). However, the rate of surgery involving bones was significantly higher in de-escalated group than standard group (RR 1.92, 95% CI 1.17-3.15; P = 0.01; I 2 = 0%) among individual types of SRE. Several trials also demonstrated increased levels of C-terminal or N-terminal telopeptide in de-escalated group. Meta-analyses for gastrointestinal disorders, dizziness and back pain showed significant reductions by 27% (RR 0.73, 95% CI 0.57-0.94; P = 0.01; I 2 = 0%), 48% (RR 0.52 95% CI 0.32-0.86; P = 0.01; I 2 = 0%), and 29% (RR 0.71, 0.51-0.99; P = 0.04; I 2 = 0%), respectively, compared to the standard therapy. Conclusion: For malignant tumor patients with bone metastases, a de-escalated BPs strategy is proved to have a better safety profile compared to standard dosing. Although the efficacy is generally comparable on SRE and SMR between the two dosing regimens, trials with long duration and large sample sizes are still warranted to make a solid judgment.
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Affiliation(s)
- Qiuhua Luo
- Department of Pharmacy, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Zhiyong Liu
- Liaoning Center for Drug and Device Evaluation and Monitoring, Shenyang, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Mingyan Jiang
- Department of Pharmacy, The First Affiliated Hospital of China Medical University, Shenyang, China
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Awan AA, Hutton B, Hilton J, Mazzarello S, Van Poznak C, Vandermeer L, Bota B, Stober C, Sienkiewicz M, Fergusson D, Shorr R, Clemons M. De-escalation of bone-modifying agents in patients with bone metastases from breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat 2019; 176:507-517. [PMID: 31079283 DOI: 10.1007/s10549-019-05265-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Bone-modifying agents (BMAs) such as bisphosphonates and denosumab are usually administered every 4 weeks (standard) in patients with bone metastases from breast cancer to prevent skeletal-related events (SREs). Recent randomized controlled trials suggest every 12-week (de-escalated) dosing interval may be non-inferior. The objective of this systematic review and meta-analysis was to compare the efficacy and harms of standard with de-escalated administration of BMA's in patients with bone metastases from breast cancer. METHODS We searched Medline, PubMed, and the Cochrane Register of Controlled Trials from 1947 to March 14, 2018 and conference abstracts from (2014-March 14, 2018) for randomized clinical trials comparing every 4-week and every 12-week dosing interval of bone-modifying agents. Using PRISMA guidelines, meta-analyses were performed using random-effects models, with findings reported as risk ratios with 95% confidence intervals (CI). RESULTS From a total of 1311 citations, we identified 8 full-text articles and 1 abstract comprising data from 5 completed randomized clinical trials (n = 1807). Zoledronate administration every 12 weeks compared to every 4 weeks produced a summary risk ratio of 1.05 (95% CI 0.88-1.25) for patients with ≥ 1 on-study SRE indicating similar efficacy. These results did not differ whether patients had received prior intravenous bisphosphonate. De-escalation was associated with a non-statistically significant lower risk of increased creatinine (summary risk ratio 0.41 [95% CI 0.15-1.16]). Currently, there are insufficient data for pamidronate and denosumab de-escalation. CONCLUSIONS These data are supportive of de-escalation of zoledronate from onset for patients with bone metastases from breast cancer.
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Affiliation(s)
- Arif Ali Awan
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - Brian Hutton
- Department of Medicine and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - John Hilton
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - Sasha Mazzarello
- Cancer Research Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Lisa Vandermeer
- Cancer Research Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brianne Bota
- Cancer Research Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Carol Stober
- Cancer Research Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marta Sienkiewicz
- Cancer Research Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dean Fergusson
- Department of Medicine and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | | | - Mark Clemons
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada. .,Department of Medicine and School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada. .,Cancer Research Group, Ottawa Hospital Research Institute, Ottawa, Canada.
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Liu C, Wang L, Liu L, Zhuang J, Tang S, Zhang T, Zhou C, Feng F, Liu R, Zhang J, Zhang T, Gao C, Li H, Li J, Sun C. Efficacy and safety of de-escalation bone- modifying agents for cancer patients with bone metastases: a systematic review and meta-analysis. Cancer Manag Res 2018; 10:3809-3823. [PMID: 30288112 PMCID: PMC6159799 DOI: 10.2147/cmar.s176811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Compared with application of bone-modifying agents (BMAs) every 4 weeks, it is unclear whether 12-weekly de-escalated therapy can be used as a substitute strategy. Methods A systematic search of PubMed, EMBASE, and the Cochrane Register of Controlled Trials until November 22, 2017, was performed. Randomized controlled trials (RCTs) were included to assess skeletal-related event (SRE) rates, adverse events, and bone turnover biomarkers, comparing 12-weekly de-escalated treatments with standard 4-weekly dosage regimens. Risk ratios (RRs) with 95% CIs were pooled in fixed-effect meta-analyses. Results A total of eight citations were eligible comprising 2,878 patients: zoledronate (three studies, 2,650 patients), pamidronate (two studies, 68 patients), and denosumab (three studies, 160 patients). Summary RR (0.98; 95% CI 0.87–1.12; P=0.82) for SRE rates between de-escalated and standard arms was produced when seven low risk of bias trials (695 patients) were pooled, and results without statistical significance also appeared in the analysis of adverse events and bone turnover biomarkers. Due to the limited sample size and methodological differences, the data for skeletal morbidity rates (SMRs), time to first SRE, serum C-telopeptide (sCTx) levels, and hypocalcemia were not combined, but systematic review still obtained similar indistinguishableness. Conclusion In this meta-analysis of randomized clinical trials, the results “appeared” to show non-inferiority of the 12-weekly treatment. Due to the difference in available data, the results for bisphosphonates are more solid than for the receptor activator of nuclear factor-κB ligand (RANKL) antibodies.
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Affiliation(s)
- Cun Liu
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People's Republic of China
| | - Lu Wang
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People's Republic of China
| | - Lijuan Liu
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Jing Zhuang
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Shifeng Tang
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Tiansong Zhang
- Department of Traditional Chinese Medicine, Jing'an District Central Hospital, Shanghai, People's Republic of China
| | - Chao Zhou
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Fubin Feng
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Ruijuan Liu
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Jinmei Zhang
- Department of Endocrinology, Weifang Traditional Chinese Hospital, Weifang, Shandong, Province People's Republic of China
| | - Tingting Zhang
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People's Republic of China
| | - Chundi Gao
- First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People's Republic of China
| | - Huayao Li
- First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People's Republic of China
| | - Jia Li
- College of Basic Medicine, Weifang Medical University, Weifang, Shandong Province, People's Republic of China
| | - Changgang Sun
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China, .,Department of Oncology, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, People's Republic of China,
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Hilton JF, Clemons M, Pond G, Zhao H, Mazzarello S, Vandermeer L, Addison CL. Effects on bone resorption markers of continuing pamidronate or switching to zoledronic acid in patients with high risk bone metastases from breast cancer. J Bone Oncol 2017; 10:6-13. [PMID: 29204337 PMCID: PMC5709351 DOI: 10.1016/j.jbo.2017.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 02/02/2023] Open
Abstract
Background Switching patients who remain at high risk of skeletal related events (SREs) despite pamidronate to the more potent bisphosphonate zoledronate, may be an effective treatment strategy. As part of a previously reported clinic study in this setting, we evaluated whether biomarkers for bone resorption, such as Bone-Specific Alkaline Phosphatase (BSAP), bone sialoprotein (BSP), and N-terminal telopeptide (NTX) correlated with subsequent SRE risk. Methods Breast cancer patients who remained at high risk of SREs despite at least 3 months of q.3–4 weekly pamidronate were randomized to either continue on pamidronate or to switch to zoledronate (4 mg) once every 4 weeks for 12-weeks. High risk bone metastases were defined by either: occurrence of a prior SRE, bone pain, radiologic progression of bone metastases and/or serum C-terminal telopeptide (CTx) levels > 400 ng/L despite pamidronate use. Serum samples were collected at baseline and weeks 1, 4, 8 and 12 (CTx and BSAP) and baseline and week 12 (NTx and BSP), and all putative biomarkers were measured by ELISA. Follow up was extended to 2 years post trial entry for risk of subsequent SREs. The Kaplan-Meier method was used to estimate time-to-event outcomes. Generalized estimating equations (GEE) were used to evaluate if laboratory values over time or the change in laboratory values from baseline were associated with having a SRE within the time frame of this study. Results From March 2012 to May 2014, 76 patients were screened, with 73 eligible for enrolment. All 73 patients were available for biochemical analysis, with 35 patients receiving pamidronate and 38 patients receiving zoledronate. The GEE analysis found that no laboratory value was associated with having a subsequent SRE. Interaction between visit and laboratory values was also investigated, but no interaction effect was statistically significant. Only increased number of lines of prior hormonal treatment was associated with subsequent SRE risk. Conclusion Our analysis failed to find any association between serum BSAP, BSP, CTx or NTx levels and subsequent SRE risk in this cohort of patients. This lack of correlation between serum biomarkers and clinical outcomes could be due to influences of prior bisphosphonate treatment or presence of extra-osseous metastases in a significant proportion of enrolled patients. As such, caution should be used in biomarker interpretation and use to direct decision making regarding SRE risk for high risk patients in this setting.
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Affiliation(s)
- J F Hilton
- Division of Medical Oncology and Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - M Clemons
- Division of Medical Oncology and Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - G Pond
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - H Zhao
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - S Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - L Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - C L Addison
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
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Hortobagyi GN, Van Poznak C, Harker WG, Gradishar WJ, Chew H, Dakhil SR, Haley BB, Sauter N, Mohanlal R, Zheng M, Lipton A. Continued Treatment Effect of Zoledronic Acid Dosing Every 12 vs 4 Weeks in Women With Breast Cancer Metastatic to Bone: The OPTIMIZE-2 Randomized Clinical Trial. JAMA Oncol 2017; 3:906-912. [PMID: 28125763 DOI: 10.1001/jamaoncol.2016.6316] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Importance Zoledronic acid, a potent bisphosphonate, is commonly administered to patients with bone metastases to reduce the risk of skeletal-related events (SREs). However, there have been concerns regarding its long-term monthly administration. Objective To examine whether zoledronic acid every 12 weeks was noninferior to zoledronic acid every 4 weeks in patients with metastatic breast cancer that involved the bone who had previously received a standard dosing regimen of zoledronic acid and/or pamidronate disodium. Design, Setting, and Participants OPTIMIZE-2 was a prospective, randomized, double-blind, multicenter phase 3 trial of intention-to-treat (full analysis set), evaluable (per protocol), and safety populations. Patients were randomized (1:1) to receive 4.0 mg of intravenous zoledronic acid every 4 or every 12 weeks with placebo for interim infusions for 1 year. The study was conducted at 102 clinical trial centers in the United States from March 3, 2006, to July 25, 2013. Data analysis was performed from October 7, 2013, to March 24, 2014. The study randomized 416 women (≥18 years old) with bone metastases from breast cancer who previously received 9 or more doses of zoledronic acid and/or pamidronate during the first 10 to 15 months of therapy. Main Outcomes and Measures The primary end point was the proportion of patients with 1 or more SRE on study (SRE rate). The key secondary end points included time to first SRE and skeletal morbidity rate (SMR). Results A total of 416 women were randomized: 200 patients received zoledronic acid every 4 weeks (mean [SD] age, 59.2 [11.1] years; 173 were white [86.5%]), 203 patients received zoledronic acid every 12 weeks (mean [SD] age, 58.6 [11.2] years; 178 were white [87.7%]), and 13 patients received placebo (mean [SD] age, 60.8 [12.2] years; 13 were white [100%]). Baseline characteristics were similar in both zoledronic acid treatment arms. After 1 year of follow-up, SREs occurred in 44 patients (22.0%) in the zoledronic acid every 4 weeks group and 47 patients (23.2%) in the zoledronic acid every 12 weeks group (proportional difference of -1.2%; 1-sided 97.5% CI bound of the difference in SRE rate between arms, -9.8%; noninferiority P = .02). The time to first SRE between treatment groups was not statistically significantly different (hazard ratio [HR], 1.06; 95% CI, 0.70-1.60; P = .79). The mean (SD) SMR was 0.46 (1.06) vs 0.50 (1.50) events per year in the every 4 weeks vs every 12 weeks groups (P = .85). The safety profiles of the every 4 weeks and every 12 weeks groups were comparable, with 189 patients (95.5%) in the every 4 weeks group having at least 1 adverse event compared with 189 (93.5%) in the every 12 weeks group. Conclusions and Relevance The every 12 weeks regimen of zoledronic acid was noninferior to the every 4 weeks regimen for the proportion of patients experiencing 1 or more SRE. These results may have a substantial influence on current clinical practice for treatment of patients with bone metastasis from breast cancer. Trial Registration clinicaltrials.gov Identifier: NCT00320710.
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Affiliation(s)
- Gabriel N Hortobagyi
- Department of Breast Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston
| | - Catherine Van Poznak
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - William J Gradishar
- Department of Medicine-Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Helen Chew
- Department of Internal Medicine-Hematology/Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Shaker R Dakhil
- Department of Hematology/Oncology, Cancer Center of Kansas, Wichita
| | - Barbara B Haley
- Department of Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Nicholas Sauter
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, New Jersey
| | - Ramon Mohanlal
- Consultant, AstraZeneca, London, England10Consultant, BeyondSpring Pharmaceuticals, New York, New York
| | - Ming Zheng
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, New Jersey
| | - Allan Lipton
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Addison CL, Simos D, Wang Z, Pond G, Smith S, Robertson S, Mazzarello S, Singh G, Vandermeer L, Fernandes R, Iyengar A, Verma S, Clemons M. A phase 2 trial exploring the clinical and correlative effects of combining doxycycline with bone-targeted therapy in patients with metastatic breast cancer. J Bone Oncol 2016; 5:173-179. [PMID: 28008379 PMCID: PMC5154696 DOI: 10.1016/j.jbo.2016.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/14/2016] [Accepted: 06/28/2016] [Indexed: 11/25/2022] Open
Abstract
Background Bone-targeting agents (BTAs), such as bisphosphonates and denosumab, have demonstrated no discernable effects on tumour response or disease free/overall survival in patients with bone metastases from breast cancer. Doxycycline is both osteotropic and has anti-cancer effects. When combined with zoledronate in animal models, doxycycline showed significantly increased inhibition of tumour burden and increased bone formation. We evaluated the effects of adding doxycycline to ongoing anti-cancer therapy in patients with metastatic breast cancer. Methods Breast cancer patients with bone metastases and ≥3 months of BTA use, entered this single-arm study. Patients received doxycycline 100 mg orally, twice a day for 12 weeks. The co-primary endpoints were; effect on validated pain scores (FACT-Bone pain and Brief Pain Inventory) and bone resorption markers (serum C-telopeptide, [sCTx]). All endpoints (pain scores, sCTx, bone-specific alkaline phosphatase, skeletal-related events, toxicity) were evaluated at baseline, 4, 8 and 12 weeks. Bone marrow was sampled at baseline and week 12 for exploratory biomarker analysis. Results Out of 37 enroled patients, 27 (73%) completed 12 weeks of therapy. No significant changes were seen in pain scores or bone turnover markers. Failure to complete treatment: drug toxicity (70%) and disease progression (30%). Sixteen (43%) patients had GI adverse events. Conclusions Doxycycline 100 mg twice daily for 12 weeks had no significant effects on either bone pain or bone turnover markers. Its toxicity profile in this patient population would make further evaluation challenging.
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Affiliation(s)
- C L Addison
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - D Simos
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Z Wang
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - G Pond
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - S Smith
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - S Robertson
- Department of Pathology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - S Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - G Singh
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - L Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada
| | - R Fernandes
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - A Iyengar
- Division of Hematology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - S Verma
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - M Clemons
- Ottawa Hospital Research Institute and University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada; Division of Medical Oncology, The Ottawa Hospital Cancer Centre and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Fernandes R, Siegel P, Komarova S, Hilton J, Addison C, Ibrahim MFK, Werier J, Dennis K, Singh G, Amir E, Jarvis V, Emmenegger U, Mazzarello S, Clemons M. Future directions for bone metastasis research - highlights from the 2015 bone and the Oncologist new updates conference (BONUS). J Bone Oncol 2016; 5:57-62. [PMID: 27335772 PMCID: PMC4908181 DOI: 10.1016/j.jbo.2016.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 12/21/2022] Open
Abstract
In an era of reduced peer-reviewed grant funding, performing academic bone oncology-related research has become increasingly challenging. Over the last 10 years we have held an annual meeting to bring together clinicians, clinician/scientists and basic biomedical researchers interested in the effects of cancer and its treatment on skeletal tissues. In the past these "Bone and the Oncologist New Updates Conference (BONUS)" meetings have served as critical catalyst for initiating productive research collaborations between attendees. The 2015 BONUS meeting format focused on potential key research themes that could form the basis of a coordinated national research strategy to tackle unmet clinical and research needs related to complications associated with cancer metastasis to bone. The three themes planned for discussion were: Is bone metastases-related pain the main issue facing patients? Are there new therapeutic targets for patients with bone metastases? How do we more firmly link basic science with clinical practice? We present a summary of lectures and commentaries from the attendees to serve as an example that other similarly motivated groups can model and share their experiences. It is our hope that these presentations will result in comments, feedback and suggestions from all those researchers interested in this important area.
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Affiliation(s)
- Ricardo Fernandes
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Peter Siegel
- Department of Medicine, Goodman Cancer Research Centre, McGill University, Montreal, Canada
| | - Svetlana Komarova
- Department of Medicine, Goodman Cancer Research Centre, McGill University, Montreal, Canada
- Faculty of Dentistry, McGill University, Montreal, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Christina Addison
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Mohammed F K Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Joel Werier
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
- Department of Surgery, Division of Orthopaedic Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Kristopher Dennis
- Ottawa Hospital Division of Radiation Oncology and University of Ottawa, Ottawa, Ontario, Canada
| | | | - Eitan Amir
- Division of Medical Oncology, Department of Medicine, University Health Network and Princess Margaret Hospital and University of Toronto, Toronto, Canada
| | - Virginia Jarvis
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sasha Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
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13
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Ibrahim MFK, Mazzarello S, Shorr R, Vandermeer L, Jacobs C, Hilton J, Hutton B, Clemons M. Should de-escalation of bone-targeting agents be standard of care for patients with bone metastases from breast cancer? A systematic review and meta-analysis. Ann Oncol 2015; 26:2205-13. [PMID: 26122727 DOI: 10.1093/annonc/mdv284] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 06/24/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND De-escalation of bone-targeted agents, such as bisphosphonates and denosumab, from 4- to 12-weekly dosing is an increasingly used strategy in patients with bone metastases from breast cancer. It is unclear whether there is sufficient evidence to support de-escalation as a standard of care. METHODS A systematic review of randomized trials comparing standard 4-weekly administration of bone-targeted agents with de-escalated (Q12-weekly) dosing in breast cancer patients was carried out. Medline, PubMed and the Cochrane Register of Controlled Trials were searched from inception until November 2014 for relevant studies. Outcomes of interest included skeletal-related event (SRE) rates, bone pain, adverse events (AEs) and bone turnover biomarkers. Random-effects meta-analyses were carried out. RESULTS A total of nine citations representing seven unique studies were eligible. One study is ongoing with no reported data. Six studies reported data for at least one outcome of interest. Data were available comparing standard versus de-escalated therapy for pamidronate (1 study, 38 patients), zoledronate (3 studies, 1117 patients) and denosumab (2 studies, 284 patients). Meta-analysis of five trials reporting data for on-study SRE rates between standard (61/443 patients) and de-escalated (49/392 patients) arms produced a summary risk ratio of 0.90 (95% confidence interval 0.63-1.29). Meta-analyses of data for AEs and bone turnover biomarkers also showed no statistically significant differences between standard and de-escalated arms, though only limited numbers of patients and events were present for most analyses. CONCLUSION In this systematic review of studies of bisphosphonates and denosumab, there appears to be no difference in SREs or pain with de-escalated therapy. While a large, hopefully definitive study is ongoing, the data presented so far are consistent with de-escalation of bone-targeting agents becoming a standard of care for patients with bone metastases from breast cancer.
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Affiliation(s)
- M F K Ibrahim
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital
| | - S Mazzarello
- Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa
| | - R Shorr
- The Ottawa General Hospital, Ottawa, Canada
| | - L Vandermeer
- Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa
| | - C Jacobs
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital
| | - J Hilton
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa
| | - B Hutton
- Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa
| | - M Clemons
- Department of Medicine and Division of Medical Oncology, The Ottawa Hospital Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa
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Are adjuvant bisphosphonates now standard of care of women with early stage breast cancer? A debate from the Canadian Bone and the Oncologist New Updates meeting. J Bone Oncol 2015; 4:54-8. [PMID: 26579489 PMCID: PMC4620967 DOI: 10.1016/j.jbo.2015.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/14/2015] [Indexed: 01/07/2023] Open
Abstract
The 9th Bone and the Oncologist New Updates conference was held in Ottawa, Canada during 2014. This annual meeting focuses on innovative research into the mechanisms and consequences of treatment-induced and metastatic bone disease. Given the recent presentation of the Oxford overview's “Effects of bisphosphonate treatment on recurrence and cause-specific mortality in women with early breast cancer: A meta-analysis of individual patient data from randomized trials” at the San Antonio Breast Cancer Symposium, a debate as to the pro's and con's of adjuvant bisphosphonate use in early stage breast cancer was undertaken. As bisphosphonate treatment in post-menopausal women appeared to demonstrate a similar magnitude of benefit to that of other commonly used adjuvant strategies the debate assessed whether or not there was sufficient data to incorporate adjuvant bisphosphonates into standard practice and if so, in which patient populations.
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15
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Addison CL, Pond GR, Cochrane B, Zhao H, Chia SK, Levine MN, Clemons M. Correlation of baseline biomarkers with clinical outcomes and response to fulvestrant with vandetanib or placebo in patients with bone predominant metastatic breast cancer: An OCOG ZAMBONEY sub-study. J Bone Oncol 2015; 4:47-53. [PMID: 26579488 PMCID: PMC4620970 DOI: 10.1016/j.jbo.2015.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/16/2015] [Accepted: 04/17/2015] [Indexed: 12/14/2022] Open
Abstract
Background Bone metastases are common in women with breast cancer and often result in skeletal related events (SREs). As the angiogenic factor vascular endothelial growth factor (VEGF) regulates osteoclast activity and is associated with more extensive bone metastases and SRE risk in metastatic breast cancer, we hypothesized that blockade of VEGF signaling could be a therapeutic strategy for inhibiting bone metastases progression and possibly prolonging overall (OS) or progression-free survival (PFS). The Zamboney trial was a randomized placebo-controlled study designed to assess whether patients with bone predominant metastatic breast cancer benefited from addition of the VEGF receptor (VEGFR) targeting agent, vandetanib, to endocrine therapy with fulvestrant. As a companion study, evaluation of biomarkers and their potential association with response to vandetanib or SRE risk was performed. Methods Baseline overnight fasted serum from enrolled patients was analyzed for levels of various putative biomarkers including; VEGF-A, soluble (s)VEGFR2, sVEGFR3, transforming growth factor (TGF)-β1 and activinA by ELISA. Spearman correlation coefficients and Wilcoxon rank sum tests were used to investigate potential relationships between biomarker values and baseline clinical parameters. Prognostic and predictive ability of each marker was investigated using Cox proportional hazards regression with adjustments for treatment and baseline strata of serum CTx (<400 versus ≥400 ng/L). Results Of 129 enrolled patients, serum was available for analysis in 101; 51 in vandetanib and 50 in placebo arm. Mean age amongst consenting patients was 59.8 years. Clinical characteristics were not significantly different between patients with or without serum biomarker data and serum markers were similar for patients by treatment arm. Baseline sVEGFR2 was prognostic for OS (HR=0.77, 95% CI=0.61–0.96, p=0.020), and although a modest association was observed, it was not significant for PFS (HR=0.90, 95% CI=0.80–1.01, p=0.085) nor time to first SRE (HR=0.82, 95% CI=0.66–1.02, p=0.079). When interaction terms were evaluated, sVEGFR2 was not found to be predictive of response to vandetanib, although a modest association remained with respect to PFS (interaction p=0.085). No other marker showed any significant prognostic or predictive ability with any measured outcome. Conclusions In this clinical trial, sVEGFR2 appeared prognostic for OS, hence validation of sVEGFR2 should be conducted. Moreover, the role of sVEGFR2 in breast cancer bone metastasis progression should be elucidated. Baseline VEGF, sVEGFR3, TGF-β or activinA were not associated with clinical outcomes in patients treated with fulvestrant in conjunction with vandetanib or placebo. Baseline sVEGFR2 was modestly associated with clinical outcomes including PFS, OS and time to first skeletal event. Increased baseline sVEGFR2 was associated with improved clinical outcomes in this study sample. These findings support the need for future studies of the role of sVEGFR2 in bone metastasis progression.
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Key Words
- BP, bisphosphonate
- BPI, brief pain inventory
- Biomarker
- Bone metastasis
- Breast cancer
- CTx, C-telopeptide
- ER, estrogen receptor
- FACT-BP, Functional assessment of cancer therapy-bone pain
- OS, overall survival
- PFS, progression free survival
- PR, progesterone receptor
- Patient outcome
- RANKL, Receptor Activator NF-KB ligand
- SRE, skeletal related event
- Skeletal related event
- TGF-β, transforming growth factor beta
- VEGF, vascular endothelial growth factor
- Vandetanib
- sVEGFR, soluble vascular endothelial growth factor receptor
- uNTx, urinary N-telopeptide
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Affiliation(s)
- Christina L Addison
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Box 926, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 ; Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Department of Biochemistry, Microbiology and Immunology University of Ottawa, Ottawa, ON, Canada
| | - Gregory R Pond
- McMaster University and Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | - Brandy Cochrane
- McMaster University and Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | - Huijun Zhao
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Box 926, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
| | | | - Mark N Levine
- McMaster University and Ontario Clinical Oncology Group, Hamilton, ON, Canada
| | - Mark Clemons
- Program for Cancer Therapeutics, Ottawa Hospital Research Institute, Box 926, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 ; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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