Dose-dense adjuvant chemotherapy for primary breast cancer

The protective effect of vitamin D on ovarian reserve and anti-mullerian hormone in patients undergoing chemotherapy for breast cancer, a randomized phase ΙΙ clinical trial

BACKGROUND

Reduced ovarian reserve is among the crucial long-term side effects of using chemotherapy agents in breast cancer, yielding early ovarian failure. On the other hand, vitamin D is an essential factor in protecting the follicles and an important predictive factor for successful IVF therapy.

AIM

The aim of this study is evaluation of vitamin D as a agent that can reduce fertility complications of chemotherapy specially in young women.

METHODS

Breast cancer patients undergoing chemotherapy at two cancer institutes were enrolled in this study. The case group received 1000 IU of calcitriol, and the AMH level was measured at the baseline, after chemotherapy, and six months after chemotherapy. The primary end point was improvement in the AMH level after six months of chemotherapy. the secondary endpoint was to evaluate the predictive factors of AMH level decline during chemotherapy.

RESULTS

Between 2018 and 2019, 18 and 15 patients were enrolled in the case and control groups, respectively. The mean AMH level (ngr/ml) of the patients in the case and control group were 3.16 and 2.37 ng/mL, respectively (p-value = .16). These levels were 0.387 and 0.19 after six months (p-value = .38). The AMH rise immediately after chemotherapy cycles to six months after chemotherapy, in the case and control groups were 0.86 and 0.44 ng/mL, respectively, which was slightly higher in the case group but not statistically significant between two groups (p-value = .054).

CONCLUSION

Despite a minimal rise in the AMH level after six months of chemotherapy, the study could not demonstrate any protective effect of vitamin D on patients' ovarian reserve undergoing chemotherapy for breast cancer. Further larger studies are needed to evaluate the effect of vitamin D supplements on ovarian reserve beside optimal dose and duration.

Systemic Administration of Cowpea Mosaic Virus Demonstrates Broad Protection Against Metastatic Cancers

The key challenge in cancer treatment is prevention of metastatic disease which is therapeutically resistant and carries poor prognoses necessitating efficacious prophylactic approaches that prevent metastasis and recurrence. It is previously demonstrated that cowpea mosaic virus (CPMV) induces durable antitumor responses when used in situ, i.e., intratumoral injection. As a new direction, it is showed that CPMV demonstrates widespread effectiveness as an immunoprophylactic agent - potent efficacy is demonstrated in four metastatic models of colon, ovarian, melanoma, and breast cancer. Systemic administration of CPMV stimulates the innate immune system, enabling attack of cancer cells; processing of the cancer cells and associated antigens leads to systemic, durable, and adaptive antitumor immunity. Overall, CPMV demonstrated broad efficacy as an immunoprophylactic agent in the rejection of metastatic cancer.

Local dose-dense chemotherapy for triple-negative breast cancer via minimally invasive implantation of 3D printed devices

Dose-dense chemotherapy is the preferred first-line therapy for triple-negative breast cancer (TNBC), a highly aggressive disease with a poor prognosis. This treatment uses the same drug doses as conventional chemotherapy but with shorter dosing intervals, allowing for promising clinical outcomes with intensive treatment. However, the frequent systemic administration used for this treatment results in systemic toxicity and low patient compliance, limiting therapeutic efficacy and clinical benefit. Here, we report local dose-dense chemotherapy to treat TNBC by implanting 3D printed devices with time-programmed pulsatile release profiles. The implantable device can control the time between drug releases based on its internal microstructure design, which can be used to control dose density. The device is made of biodegradable materials for clinical convenience and designed for minimally invasive implantation via a trocar. Dose density variation of local chemotherapy using programmable release enhances anti-cancer effects in vitro and in vivo. Under the same dose density conditions, device-based chemotherapy shows a higher anti-cancer effect and less toxic response than intratumoral injection. We demonstrate local chemotherapy utilizing the implantable device that simulates the drug dose, number of releases, and treatment duration of the dose-dense AC (doxorubicin and cyclophosphamide) regimen preferred for TNBC treatment. Dose density modulation inhibits tumor growth, metastasis, and the expression of drug resistance-related proteins, including p-glycoprotein and breast cancer resistance protein. To the best of our knowledge, local dose-dense chemotherapy has not been reported, and our strategy can be expected to be utilized as a novel alternative to conventional therapies and improve anti-cancer efficiency.

Implantable smart hyperthermia nanofibers for cancer therapy: Challenges and opportunities

Nanofibers (NFs) with practical drug-loading capacities, high stability, and controllable release have caught the attention of investigators due to their potential applications in on-demand drug delivery devices. Developing novel and efficient multidisciplinary management of locoregional cancer treatment through the design of smart NF-based systems integrated with combined chemotherapy and hyperthermia could provide stronger therapeutic advantages. On the other hand, implanting directly at the tumor area is a remarkable benefit of hyperthermia NF-based drug delivery approaches. Hence, implantable smart hyperthermia NFs might be very hopeful for tumor treatment in the future and provide new avenues for developing highly efficient localized drug delivery systems. Indeed, features of the smart NFs lead to the construction of a reversibly flexible nanostructure that enables hyperthermia and facile switchable release of antitumor agents to eradicate cancer cells. Accordingly, this study covers recent updates on applications of implantable smart hyperthermia NFs regarding their current scope and future outlook. This article is categorized under: Implantable Materials and Surgical Technologies > Nanomaterials and Implants.

Dose-dense Paclitaxel and Carboplatin as Neoadjuvant Chemotherapy for Stage IIB/IIIA Non-small Cell Lung Cancer - A Phase II trial

AIMS

The approach to potentially resectable non-small cell lung cancer (NSCLC) remains controversial. There is a benefit of neoadjuvant chemotherapy (NACT), but the ideal regimen is unknown. We evaluated the efficacy and safety of dose-dense NACT in potentially resectable NSCLC in this phase II trial.

MATERIALS AND METHODS

Paclitaxel at 80 mg/m² on days 1, 8 and 15 with AUC-6 carboplatin on day 1, 3 weekly for four cycles was evaluated as NACT. Patients with Eastern Cooperative Oncology Group performance status 0-2, stage IIB and IIIA (with only non-bulky N2 nodes) were included. The primary end point was the objective response rate. Secondary end points included toxicity, progression-free survival, recurrence-free survival, complete resection rate and overall survival. The relative dose intensity (RDI) was calculated to define tolerability (CTRI/2016/05/006916).

RESULTS

In total, 37 patients were enrolled (median age 55 years). Most (78.8%) were smokers. Most patients had adenocarcinoma (57.6%) and stage IIIA disease (81.0%) according to the seventh American Joint Committee on Cancer staging system. Seventy-eight per cent of patients completed four cycles. The objective response rate was 75.6% with a complete response in 10.8%. The mean RDI of paclitaxel was 88.61%, with 68.0% of patients able to maintain an RDI ≥85.0%. In total, 187 toxicity events were recorded (120 grade 1, 64 grade 2 and three grade 3 events). Common toxicities were peripheral neuropathy (20.3%), myalgia (19.8%), nausea (15.7%) and neutropenia (10.2%). There were no treatment-related deaths. Seventeen patients underwent surgery (lobectomy 82.4%). After a median follow-up of 47 months (95% confidence interval 27-50.7 months), the median progression-free survival was 9.6 months (7.4-17.4) and overall survival was 29.2 months (16.0-37.2).

CONCLUSION

Dose-dense paclitaxel-carboplatin is feasible, safe and efficacious and should be evaluated further in potentially resectable NSCLC.

Early breast cancer patients benefit more from longer course chemotherapy: a matched-pair analysis

Aim: Benefit of longer course of taxane-anthracycline-based adjuvant chemotherapy is yet to be identified. Patients & methods: We conducted a retrospectively matched-pair analysis to compare four cycles of fluorouracil, epirubicin and cyclophosphamide followed by four cycles of docetaxel (4FEC-4T) with three cycles of FEC followed by three cycles of docetaxel (3FEC-3T) as adjuvant chemotherapy for early-stage breast cancer. One hundred and thirty-seven patients treated with 4FEC-4T were matched to 411 in 3FEC-3T. The primary end point was event-free survival (EFS). The secondary end point was distant disease-free survival (DDFS). Results: The 4FEC-4T resulted in significantly longer EFS than matched 3FEC-3T (p = 0.020). Furthermore, DDFS was superior in the 4FEC-4T to that in the 3FEC-3T (p = 0.046). Conclusion: Extending taxane-anthracycline-based regimens with identical schedules significantly improves EFS and DDFS for early-stage breast cancer.

Alternating Magnetic Field-Triggered Switchable Nanofiber Mesh for Cancer Thermo-Chemotherapy

We have developed a smart anti-cancer fiber mesh that is able to control tumor-killing activity against lung adenocarcinoma precisely. The mesh is capable of carrying large loads of chemotherapeutic drug, paclitaxel (PTX), as well as magnetic nanoparticles (MNPs). The mesh generates heat when the loaded MNPs are activated in an alternating magnetic field (AMF). The mesh is thermo-responsive, so the heat generated can be also used to trigger PTX release from the mesh. An electrospinning method was employed to fabricate the mesh using a copolymer of N-isopropylacrylamide and N-hydroxymethylacrylamide, the phase transition temperature of which was adjusted to the mild-hyperthermia temperature range around 43 °C. In vitro anti-tumor studies demonstrated that both MNP- and PTX-loaded mesh killed about 66% of cells, whereas only PTX-loaded mesh killed about 43% of cells. In a mouse lung cancer model, the thermo-chemotherapy combo displayed enhanced anti-tumor activity and the systemic toxic effects on mice were eliminated due to local release of the chemotherapeutic agents. The proposed fiber system might provide a blueprint to guide the design of the next generation of local drug delivery systems for safe and effective cancer treatment.

Insights Into Breast Cancer Screening: A Computer Simulation of Two Contemporary Screening Strategies

OBJECTIVE

The debate over the value of screening mammography is rekindled with each new published study or guideline. Central to the discussion are the uncertainties about screening benefits and harms and the criteria used to assess them. Today, the magnitude of benefits for a population is less certain, and the evolving concept of harm has come to encompass false-positives (FPs), unnecessary biopsies, overdiagnosis, and overtreatment. This study uses a Monte Carlo computer simulation to study the balance of benefits and harms of mammographic breast cancer screening for average-risk women.

MATERIALS AND METHODS

This investigation compares the American Cancer Society's 2015 mixed annual-biennial guideline with the U.S. Preventive Services Task Force's 2016 fixed biennial guideline. Screening strategies are compared using cost-effectiveness acceptability curves, an economic analysis describing uncertainty in evaluating costs and health outcomes. Strategy preference is examined under changing assumptions of willingness to pay for a quality-adjusted life-year. Additionally, comparative effectiveness analysis is performed using FP screens and unnecessary biopsies per life-year gained. Alternative scenarios are compared assuming a reduced mortality benefit of screening.

RESULTS

In general, results using both cost-effectiveness and clinical measures indicate that American Cancer Society's 2015 mixed annual-biennial guideline is preferred. Assuming decreases in the mortality benefit of mammography, no screening may be reasonable.

CONCLUSION

The use of a mixed annual-biennial strategy for population screening takes advantage of the nonuniformity of occurrence of mammography benefits and harms over the duration of screening. This approach represents a step toward improving guidelines by exploiting age dependencies at which benefits and harms accrue.

A Predictive Mathematical Modeling Approach for the Study of Doxorubicin Treatment in Triple Negative Breast Cancer

Doxorubicin forms the basis of chemotherapy regimens for several malignancies, including triple negative breast cancer (TNBC). Here, we present a coupled experimental/modeling approach to establish an in vitro pharmacokinetic/pharmacodynamic model to describe how the concentration and duration of doxorubicin therapy shape subsequent cell population dynamics. This work features a series of longitudinal fluorescence microscopy experiments that characterize (1) doxorubicin uptake dynamics in a panel of TNBC cell lines, and (2) cell population response to doxorubicin over 30 days. We propose a treatment response model, fully parameterized with experimental imaging data, to describe doxorubicin uptake and predict subsequent population dynamics. We found that a three compartment model can describe doxorubicin pharmacokinetics, and pharmacokinetic parameters vary significantly among the cell lines investigated. The proposed model effectively captures population dynamics and translates well to a predictive framework. In a representative cell line (SUM-149PT) treated for 12 hours with doxorubicin, the mean percent errors of the best-fit and predicted models were 14% (±10%) and 16% (±12%), which are notable considering these statistics represent errors over 30 days following treatment. More generally, this work provides both a template for studies quantitatively investigating treatment response and a scalable approach toward predictions of tumor response in vivo.

The dose-dense principle in chemotherapy

Chemotherapy is a cancer treatment modality that uses drugs to kill tumor cells. A typical chemotherapeutic protocol consists of several drugs delivered in cycles of three weeks. We present mathematical analyses demonstrating the existence of a maximum time between cycles of chemotherapy for a protocol to be effective. A mathematical equation is derived, which relates such a maximum time with the variables that govern the kinetics of the tumor and those characterizing the chemotherapeutic treatment. Our results suggest that there are compelling arguments supporting the use of dose-dense protocols. Finally, we discuss the limitations of these protocols and suggest an alternative.

Efficacy, safety and proper dose analysis of PEGylated granulocyte colony-stimulating factor as support for dose-dense adjuvant chemotherapy in node positive Chinese breast cancer patients

For high-risk breast cancer patients with positive axillary lymph nodes, dose-dense every-two-week epirubicin/cyclophosphamide-paclitaxel (ddEC-P) regimen is the optimal postoperative adjuvant therapy. However, this regimen is limited by the grade 3/4 neutropenia and febrile neutropenia (FN). There is an urgent need to explore the efficacy, safety and proper dosage of PEGylated granulocyte colony-stimulating factor (PEG-G-CSF) as support for ddEC-P in Chinese breast cancer patients with positive axillary lymph nodes. Prospectively, 40 women with stage IIIA to IIIC breast cancer received ddEC-P ± trastuzumab as adjuvant treatment. PEG-G-CSF was injected subcutaneously in a dose of 6 mg or 3 mg on the 2^th day of each treatment cycle. With administration of PEG-G-CSF, all of the 40 patients completed 8 cycles of ddEC-P ± trastuzumab regimen without dose reductions or treatment delays. Moreover, no FN cases were observed. Further analysis showed that the proper dosage of PEG-G-CSF was 6 mg for ddEC treatment, and 3 mg for ddP treatment. PEG-G-CSF exhibits advantages compared with G-CSF in convenient of administration and tolerance for high risk Chinese breast cancer patients. More importantly, the proper dose of PEG-G-CSF for high risk Chinese breast cancer patients during ddEC-P chemotherapy may be 6 mg for ddEC treatment and 3 mg for ddP treatment.

Model-based meta-analysis for quantifying Paclitaxel dose response in cancer patients

Model-based meta-analysis of dose response is a sophisticated method to guide dose and regimen selection. In this report, the effects of paclitaxel dose and regimen (weekly or every 3 weeks) on the efficacy and safety in cancer patients were quantified by model-based meta-analysis of 29 monotherapy trials. Logistic regression models were developed to assess the relationship between dose and objective response rate or neutropenia rate. Survival models were developed to assess the relationship between dose and overall survival or progression-free survival. Paclitaxel efficacy (e.g., objective response rate, median overall survival, and progression-free survival) is correlated with average dose per week (mg/m²/week), whereas safety (e.g., neutropenia rate) is correlated with dose per administration (mg/m²). Weekly paclitaxel regimen at 65–80 mg/m² is supported to have comparable to better efficacy and lower neutropenia incidence than an every-3-week regimen at 175 mg/m².

Rationale for ablation of oligometastatic disease and the role of stereotactic body radiation therapy for hepatic metastases

Management paradigms for metastatic solid tumors are evolving. Once regarded as uniformly incurable, today there is recognition of an intermediate oligometastatic state, where ablation of metastatic foci may improve disease control and prolong survival. In the setting of limited colorectal liver metastases, hepatic resection has resulted in favorable long-term outcomes, but is technically unsuitable for most patients. Stereotactic body radiation therapy represents an effective, noninvasive means of tumor ablation, supported by a large body of prospective evidence specific to hepatic metastases. This review examines the current rationale for ablation of oligometastatic disease, including various objectives beyond indefinite disease-free survival. The role of stereotactic body radiation therapy for ablation of hepatic metastases is then comprehensively reviewed.

Center of cancer systems biology second annual workshop--tumor metronomics: timing and dose level dynamics

Metronomic chemotherapy, the delivery of doses in a low, regular manner so as to avoid toxic side effects, was introduced over 12 years ago in the face of substantial clinical and preclinical evidence supporting its tumor-suppressive capability. It constituted a marked departure from the classic maximum-tolerated dose (MTD) strategy, which, given its goal of rapid eradication, uses dosing sufficiently intense to require rest periods between cycles to limit toxicity. Even so, upfront tumor eradication is frequently not achieved with MTD, whereupon a de facto goal of longer-term tumor control is often pursued. As metronomic dosing has shown tumor control capability, even for cancers that have become resistant to the same drug delivered under MTD, the question arises whether it may be a preferable alternative dosing approach from the outset. To date, however, our knowledge of the coupled dynamics underlying metronomic dosing is neither sufficiently well developed nor widely enough disseminated to establish its actual potential. Meeting organizers thus felt the time was right, armed with new quantitative approaches, to call a workshop on "Tumor Metronomics: Timing and Dose Level Dynamics" to explore prospects for gaining a deeper, systems-level appreciation of the metronomics concept. The workshop proved to be a forum in which experts from the clinical, biologic, mathematical, and computational realms could work together to clarify the principles and underpinnings of metronomics. Among other things, the need for significant shifts in thinking regarding endpoints to be used as clinical standards of therapeutic progress was recognized.

Accelerated BEP: a phase I trial of dose-dense BEP for intermediate and poor prognosis metastatic germ cell tumour

Background:

We used bleomycin, etoposide, cisplatin (BEP), the most effective regimen in the treatment of germ cell tumours (GCTs) and increased dose-density by using pegfilgrastim to shorten cycle length. Our aim was to assess safety and tolerability.

Methods:

Sixteen male patients with intermediate or poor prognosis metastatic GCT were treated with four cycles of 3-day BEP with G-CSF on a 14-day cycle for a planned relative dose-density of 1.5 compared with standard BEP.

Results:

Eleven intermediate and five poor prognosis patients were treated. In all, 14 of 16 patients completed the study treatment. Toxicities were comparable to previous studies using standard BEP, except for mucositis and haematological toxicity that were more severe. The overall relative dose-density for all 16 patients was mean 1.38 (range 0.72–1.5; median 1.46). Complete response was achieved after chemotherapy alone in two patients (13%) and following chemotherapy plus surgery in nine additional patients (56%). Four patients (25%) had a partial response and normalised their marker levels. At a median follow-up of 4.4 years (range 2.1–6.8) the estimated 5-year progression-free survival probability is 81% (95% CI 64–100%).

Conclusion:

Accelerated BEP is tolerable without major additional toxicity. A randomised controlled trial will be required to obtain comparative efficacy data.

Rhodiola algida improves chemotherapy-induced oral mucositis in breast cancer patients

OBJECTIVE

Oral ulcerative mucositis, a common adverse effect due to mainstream cytotoxic drugs, limits the nutritional intake of cancer patients. Rhodiola algida is widely used in traditional Chinese medicine to stimulate the immune system. The aim of this study is to investigate the effect of this herbal extract on healthy human lymphocytes in vitro, the homeostasis of cancer patients and the healing time of oral ulcers.

METHOD

The constituents of Rhodiola algida were analyzed by RP-HPLC. Lymphocytes isolated from 462 healthy subjects were treated with 100 ug/ml Rhodiola algida for 48 h. The activity of the cells was measured by cell proliferation reagent and ATP assay. The level of various cytokines and mRNA content of lymphocytes were determined. Rhodiola algida demonstrated no toxicity in animals, which had been orally fed with 1 mg/ml Rhodiola algida for 30 days. 130 breast cancer patients from Huaxi Hospital of Sichuan University were recruited between 2006 and 2007. They received four cycles of 5-fluorouracil, epirubicin and cyclophosphamide after modified total mastectomy. These patients were randomly assigned to test and control groups. Rhodiola algida mixture was consumed by the test group for 14 consecutive days after each cycle of chemotherapy. All patients were given 0.2% chlorohexidine mouth wash to be used every day. Complete blood counts, liver and renal function tests together with the number and size of oral ulcerations were analyzed after each cycle. Weight loss, complaints of nausea or vomiting and degree of pain were noted.

RESULTS

The optimal concentration of Rhodiola algida favored the proliferation of lymphocytes. The levels of IL-2, IL-4, granulocyte-macrophage colony-stimulating factor and the mRNA content of these cytokines were also enhanced. White blood cell (WBC) levels returned to normal range in both groups 1 week after every cycle of chemotherapy. WBC count increased faster in patients using Rhodiola algida; they presented with smaller and fewer oral ulcers. There were no liver or renal complications observed in any patients.

CONCLUSION

Rhodiola algida increases immunity of patients who are receiving chemotherapy post mastectomy and decreases the quantity of oral ulcers. Thus Rhodiola algida has the potential to be used concurrently with chemotherapy to alleviate the occurrence of oral ulcers.

Systems engineering medicine: engineering the inflammation response to infectious and traumatic challenges

The complexity of the systemic inflammatory response and the lack of a treatment breakthrough in the treatment of pathogenic infection demand that advanced tools be brought to bear in the treatment of severe sepsis and trauma. Systems medicine, the translational science counterpart to basic science's systems biology, is the interface at which these tools may be constructed. Rapid initial strides in improving sepsis treatment are possible through the use of phenomenological modelling and optimization tools for process understanding and device design. Higher impact, and more generalizable, treatment designs are based on mechanistic understanding developed through the use of physiologically based models, characterization of population variability, and the use of control-theoretic systems engineering concepts. In this review we introduce acute inflammation and sepsis as an example of just one area that is currently underserved by the systems medicine community, and, therefore, an area in which contributions of all types can be made.

Maitake beta-glucan promotes recovery of leukocytes and myeloid cell function in peripheral blood from paclitaxel hematotoxicity

Bone marrow myelotoxicity is a major limitation of chemotherapy. While granulocyte colony stimulating factor (G-CSF) treatment is effective, alternative approaches to support hematopoietic recovery are sought. We previously found that a beta-glucan extract from maitake mushroom Grifola frondosa (MBG) enhanced colony forming unit-granulocyte monocyte (CFU-GM) activity of mouse bone marrow and human hematopoietic progenitor cells (HPC), stimulated G-CSF production and spared HPC from doxorubicin toxicity in vitro. This investigation assessed the effects of MBG on leukocyte recovery and granulocyte/monocyte function in vivo after dose intensive paclitaxel (Ptx) in a normal mouse. After a cumulative dose of Ptx (90-120 mg/kg) given to B6D2F1mice, daily oral MBG (4 or 6 mg/kg), intravenous G-CSF (80 microg/kg) or Ptx alone were compared for effects on the dynamics of leukocyte recovery in blood, CFU-GM activity in bone marrow and spleen, and granulocyte/monocyte production of reactive oxygen species (ROS). Leukocyte counts declined less in Ptx + MBG mice compared to Ptx-alone (p = 0.024) or Ptx + G-CSF treatment (p = 0.031). Lymphocyte levels were higher after Ptx + MBG but not Ptx + G-CSF treatment compared to Ptx alone (p < 0.01). MBG increased CFU-GM activity in bone marrow and spleen (p < 0.001, p = 0.002) 2 days after Ptx. After two additional days (Ptx post-day 4), MBG restored granulocyte/monocyte ROS response to normal levels compared to Ptx-alone and increased ROS response compared to Ptx-alone or Ptx + G-CSF (p < 0.01, both). The studies indicate that oral MBG promoted maturation of HPC to become functionally active myeloid cells and enhanced peripheral blood leukocyte recovery after chemotoxic bone marrow injury.

Tumor growth instability and its implications for chemotherapy

Optimal delivery of chemotherapy intensity is dependent on host- and tumor-specific characteristics. In this article, the chemotherapy late intensity schedule is revised to account for tumor growth instability, where a small tumor cell fraction emerges that exhibits a higher proliferation rate than the parent strain. Modeling this instability as simplified two-population dynamics, we find that: (a) if this instability precedes the onset of treatment, the slope of the linear increase of the drug concentration for the standard "Norton-Simon late intensity schedule" changes and the initial value of the dose strongly depends on the ratio of the two tumor cell populations and on their distinct growth rates; and (b) if the instability trails the initial treatment, the effective chemotherapeutic drug concentration changes as well. Both cases point toward testable potential refinements of the Norton-Simon late intensity schedule.

Gemcitabine and taxanes in metastatic breast cancer: a systematic review

Incremental advances over the last two decades in the treatment of stage IV metastatic breast cancer (MBC) have resulted in significantly prolonging the average life expectancy. In 2008, the estimated 5-year relative survival rate for MBC is 27% which compares favorably to rates in stage IV lung (3%) and pancreatic cancers (1%). Despite these advances, MBC remains an incurable disease, often associated with many symptoms and a decreased quality of life (QoL). Therefore, therapy goals in the treatment of MBC include prolonging both progression-free survival and overall survival rates, while at the same time improving QoL by palliation of symptoms. Therefore, systemic chemotherapy ideally should not induce unnecessary toxicities. Once chemotherapy is indicated, a number of drugs and regimens are available but only a few offer both palliation of symptoms (responses to therapy) and overall survival benefit. The addition of novel biologic compounds to chemotherapy has been shown in phase III trials to improve all the above mentioned clinical outcomes in MBC. This review will discuss data supporting the use of gemcitabine/taxane combinations in the treatment of MBC.

A phase II trial of vinorelbine and intensive temozolomide for patients with recurrent or progressive brain metastases

PURPOSE

To investigate the efficacy and safety of the combination of vinorelbine and intensive temozolomide for recurrent or progressive brain metastases from solid tumors.

METHODS

Patients > or =18 years of age and with Karnofsky performance scale (KPS) > or = 60, adequate organ function and progressive or recurrent brain metastases were eligible. This was a phase II trial with 28-day cycles using temozolomide (150 mg/m(2), days 1-7 and 15-21) and vinorelbine 25 or 30 mg/m(2 )on days one and eight. The primary endpoint was objective radiographic response.

RESULTS

Thirty-eight patients (15 men, 23 women) with a median age of 57 years (range, 39-75) and median KPS of 80 were enrolled. The primary tumor sites were lung (n = 20), breast (n = 11), colorectal (n = 2), kidney (n = 2), bladder (n = 1), endometrium (n = 1), head and neck (n = 1). Prior therapies included chemotherapy (97%), whole-brain radiation therapy (79%), brain metastasis resection (53%) and stereotatic radiosurgery (47%). Objective radiographic response rate was 5% (one complete response and one minor response); five patients had stable disease, 29 progressive disease and two patients were not evaluable. Twenty-nine patients (76%) have died and the median follow-up of survivors was six months. Median progression-free and overall survivals were 1.9 and 5 months, respectively. Grade 3/4 toxicities were mainly hematological and two patients discontinued the study due to myelosuppression.

CONCLUSIONS

In this heavily pretreated population of patients with brain metastases, adding vinorelbine and increasing the intensity of temozolomide do not improve response rates compared to previous studies with single-agent temozolomide at standard doses.

Extracranial Radiosurgery (Stereotactic Body Radiation Therapy) for Oligometastases

Extracranial radiosurgery, also known as stereotactic body radiation therapy (SBRT), is an increasingly used method of treatment of limited cancer metastases located in a variety of organs/sites including the spine, lungs, liver, and other areas in the abdomen and pelvis. The techniques used to perform SBRT were initially modeled after intracranial radiosurgery, although considerable evolution in technique and conduct has occurred for extracranial applications. Unlike intracranial radiosurgery, SBRT requires characterization and accounting for inherent organ movement including breathing motion. Potent dose hypofractionation schedules have been used with SBRT such that the treatment is generally both ablative and convenient. Because the treatment is severely damaging to tissues within and about the target, the volume of adjacent normal tissue must be strictly minimized to avoid toxic late effects. Outcomes in various sites show very high rates of local control with toxicity mostly related to tubular tissues like the airways and bowels. With proper conduct though, SBRT can be an extremely effective treatment option for oligometastases.