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Adesoye T, Liao K, Peterson S, Li L, Zorzi D, Holmes HM, Chavez‐MacGregor M, Giordano SH. Patient-reported outcomes in older breast cancer survivors with and without prior chemotherapy treatment. Cancer Med 2023; 12:17740-17752. [PMID: 37551136 PMCID: PMC10524015 DOI: 10.1002/cam4.6394] [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: 02/05/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Little is known about long-term treatment-related symptoms in older breast cancer survivors. We characterized long-term patient-reported symptoms and examined factors associated with the presence and severity of symptoms, and symptom interference with daily activities. METHODS Texas Cancer Registry (TCR) Medicare linkage data was used to identify breast cancer patients age 65 and older with local/regional stage disease diagnosed between 2012-2013. Symptom burden was assessed using breast-specific items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™). Demographic and clinical data also were collected. Logistic regression models were used to assess the association between symptom burden and respondent sociodemographic and clinical characteristics. RESULTS Of 4448 eligible patients, 1594 (response-rate 35.8%) completed questionnaires. Of these, 1245 eligible respondents were included in the analysis based on self-reported data. Median time from diagnosis to survey completion was 68 months (IQR: 62-73). Most frequently reported symptoms were fatigue/lack of energy (76.8%), aching muscles (72.1%) and aching joints (72.5%). Receipt of chemotherapy was associated with higher symptom burden. Patients treated with adjuvant chemotherapy had higher risk of numbness/tingling (OR: 3.16; 95% CI: 2.36-4.24), hair loss (OR: 2.72; 95% CI: 2.05-3.60), and fatigue/lack of energy (OR: 1.80; 95% CI: 1.29-2.52). Similarly, patients who received chemotherapy were more likely to report the majority of symptoms as moderate to severe and as interfering with daily activities. CONCLUSION Receipt of chemotherapy is associated with significant symptom burden more than 5 years after breast cancer treatment. Long-term chemotherapy impact should be discussed with patients in a shared-decision making process and approaches to symptom management during survivorship care are needed.
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Affiliation(s)
- Taiwo Adesoye
- Department of Breast Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kai‐Ping Liao
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Susan Peterson
- Department of Behavioral Science, Division of Cancer Prevention and Population SciencesThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Liang Li
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Daria Zorzi
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Holly M. Holmes
- Division of Geriatric and Palliative Medicine, Department of Internal MedicineUniversity of Texas Houston McGovern Medical SchoolHoustonTexasUSA
| | - Mariana Chavez‐MacGregor
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Breast Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sharon H. Giordano
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Breast Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Abstract
Dr. Bernard Fisher (1918-2019) was an early proponent of evidence-based medicine using the mechanism of prospective, multicenter, randomized clinical trials to test biological and clinical hypotheses. In this article, I trace how his early scientific work in striving to understand the nature of cancer metastasis through animal experiments led to a new, testable, clinical hypothesis: that surgery to remove only the tumor and a small amount of tissue around it was as effective as the more disfiguring operations that were then the standard treatment. Fisher's work with the National Surgical Adjuvant Breast and Bowel Project (NSABP) using large, randomized clinical trials to demonstrate the veracity of this hypothesis led to a new paradigm in which the emphasis was placed on how systemic therapies used at an early stage of disease could effectively eradicate breast cancer for many patients. This new therapeutic approach led to the successful development of new treatments, many of which are widely used today. Ultimately, the new paradigm led to successfully preventing breast cancer in women who were at high risk for the disease but who had not yet been diagnosed with the disease. Throughout his entire career, Fisher championed the use of large prospective, randomized clinical trials despite criticism from many in the medical community who strongly criticized his use of randomization as a mechanism for testing clinical hypotheses. The approach he and the NSABP employed is still considered to be the highest standard of evidence in conducting clinical studies.
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Affiliation(s)
- Stewart Anderson
- University of Pittsburgh Graduate School of Public Health - Biostatistics, Pittsburgh, PA, USA
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Wan L, Yin J, Skoko J, Schwartz R, Zhang M, LeDuc PR, Neumann CA. 3D Collagen Vascular Tumor-on-a-Chip Mimetics for Dynamic Combinatorial Drug Screening. Mol Cancer Ther 2021; 20:1210-1219. [PMID: 33785649 DOI: 10.1158/1535-7163.mct-20-0880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/15/2021] [Accepted: 03/19/2021] [Indexed: 01/02/2023]
Abstract
Disease models, including in vitro cell culture and animal models, have contributed significantly to developing diagnostics and treatments over the past several decades. The successes of traditional drug screening methods were generally hampered by not adequately mimicking critical in vivo features, such as a 3D microenvironment and dynamic drug diffusion through the extracellular matrix (ECM). To address these issues, we developed a 3D dynamic drug delivery system for cancer drug screening that mimicks drug dissemination through the tumor vasculature and the ECM by creating collagen-embedded microfluidic channels. Using this novel 3D ECM microsystem, we compared viability of tumor pieces with traditionally used 2D methods in response to three different drug combinations. Drug diffusion profiles were evaluated by simulation methods and tested in the 3D ECM microsystem and a 2D 96-well setup. Compared with the 2D control, the 3D ECM microsystem produced reliable data on viability, drug ratios, and combination indeces. This novel approach enables higher throughput and sets the stage for future applications utilizing drug sensitivity predicting algorithms based on dynamic diffusion profiles requiring only minimal patient tissue. Our findings moved drug sensitivity screening closer to clinical implications with a focus on testing combinatorial drug effects, an option often limited by the amount of available patient tissues.
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Affiliation(s)
- Li Wan
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Jun Yin
- Department of Developmental Biology, University of Pittsburgh Medical Center Cancer Institute, Magee Womens Research Institute, Pittsburgh, Pennsylvania
| | - John Skoko
- Department of Pharmacology and Chemical Biology, University of Pittsburgh Medical Center Cancer Institute, Magee Womens Research Institute, Pittsburgh, Pennsylvania
| | - Russell Schwartz
- Computational Biology Department, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Mei Zhang
- Department of Developmental Biology, University of Pittsburgh Medical Center Cancer Institute, Magee Womens Research Institute, Pittsburgh, Pennsylvania
| | - Philip R LeDuc
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania.
| | - Carola A Neumann
- Department of Pharmacology and Chemical Biology, University of Pittsburgh Medical Center Cancer Institute, Magee Womens Research Institute, Pittsburgh, Pennsylvania.
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Joy AA, Vos LJ, Pituskin E, Cook SF, Bies RR, Vlahadamis A, King K, Basi SK, Meza-Junco J, Mackey JR, Stanislaus A, Damaraju VL, Damaraju S, Sawyer MB. Uridine Glucuronosyltransferase 2B7 Polymorphism-Based Pharmacogenetic Dosing of Epirubicin in FEC Chemotherapy for Early-Stage Breast Cancer. Clin Breast Cancer 2021; 21:e584-e593. [PMID: 33832852 DOI: 10.1016/j.clbc.2021.03.001] [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: 10/13/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epirubicin is metabolized by uridine glucuronosyltransferase 2B7 (UGT2B7). Patients homozygous for the minor allele (CC) in the UGT2B7 -161 promoter polymorphism have lower clearance and significantly higher rates of leukopenia compared to wild-type homozygote (TT) or heterozygote (CT) patients. This study was designed to determine if TT and CT genotype patients could tolerate a higher epirubicin dose compared to CC genotype patients. PATIENTS AND METHODS We studied women with histologically confirmed non-metastatic, invasive breast cancer who were scheduled to receive at least three cycles of FE100C in the (neo)adjuvant setting. Patients received standard-dose FE100C during the first 21-day cycle. Based on genotype, the epirubicin dose was escalated in the second and third cycles to 115 and 130 mg/m2 or to 120 and 140 mg/m2 for CT and TT genotype patients, respectively. The main outcome measurements were myelosuppression and dose-limiting toxicity. These were analyzed for relationships with the three genotypes. RESULTS Forty-five patients were enrolled (10 CC, 21 CT, and 14 TT genotypes) and received 100 mg/m2 of epirubicin in the first cycle. Twelve and 10 TT patients were dose escalated at the second and third cycles, respectively; 16 CT patients were dose escalated at the second and third cycles. Leukopenia, but not febrile neutropenia, was genotype and dose dependent and increased in patients with CT and TT genotypes as their dose was increased. However, the third-cycle leukopenia rates were comparable to patients with the CC genotype receiving standard-dose epirubicin. CONCLUSION Pharmacogenetically guided epirubicin dosing is well tolerated and allowed dose escalation without increased toxicity.
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Affiliation(s)
- Anil A Joy
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Larissa J Vos
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Edith Pituskin
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sarah F Cook
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Robert R Bies
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Ann Vlahadamis
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Karen King
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sanraj K Basi
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Judith Meza-Junco
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John R Mackey
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Avalyn Stanislaus
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Vijaya L Damaraju
- Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sambasivarao Damaraju
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Michael B Sawyer
- Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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Veitch Z, Khan OF, Tilley D, Tang PA, Ribnikar D, Stewart DA, Kostaras X, King K, Lupichuk S. Impact of Cumulative Chemotherapy Dose on Survival With Adjuvant FEC-D Chemotherapy for Breast Cancer. J Natl Compr Canc Netw 2020; 17:957-967. [PMID: 31390594 DOI: 10.6004/jnccn.2019.7286] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/21/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Reductions in adjuvant chemotherapy dose <85% for historical regimens (ie, cyclophosphamide/methotrexate/fluorouracil) are known to affect breast cancer survival. This threshold, in addition to early versus late dose reductions, are poorly defined for third-generation anthracycline/taxane-based chemotherapy. In patients with breast cancer receiving adjuvant 5-fluorouracil/epirubicin/cyclophosphamide followed by docetaxel (FEC-D), we evaluated the impact of chemotherapy total cumulative dose (TCD), and early (FEC) versus late (D only) dose reductions, on survival outcomes. PATIENTS AND METHODS Women with stage I-III, hormone receptor-positive/negative, HER2-negative breast cancer treated with adjuvant FEC-D chemotherapy from 2007 through 2014 in Alberta, Canada, were included. TCD for cycles 1 to 6 of <85% or ≥85% was calculated. Average cumulative dose was also calculated for early (cycles 1-3) and late (cycles 4-6) chemotherapy. Survival outcomes (disease-free survival [DFS] and overall survival [OS]) were estimated using Kaplan-Meier and multivariate analysis. Cohorts were evaluated for uniformity. RESULTS Characteristics were reasonably balanced for all cohorts. Overall, 1,302 patients were evaluated for dose reductions, with 16% being reduced <85% (n=202) relative to ≥85% (n=1,100; 84%). Patients who received TCD ≥85% relative to <85% had superior 5-year DFS (P=.025) and OS (P<.001) according to Kaplan-Meier analysis, which remained significant on univariate and multivariate analyses. In stratified late and early dose reduction cohorts, DFS and OS showed a significant inferior survival trend for dose reduction early in treatment administration in 5-year Kaplan-Meier (P=.002 and P<.001, respectively) and multivariate analyses (hazard ratio [HR], 1.46; P=.073, and HR, 1.77; P=.011, respectively). Dose delays of <14 or ≥14 days and granulocyte colony-stimulating factor use did not affect outcomes. CONCLUSIONS Chemotherapy TCD <85% for adjuvant FEC-D affects breast cancer survival. Late reductions (D only) were not shown to adversely affect DFS or OS. Conversely, early reductions (FEC±D) negatively affected patient outcomes.
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Affiliation(s)
- Zachary Veitch
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta.,Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario
| | - Omar F Khan
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
| | - Derek Tilley
- CancerControl Alberta, Alberta Health Services, Calgary, Alberta; and
| | - Patricia A Tang
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
| | - Domen Ribnikar
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario
| | - Douglas A Stewart
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
| | | | - Karen King
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Sasha Lupichuk
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta
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Poikonen-Saksela P, Lindman H, Sverrisdottir A, Edlund P, Villman K, Tennvall Nittby L, Cold S, Bechmann T, Stenbygaard L, Ejlertsen B, Andersson M, Blomqvist C, Bergh J, Ahlgren J. Leukocyte nadir as a predictive factor for efficacy of adjuvant chemotherapy in breast cancer. Results from the prospective trial SBG 2000-1. Acta Oncol 2020; 59:825-832. [PMID: 32347139 DOI: 10.1080/0284186x.2020.1757149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Retrospective studies have suggested that chemotherapy-induced leukopenia is associated with improved recurrence-free or overall survival. The SBG 2000-1 trial was designed to verify the favorable prognosis associated with chemotherapy-induced leukopenia in early breast cancer. Patients not experiencing chemotherapy-induced leukopenia were randomized into standard dosed or individually escalated chemotherapy doses based on the grade of leukopenia after a first standard dose.Patients and methods: 1452 women in Sweden and Denmark with operable node-positive or high-risk node-negative breast cancer aged 18-60 years were recruited to participate in this trial. Participants received a first FEC cycle at standard doses (600/60/600 mg/m2). Patients (n = 1052) with nadir leukopenia grade 0-2 after the first cycle were randomized between either 6 standard FEC or 6 tailored FEC courses with doses of epirubicin and cyclophosphamide escalated during courses 2 and 3 and thereafter aimed at achieving grade 3 leukopenia. Patients with nadir leukopenia grade 3-4 after the first course continued treatment with standard FEC. Results of the randomized comparison has been published previously. The present study focuses on chemotherapy-induced leukopenia as a covariable with outcome in randomized and non-randomized patients. The prognostic value of leukopenia after course 3, was studied in a Cox model adjusted for cumulative doses of epirubicin and cyclophosphamide. The association of chemotherapy-induced leukopenia with prognosis was a preplanned secondary endpoint for this trial.Results: The eight-year distant disease-free survival was 73%, 77%, 78% and 83% for patients with leucocyte nadir grade 0, 1, 2 and 3-4, respectively. Higher degree of leukopenia was highly significantly associated to improved distant disease-free survival (HR 0.84, 95% CI 0.74-0.96, p = .008) and overall survival (HR 0.87 (0.76-0.99, p = .032).Conclusion: This prospective study confirms that chemotherapy-induced leukopenia is a covariable with outcome in primary breast cancer, even after adjustment for chemotherapy doses.
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Affiliation(s)
- Paula Poikonen-Saksela
- Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Henrik Lindman
- Department of Immunology, Genetics and Pathology University Hospital, Uppsala, Sweden
| | | | - Per Edlund
- Department of Oncology, Gävle Hospital, Sweden
| | - Kenneth Villman
- Department of Oncology, Örebro University Hospital, Örebro, Sweden
| | | | - Søren Cold
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Troels Bechmann
- Department of Oncology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Lars Stenbygaard
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Bent Ejlertsen
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | | | - Carl Blomqvist
- Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Oncology, Örebro University Hospital, Örebro, Sweden
| | - Jonas Bergh
- Department of Oncology-Pathology, Karolinska Institutet, Breast, Endocrine and Sarcoma Section, Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
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Burotto M, Wilkerson J, Stein WD, Bates SE, Fojo T. Adjuvant and neoadjuvant cancer therapies: A historical review and a rational approach to understand outcomes. Semin Oncol 2019; 46:83-99. [DOI: 10.1053/j.seminoncol.2019.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 12/11/2022]
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Wöckel A, Festl J, Stüber T, Brust K, Krockenberger M, Heuschmann PU, Jírů-Hillmann S, Albert US, Budach W, Follmann M, Janni W, Kopp I, Kreienberg R, Kühn T, Langer T, Nothacker M, Scharl A, Schreer I, Link H, Engel J, Fehm T, Weis J, Welt A, Steckelberg A, Feyer P, König K, Hahne A, Baumgartner T, Kreipe HH, Knoefel WT, Denkinger M, Brucker S, Lüftner D, Kubisch C, Gerlach C, Lebeau A, Siedentopf F, Petersen C, Bartsch HH, Schulz-Wendtland R, Hahn M, Hanf V, Müller-Schimpfle M, Henscher U, Roncarati R, Katalinic A, Heitmann C, Honegger C, Paradies K, Bjelic-Radisic V, Degenhardt F, Wenz F, Rick O, Hölzel D, Zaiss M, Kemper G, Budach V, Denkert C, Gerber B, Tesch H, Hirsmüller S, Sinn HP, Dunst J, Münstedt K, Bick U, Fallenberg E, Tholen R, Hung R, Baumann F, Beckmann MW, Blohmer J, Fasching P, Lux MP, Harbeck N, Hadji P, Hauner H, Heywang-Köbrunner S, Huober J, Hübner J, Jackisch C, Loibl S, Lück HJ, von Minckwitz G, Möbus V, Müller V, Nöthlings U, Schmidt M, Schmutzler R, Schneeweiss A, Schütz F, Stickeler E, Thomssen C, Untch M, Wesselmann S, Bücker A, Buck A, Stangl S. Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 2 with Recommendations for the Therapy of Primary, Recurrent and Advanced Breast Cancer. Geburtshilfe Frauenheilkd 2018; 78:1056-1088. [PMID: 30581198 PMCID: PMC6261741 DOI: 10.1055/a-0646-4630] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 12/29/2022] Open
Abstract
Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Method The process of updating the S3 guideline published in 2012 was based on the adaptation of identified source guidelines. They were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and with the results of a systematic search of literature databases followed by the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point and used them to develop suggestions for recommendations and statements, which were then modified and graded in a structured consensus process procedure. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of primary, recurrent and metastatic breast cancer. Loco-regional therapies are de-escalated in the current guideline. In addition to reducing the safety margins for surgical procedures, the guideline also recommends reducing the radicality of axillary surgery. The choice and extent of systemic therapy depends on the respective tumor biology. New substances are becoming available, particularly to treat metastatic breast cancer.
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Affiliation(s)
- Achim Wöckel
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Jasmin Festl
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Tanja Stüber
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Katharina Brust
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | | | - Peter U. Heuschmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | - Steffi Jírů-Hillmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | | | - Wilfried Budach
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Ina Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | | | - Thorsten Kühn
- Frauenklinik, Klinikum Esslingen, Esslingen, Germany
| | - Thomas Langer
- Office des Leitlinienprogrammes Onkologie, Berlin, Germany
| | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | - Anton Scharl
- Frauenklinik, Klinikum St. Marien Amberg, Amberg, Germany
| | | | - Hartmut Link
- Praxis für Hämatologie und Onkologie, Kaiserslautern, Germany
| | - Jutta Engel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Tanja Fehm
- Universitätsfrauenklinik Düsseldorf, Düsseldorf, Germany
| | - Joachim Weis
- Stiftungsprofessur Selbsthilfeforschung, Tumorzentrum/CCC Freiburg, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Anja Welt
- Innere Klinik (Tumorforschung), Westdeutsches Tumorzentrum, Universitätsklinikum Essen, Essen, Germany
| | | | - Petra Feyer
- Klinik für Strahlentherapie und Radioonkologie, Vivantes Klinikum, Neukölln Berlin, Germany
| | - Klaus König
- Berufsverband der Frauenärzte, Steinbach, Germany
| | | | | | - Hans H. Kreipe
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Wolfram Trudo Knoefel
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Denkinger
- AGAPLESION Bethesda Klinik, Geriatrie der Universität Ulm, Ulm, Germany
| | - Sara Brucker
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin, Universitätsklinikum Charité, Berlin, Germany
| | - Christian Kubisch
- Institut für Humangenetik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Gerlach
- III. Medizinische Klinik und Poliklinik, uct, Interdisziplinäre Abteilung für Palliativmedizin, Universitätsmedizin der Johannes Gutenberg Universität, Mainz, Germany
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Cordula Petersen
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Markus Hahn
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Volker Hanf
- Frauenklinik Nathanstift, Klinikum Fürth, Fürth, Germany
| | | | | | - Renza Roncarati
- Frauenselbsthilfe nach Krebs – Bundesverband e. V., Bonn, Germany
| | - Alexander Katalinic
- Institut für Sozialmedizin und Epidemiologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Christoph Heitmann
- Ästhetisch plastische und rekonstruktive Chirurgie, Camparihaus München, München, Germany
| | | | - Kerstin Paradies
- Konferenz Onkologischer Kranken- und Kinderkrankenpflege, Hamburg, Germany
| | - Vesna Bjelic-Radisic
- Universitätsfrauenklinik, Abteilung für Gynäkologie, Medizinische Universität Graz, Graz, Austria
| | - Friedrich Degenhardt
- Klinik für Frauenheilkunde und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany
| | - Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Oliver Rick
- Klinik Reinhardshöhe Bad Wildungen, Bad Wildungen, Germany
| | - Dieter Hölzel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Matthias Zaiss
- Praxis für interdisziplinäre Onkologie & Hämatologie, Freiburg, Germany
| | | | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Denkert
- Institut für Pathologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Rostock, Germany
| | - Hans Tesch
- Centrum für Hämatologie und Onkologie Bethanien, Frankfurt, Germany
| | | | - Hans-Peter Sinn
- Pathologisches Institut, Universität Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Karsten Münstedt
- Frauenklinik Offenburg, Ortenau Klinikum Offenburg-Gengenbach, Offenburg, Germany
| | - Ulrich Bick
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Fallenberg
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Reina Tholen
- Deutscher Verband für Physiotherapie, Referat Bildung und Wissenschaft, Köln, Germany
| | - Roswita Hung
- Frauenselbsthilfe nach Krebs, Wolfsburg, Germany
| | - Freerk Baumann
- Centrum für Integrierte Onkologie Köln, Uniklinik Köln, Köln, Germany
| | - Matthias W. Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jens Blohmer
- Klinik für Gynäkologie incl. Brustzentrum, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael P. Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nadia Harbeck
- Brustzentrum, Frauenklinik, Universität München (LMU), München, Germany
| | - Peyman Hadji
- Klinik für Gynäkologie und Geburtshilfe, Krankenhaus Nordwest, Frankfurt, Germany
| | - Hans Hauner
- Lehrstuhl für Ernährungsmedizin, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | | | | | - Jutta Hübner
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | | | | | | | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Nöthlings
- Institut für Ernährungs- und Lebensmittelwissenschaften, Rheinische Friedrich-Wilhelms Universität Bonn, Bonn, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit, Universitätsmedizin der Johannes Gutenberg-Universität Mai, Germany nz, Mainz
| | - Rita Schmutzler
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Andreas Schneeweiss
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Florian Schütz
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Michael Untch
- Klinik für Geburtshilfe und Gynäkologie, Helios Klinikum Berlin-Buch, Berlin, Germany
| | | | - Arno Bücker
- Klinik für Diagnostische und Interventionelle Radiologie am UKS, Universität des Saarlandes, Homburg, Germany
| | - Andreas Buck
- Nuklearmedizinische Klinik und Poliklinik des Universitätsklinikums Würzburg, Würzburg, Germany
| | - Stephanie Stangl
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
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9
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Lindman H, Andersson M, Ahlgren J, Balslev E, Sverrisdottir A, Holmberg S, Bengtsson N, Jacobsen E, Jensen A, Hansen J, Tuxen M, Malmberg L, Villman K, Anderson H, Ejlertsen B, Bergh J, Blomqvist C. A randomised study of tailored toxicity-based dosage of fluorouracil-epirubicin-cyclophosphamide chemotherapy for early breast cancer (SBG 2000-1). Eur J Cancer 2018; 94:79-86. [DOI: 10.1016/j.ejca.2018.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 01/24/2023]
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10
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Matikas A, Margolin S, Hellström M, Johansson H, Bengtsson NO, Karlsson L, Edlund P, Karlsson P, Lidbrink E, Linderholm B, Lindman H, Malmstrom P, Villman K, Foukakis T, Bergh J. Long-term safety and survival outcomes from the Scandinavian Breast Group 2004-1 randomized phase II trial of tailored dose-dense adjuvant chemotherapy for early breast cancer. Breast Cancer Res Treat 2017; 168:349-355. [PMID: 29190004 PMCID: PMC5838137 DOI: 10.1007/s10549-017-4599-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 11/24/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Although adjuvant polychemotherapy improves outcomes for early breast cancer, the significant variability in terms of pharmacokinetics results in differences in efficacy and both short and long-term toxicities. Retrospective studies support the use of dose tailoring according to the hematologic nadirs. METHODS The SBG 2004-1 trial was a randomized feasibility phase II study which assessed tailored dose-dense epirubicin and cyclophosphamide (EC) followed by docetaxel (T) (group A), the same regimen with fixed doses (group B) and the TAC regimen (group C). Women aged 18-65 years, ECOG PS 0-1 with at least one positive axillary lymph node were randomized 1:1:1. The primary endpoint of the study was the safety and feasibility of the treatment. Toxicity was graded according to CTC-AE version 3.0. The design and short-term toxicity have been previously published. Here, we report safety and efficacy data after 10 years of follow-up. RESULTS A total of 124 patients were included in the study. After a median follow-up of 10.3 years, the probability for 10-year survival was 78.5, 75.1, and 63.4% and for relapse free survival 64.1, 71.0, and 59.5% for groups A, B, and C, respectively. There were no cases of clinically diagnosed cardiotoxicity or hematologic malignancies. No patient was lost to follow-up. CONCLUSIONS In this randomized phase II trial, tailored dose adjuvant chemotherapy was feasible, without an increased risk for long-term adverse events after a median follow-up of 10 years.
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Affiliation(s)
- Alexios Matikas
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden.
| | - Sara Margolin
- Department of Oncology, Stockholm South General Hospital, Stockholm, Sweden
| | - Mats Hellström
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Elisabet Lidbrink
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Barbro Linderholm
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Lindman
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Per Malmstrom
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | - Theodoros Foukakis
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Bergh
- Department of Oncology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
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11
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Matikas A, Foukakis T, Bergh J. Dose intense, dose dense and tailored dose adjuvant chemotherapy for early breast cancer: an evolution of concepts. Acta Oncol 2017; 56:1143-1151. [PMID: 28537808 DOI: 10.1080/0284186x.2017.1329593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The introduction of adjuvant chemotherapy following surgery for early breast cancer (BC) and its integration into routine clinical practice has consistently improved clinical outcomes. Since the addition of other agents to the contemporary standard of care containing an anthracycline, cyclophosphamide and a taxane has not lead to further prolongation of survival, subsequent efforts concentrated on escalating the administered doses and reducing the time interval between chemotherapy cycles. These strategies have been extensively evaluated in randomized trials and dose dense chemotherapy is now recommended by clinical practice guidelines. METHOD Eligible trials were identified by searching the EMBASE, Pubmed, Scopus and Cochrane Library databases, as well as conference papers. The findings, shortcomings and impact of these studies are presented and critically discussed. RESULTS Although a large number of randomized trials has established the value of adjuvant chemotherapy, important questions remain unanswered. Ongoing research focuses on omitting treatment in good risk patients, identifying patients most likely to benefit from a dose dense approach and on administering personalized doses such as in tailored dose chemotherapy. CONCLUSIONS Adjuvant chemotherapy for early BC is an evolving art. Further optimizations could potentially improve outcomes for a patient subset and spare others from unnecessary treatment-related toxicity.
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Affiliation(s)
- Alexios Matikas
- Department of Oncology-Pathology, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Jonas Bergh
- Department of Oncology-Pathology, Karolinska Institutet and University Hospital, Stockholm, Sweden
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12
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BRCA1-like profile is not significantly associated with survival benefit of non-myeloablative intensified chemotherapy in the GAIN randomized controlled trial. Breast Cancer Res Treat 2017; 166:775-785. [PMID: 28822007 DOI: 10.1007/s10549-017-4444-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 08/05/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE The BRCA1-like profile identifies tumors with a defect in homologous recombination due to inactivation of BRCA1. This profile has been shown to predict which stage III breast cancer patients benefit from myeloablative, DNA double-strand-break-inducing chemotherapy. We tested the predictive potential of the BRCA1-like profile for adjuvant non-myeloablative, intensified dose-dense chemotherapy in the GAIN trial. METHODS Lymph node positive breast cancer patients were randomized to 3 × 3 dose-dense cycles of intensified epirubicin, paclitaxel, and cyclophosphamide (ETC) or 4 cycles concurrent epirubicin and cyclophosphamide followed by 10 cycles of weekly paclitaxel combined with 4 cycles capecitabine (EC-TX). Only triple negative breast cancer patients (TNBC) for whom tissue was available were included in these planned analyses. BRCA1-like or non-BRCA1-like copy number profiles were derived from low coverage sequencing data. RESULTS 119 out of 163 TNBC patients (73%) had a BRCA1-like profile. After median follow-up of 83 months, disease free survival (DFS) was not significantly different between BRCA1-like and non-BRCA1-like patients [adjusted hazard ratio (adj.HR) 1.02; 95% confidence interval (CI) 0.55-1.86], neither was overall survival (OS; adj.HR 1.26; 95% CI 0.58-2.71). When split by BRCA1-like status, DFS and OS were not significantly different between treatments. However, EC-TX seemed to result in a trend to an improvement in DFS in patients with a BRCA1-like tumor, while the reverse accounted for ETC treatment in patients with a non-BRCA1-like tumor (p for interaction = 0.094). CONCLUSIONS The BRCA1-like profile is not associated with survival benefit for a non-myeloablative, intensified regimen in this study population. Considering the limited cohort size, capecitabine might have additional benefit for TNBC patients.
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13
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Chen Y, Wang Y, Shi Y, Dai G. Timing of chemotherapy-induced neutropenia predicts prognosis in metastatic colon cancer patients: a retrospective study in mFOLFOX6 -treated patients. BMC Cancer 2017; 17:242. [PMID: 28376763 PMCID: PMC5379656 DOI: 10.1186/s12885-017-3240-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/29/2017] [Indexed: 01/19/2023] Open
Abstract
Background The occurrence of Chemotherapy-induced neutropenia (CIN) was reported to be a predictor of better survival in several cancers. The objective of our study is to evaluate the relationship between the timing of CIN and prognosis. Methods Between June 2012 and August 2014, 290 patients with confirmed metastatic colon cancer received at least one cycle of mFOLFOX6 as first-line chemotherapy were eligible for assessment as all patients group. Of the 232 received at least six cycles of mFOLFOX6 and survived 150 days after treatment were considered as landmark group. Timing of CIN was categorized into absence, early-onset and late-onset CIN groups. The end of cycle 3 was the cutoff to differentiate early-onset or late-onset. The correlation between timing of CIN with survival was analyzed by Kaplan-Meier method and Cox proportional hazards model. Results In all patients group, the median survival of patients without neutropenia, early-onset and late-onset neutropenia were 6.7, 20.7 and 12.8 months (P < 0.001). The patients with early-onset and late-onset CIN had better prognosis than CIN absence by multivariate analysis. Findings were much the same for landmark group. Conclusions In conclusion, timing of CIN is an independent predictor of prognosis in metastatic colon cancer patients received mFOLFOX6, whereas an early-onset of CIN predicts longer survival.
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Affiliation(s)
- Yang Chen
- Medical Oncology Department 2, Chinese People's Liberation Army General Hospital, Beijing, 100853, People's Republic of China
| | - YanRong Wang
- Medical Oncology Department 2, Chinese People's Liberation Army General Hospital, Beijing, 100853, People's Republic of China
| | - Yan Shi
- Medical Oncology Department 2, Chinese People's Liberation Army General Hospital, Beijing, 100853, People's Republic of China
| | - GuangHai Dai
- Medical Oncology Department 2, Chinese People's Liberation Army General Hospital, Beijing, 100853, People's Republic of China.
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14
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Calvo E, Walko C, Dees EC, Valenzuela B. Pharmacogenomics, Pharmacokinetics, and Pharmacodynamics in the Era of Targeted Therapies. Am Soc Clin Oncol Educ Book 2017; 35:e175-84. [PMID: 27249721 DOI: 10.1200/edbk_159061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The complex nature of the pharmacologic aspects of cancer therapeutics has become more apparent in the past several years with the arrival of a cascade of target-based agents and the difficult challenge of bringing individualized precision medicine to oncology. Interpatient variability in drug action, singularly in novel agents, is in part caused by pharmacogenomic (PG), pharmacokinetic, and pharmacodynamic (PD) factors, and drug selection and dosing should take this into consideration to optimize the benefit for our patients in terms of antitumor activity and treatment tolerance. In this regard, somatic genetic evaluation of tumors is useful in not only predicting response to initial targeted therapies but also in anticipating and guiding therapy after the development of acquired resistance; therapeutic drug monitoring of novel small molecules and monoclonal antibodies must be incorporated in our day-to-day practice to minimize the negative effect on clinical outcome of interindividual variability on pharmacokinetic processes of these drugs for all patients, but especially for fragile patient populations and those with organ dysfunction or comorbidities. For these populations, incorporating frailty assessment tools into trials of newer agents and validating frailty-based dose adjustment should be an important part of further drug development.
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Affiliation(s)
- Emiliano Calvo
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Christine Walko
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - E Claire Dees
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Belén Valenzuela
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
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15
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Liu R, Huang M, Zhao X, Peng W, Sun S, Cao J, Ji D, Wang C, Guo W, Li J, Yin J, Zhu X. Neutropenia predicts better prognosis in patients with metastatic gastric cancer on a combined epirubicin, oxaliplatin and 5-fluorouracil regimen. Oncotarget 2016; 6:39018-27. [PMID: 26528696 PMCID: PMC4770753 DOI: 10.18632/oncotarget.5730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 10/06/2015] [Indexed: 12/26/2022] Open
Abstract
Chemotherapy-induced neutropenia (CIN) reportedly indicated better prognosis for some cancers. We retrospectively analyzed 150 evaluable metastatic gastric cancer (MGC) patients who had received first-line EOF5 (combination regimen of epirubicin, oxaliplatin and 5-day continuous infusion of 5-fluorouracil) treatment. We divided patients into three groups according to the worst grade of CIN: absent group (grade 0), moderate group (grade 1–2) and severe group (grade 3–4). Multivariate analyses of overall survival (OS) proved moderate and severe CIN were important prognostic factors whether regarding CIN as a time-varying covariate (TVC) or not. Compared with absent CIN, hazard ratio (HR) for moderate and severe CIN were 0.31 (95% confidential interval (CI): 0.17–0.55; P < 0.001) and 0.36 (95% CI: 0.20–0.64; P = 0.001) respectively with TVC; and were 0.31 (95% CI: 0.17–0.56; P < 0.001) and 0.34 (95% CI: 0.19–0.61; P < 0.001) respectively without TVC. In progression-free survival (PFS) analyses, moderate and severe CIN showed similar results. In the landmark group (n = 122 patients) analyses with TVC, moderate and severe CIN remained prognostic factors for PFS, while only moderate CIN was prognostic factor for OS. CIN predicted longer OS and PFS in MGC patients treated with first-line EOF5 chemotherapy.
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Affiliation(s)
- Rujiao Liu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Mingzhu Huang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Xiaoying Zhao
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Wei Peng
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Si Sun
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Jun Cao
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Dongmei Ji
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Chenchen Wang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Weijian Guo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Jin Li
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Jiliang Yin
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Xiaodong Zhu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China
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16
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Jia D, Tan Y, Liu H, Ooi S, Li L, Wright K, Bennett S, Addison CL, Wang L. Cardamonin reduces chemotherapy-enriched breast cancer stem-like cells in vitro and in vivo. Oncotarget 2016; 7:771-85. [PMID: 26506421 PMCID: PMC4808032 DOI: 10.18632/oncotarget.5819] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 10/06/2015] [Indexed: 12/26/2022] Open
Abstract
The failure of cytotoxic chemotherapy in breast cancers has been closely associated with the presence of drug resistant cancer stem cells (CSCs). Thus, screening for small molecules that selectively inhibit growth of CSCs may offer great promise for cancer control, particularly in combination with chemotherapy. In this report, we provide the first demonstration that cardamonin, a small molecule, selectively inhibits breast CSCs that have been enriched by chemotherapeutic drugs. In addition, cardamonin also sufficiently prevents the enrichment of CSCs when simultaneously used with chemotherapeutic drugs. Specifically, cardamonin effectively abolishes chemotherapeutic drug-induced up-regulation of IL-6, IL-8 and MCP-1 and activation of NF-κB/IKBα and Stat3. Furthermore, in a xenograft mouse model, co-administration of cardamonin and the chemotherapeutic drug doxorubicin significantly retards tumor growth and simultaneously decreases CSC pools in vivo. Since cardamonin has been found in some herbs, this work suggests a potential new approach for the effective treatment of breast CSCs by administration of cardamonin either concurrent with or after chemotherapeutic drugs.
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Affiliation(s)
- Deyong Jia
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Yuan Tan
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Huijuan Liu
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada.,Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders, Ministry of Education, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Sarah Ooi
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Li Li
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Kathryn Wright
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Steffany Bennett
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
| | - Christina L Addison
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada.,Centre for Cancer Therapeutics, Ottawa Hospital Research Institute, Ottawa, Ontario K1H 8L6, Canada
| | - Lisheng Wang
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada.,Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario K1H 8L6, Canada.,Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
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17
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McCune JS, Games DM, Espirito JL. Assessment of ovarian failure and osteoporosis in premenopausal breast cancer survivors. J Oncol Pharm Pract 2016; 11:37-43. [PMID: 16460603 DOI: 10.1191/1078155205jp144oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Premenopausal women who develop ovarian failure after receiving chemotherapy are at a higher risk of rapid bone loss. Pharmacists have successfully implemented osteoporosis screening programmes in the general population and thus, assessment of breast cancer survivors for ovarian failure and osteopenia could represent a novel focus for oncology pharmacists. Therefore, we conducted a retrospective chart review to determine the adequacy of ovarian failure and osteoporosis assessment and management in premenopausal breast cancer survivors. Methods and results. The charts of 20 women diagnosed with early stage breast cancer treated with cyclophosphamide over a 4.5-year timespan were included. Their median age was 36.7 years (range 29.8-41). The median cyclophosphamide cumulative dose was 9 g/m2 (range 2.4-14.45), with a median duration of follow-up being 4.62 years. The assessment of ovarian failure mainly occurred by documenting menstrual periods, which has been questioned as a reliable method for assessing ovarian failure. Menses stopped while or shortly after receiving chemotherapy in 11 women. Prior to and during cyclophosphamide administration, osteoporosis screening or counselling was not documented for any patient. After completion of chemotherapy administration, eight patients were counselled regarding osteoporosis and seven women were screened for osteoporosis with a dual X-ray absorptimetry (DXA) scan. Five women had DXA scans indicative of osteopenia according to World Health Organization guidelines. Conclusions. Improvements are needed in the documentation and potentially also the management of ovarian failure and osteoporosis in premenopausal breast cancer survivors receiving cyclophosphamide-based regimens. This represents a potential opportunity for pharmacists to manage long-term chemotherapy toxicity.
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Affiliation(s)
- Jeannine S McCune
- Department of Pharmacy, University of Washington, Seattle, 91895-7630, USA.
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18
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Salek R, Bayatmokhtari N, Homaei Shandiz F, ShahidSales S. The Results of Chemotherapy with Two Variants of Intravenous CMF in Patients with Early Stage Breast Carcinoma; Does Dose Density Matter? Breast J 2016; 22:623-629. [PMID: 27540897 DOI: 10.1111/tbj.12652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
No direct comparisons can be made in early stages of breast cancer, between the intravenous combinations of: cyclophosphamide, methotrexate, and fluorouracil; named modified versions of CMF with the classical oral version of CMF. Since these modifications have different dose intensities and densities, the outcomes for their subsequent treatments may be varied, and not produce the same results. Despite that, classical CMF has been commonly replaced with intravenous modifications. This study aimed to assess the results of treatment with two common intravenous modification of CMF chemotherapy; to represent the most effective and successful substitute of classical CMF. Five hundred patients in two groups were eligible to take part in the experiment. For two hundred and twenty-nine patients in the group CMF 1&8, chemotherapy was administered intravenously on days 1 and 8 every 28 days for six cycles consisting of: cyclophosphamide 600 mg/m2 , methotrexate 40 mg/m2 , fluorouracil 600 mg/m2 . In the group CMF 1 which consisted of 271 patients, chemotherapy was administered with all the same drugs and doses, however, it was only administered on day 1 and repeated at 21-day intervals for six cycles. Overall survival (OS), disease-free survival (DFS), the prognostic factors and other probable interventional factors were then compared between the two groups. The 5-year OS rate of 87.5% and 10-year OS rate of 82% in the group CMF 1&8 were statistically significantly better than 5-year OS of 84% and 10-year OS of 61.5% in the group CMF 1 (p = 0.01). The 5-year and 10-year DFS rates were 76% and 60% respectively, in the group CMF 1&8 compared with 77% and 54% respectively in the group CMF 1 (p = 0.8). Two groups were comparable regarding their distribution of different prognostic factors and other probable interventional factors. Considering 30% higher dose density of drugs in the protocol of CMF 1&8, the improving outcome can be related to the efficacy of dose-dense chemotherapy. Therefore, this intravenous modification is the better substitute of classical CMF.
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Affiliation(s)
- Roham Salek
- Clinical Radiation Oncology, Faculty of Medicine, Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Narges Bayatmokhtari
- Clinical Radiation Oncology, Sabzevar University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Homaei Shandiz
- Clinical Radiation Oncology, Faculty of Medicine, Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soodabeh ShahidSales
- Clinical Radiation Oncology, Faculty of Medicine, Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Tanaka S, Hayek G, Jayapratap P, Yerrasetti S, Hilaire HS, Sadeghi A, Corsetti R, Fuhrman G. The Impact of Chemotherapy on Complications Associated with Mastectomy and Immediate Autologous Tissue Reconstruction. Am Surg 2016. [DOI: 10.1177/000313481608200830] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We performed this study to evaluate the impact of chemotherapy on the outcomes associated with immediate autologous tissue reconstruction (IATR) in the treatment of breast cancer. Patients were divided into two groups: Group 1 received chemotherapy before surgery and Group 2 did not receive chemotherapy. Records were reviewed to identify demographics, comorbidities, histology, and wound healing complications. Groups were compared using Kruskal-Wallis and Fisher exact tests as appropriate. A total of 128 patients were identified: 29 received chemotherapy before surgery (Group 1) and 99 did not receive chemotherapy (Group 2). Group 1 patients were more likely to have diabetes 27 per cent versus 6 per cent ( P = 0.005) despite both groups having a mean body mass index of 30. Group 2 patients had less advanced stage disease as expected because they did not receive chemotherapy; 37 per cent of Group 2 patients had stage 0 breast cancer ( P < 0.001). The incidence of wound complications was 17 per cent in Group 1 and 12 per cent in Group 2 ( P = NS). Preoperative chemotherapy for breast cancer followed by IATR was associated with no increased risk of healing complications. IATR can be offered to patients who require preoperative chemotherapy, and their healing will not be impaired as a result of the chemotherapy.
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Affiliation(s)
- Shoichiro Tanaka
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Genevieve Hayek
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Pravitha Jayapratap
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, Louisiana
| | - Sita Yerrasetti
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, Louisiana
| | - Hugo St. Hilaire
- Department of Surgery, Louisiana State University, New Orleans, Louisiana
| | - Ali Sadeghi
- Department of Surgery, Louisiana State University, New Orleans, Louisiana
| | - Ralph Corsetti
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, Louisiana
| | - George Fuhrman
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Abstract
Objective. Our objective was to review oprelvekin, which is a new thrombopoietic cytokine approved in the United States to prevent severe thrombocytopenia and reduce the number of platelet transfusions after myelosuppressive chemotherapy. This article focuses on oprelvekin’s pharmacology, pharmacokinetics, and place in therapy. Data Sources. A search of the National Cancer Institute-sponsored Cancerlit database from 1963 to 1999 was completed. Subject mesh headings that were searched included interleukin-11, oprelvekin, breast cancer, chemotherapy dose intensity, and cancer pharmacoeconomics. Data were also collected from the package insert and from Genetics Institute (Cambridge, MA) publications. Study Selection. Searches were limited to studies with humans, which included clinical trials, news articles, and review articles. After reading all of the human clinical trials, additional pertinent citations were obtained and read. Data Synthesis. Oprelvekin has been studied in both adults and children, with the bulk of the data coming from the treatment of women with breast cancer. A phase I study in adults evaluated doses of 10, 25, 50, 75, and 100 mg/kg/day and determined the maximum tolerated dose to be 50 mg/kg/day. The toxicity seen with the 75 and 100 mg/kg/day doses includes constitutional symptoms (arthralgias, myalgias, fatigue, nausea, and headache) and a cerebral vascular accident. Phase II and III trials showed that 25-50 mg/kg/day effectively reduced the number of patients requiring platelet transfusions and decreased the number of platelet transfusions after chemotherapy. Pharmacokinetics performed with the 50 mg/kg/day subcutaneous (s.c.) dose resulted in a maximum sera concentration of 17.4 6 5.4 ng/mL, which occurred at 3.2 6 2.4 hours. The terminal half-life was 6.9 6 1.7 hours. Clearance decreases with increasing age, and pediatric patients have a 1.2- to 1.6-fold higher clearance than adults. These pharmacokinetic parameters led to a dosing recommendation of 75- 100 mg/kg/day in pediatric patients. Due to the high cost of oprelvekin and the lack of data demonstrating that it affects mortality, its role in current therapies is unclear. It is currently being promoted to maintain dose intensity in patients with breast cancer, testicular cancer, and lymphoma. Depending upon institutional platelet and oprelvekin costs, it may also be useful in patients receiving a large number of platelet transfusions. Thus far, it has not demonstrated efficacy in bone marrow transplant patients. Conclusion. Oprelvekin can effectively prevent the need for platelet transfusion in nontransplant patients receiving myelosuppressive chemotherapy. Due to its high cost, it will most likely be used to maintain chemotherapy dose intensity, which may translate into a survival advantage.
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Affiliation(s)
- Val R Adams
- Division of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Timothy L Brenner
- Division of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky
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Abraham JE, Hiller L, Dorling L, Vallier AL, Dunn J, Bowden S, Ingle S, Jones L, Hardy R, Twelves C, Poole CJ, Pharoah PDP, Caldas C, Earl HM. A nested cohort study of 6,248 early breast cancer patients treated in neoadjuvant and adjuvant chemotherapy trials investigating the prognostic value of chemotherapy-related toxicities. BMC Med 2015; 13:306. [PMID: 26715442 PMCID: PMC4693418 DOI: 10.1186/s12916-015-0547-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/17/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The relationship between chemotherapy-related toxicities and prognosis is unclear. Previous studies have examined the association of myelosuppression parameters or neuropathy with survival and reported conflicting results. This study aims to investigate 13 common chemotherapy toxicities and their association with relapse-free survival and breast cancer-specific survival. METHODS Chemotherapy-related toxicities were collected prospectively for 6,248 women with early-stage breast cancer from four randomised controlled trials (NEAT; BR9601; tAnGo; Neo-tAnGo). Cox proportional-hazards modelling was used to analyse the association between chemotherapy-related toxicities and both breast cancer-specific survival and relapse-free survival. Models included important prognostic factors and stratified by variables violating the proportional hazards assumption. RESULTS Multivariable analysis identified severe neutropenia (grades ≥3) as an independent predictor of relapse-free survival (hazard ratio (HR) = 0.86; 95% confidence interval (CI), 0.76-0.97; P = 0.02). A similar trend was seen for breast cancer-specific survival (HR = 0.87; 95% CI, 0.75-1.01; P = 0.06). Normal/low BMI patients experienced more severe neutropenia (P = 0.008) than patients with higher BMI. Patients with fatigue (grades ≥3) showed a trend towards reduced survival (breast cancer-specific survival: HR = 1.17; 95% CI, 0.99-1.37; P = 0.06). In the NEAT/BR9601 sub-group analysis by treatment component, this effect was statistically significant (HR = 1.61; 95% CI, 1.13-2.30; P = 0.009). CONCLUSIONS This large study shows a significant association between chemotherapy-induced neutropenia and increased survival. It also identifies a strong relationship between low/normal BMI and increased incidence of severe neutropenia. It provides evidence to support the development of neutropenia-adapted clinical trials to investigate optimal dose calculation and its impact on clinical outcome. This is important in populations where obesity may lead to sub-optimal chemotherapy doses.
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Affiliation(s)
- Jean E Abraham
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 193, Cambridge, CB2 0QQ, UK.
- NIHR Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Box 277, Hills Road, Cambridge, CB2 0QQ, UK.
- Strangeways Research Laboratory, University of Cambridge, 2 Worts Causeway, Cambridge, CB1 8RN, UK.
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Louise Hiller
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
| | - Leila Dorling
- Strangeways Research Laboratory, University of Cambridge, 2 Worts Causeway, Cambridge, CB1 8RN, UK.
| | - Anne-Laure Vallier
- Department of Oncology, Cambridge Cancer Trials Centre, Box 279 (S4), Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
| | - Sarah Bowden
- Cancer Research UK Clinical Trials Unit, Institute for Cancer Studies, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Susan Ingle
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 193, Cambridge, CB2 0QQ, UK.
- NIHR Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Box 277, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of Oncology, Cambridge Cancer Trials Centre, Box 279 (S4), Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Linda Jones
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 193, Cambridge, CB2 0QQ, UK.
- NIHR Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Box 277, Hills Road, Cambridge, CB2 0QQ, UK.
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Richard Hardy
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 193, Cambridge, CB2 0QQ, UK.
- NIHR Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Box 277, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of Oncology, Cambridge Cancer Trials Centre, Box 279 (S4), Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Christopher Twelves
- Level 4, Leeds Institute of Cancer and Pathology and Leeds Experimental Cancer Medical Centre, St James Institute of Oncology, Beckett Street, Leeds, LS9 7TF, UK.
| | - Christopher J Poole
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
| | - Paul D P Pharoah
- Strangeways Research Laboratory, University of Cambridge, 2 Worts Causeway, Cambridge, CB1 8RN, UK.
| | - Carlos Caldas
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 193, Cambridge, CB2 0QQ, UK.
- NIHR Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Box 277, Hills Road, Cambridge, CB2 0QQ, UK.
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge, CB2 0RE, UK.
| | - Helena M Earl
- Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 193, Cambridge, CB2 0QQ, UK.
- NIHR Cambridge Biomedical Research Centre and Cambridge Experimental Cancer Medicine Centre, Box 277, Hills Road, Cambridge, CB2 0QQ, UK.
- Cambridge Breast Unit and Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
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Jatoi I, Bandos H, Jeong JH, Anderson WF, Romond EH, Mamounas EP, Wolmark N. Time-Varying Effects of Breast Cancer Adjuvant Systemic Therapy. J Natl Cancer Inst 2015; 108:djv304. [PMID: 26518884 DOI: 10.1093/jnci/djv304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 09/25/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The benefits of breast cancer adjuvant systemic treatments are generally assumed to be proportional (or constant) over time, but limited data suggest that some treatment effects may vary with time. We therefore systematically assessed the proportional hazards assumption across all 19 breast cancer adjuvant systemic therapy trials in the National Surgical Adjuvant Breast and Bowel Project (NSABP) database. METHODS The NSABP breast cancer trials were tested for the proportionality of hazard rates between randomized treatment groups for five endpoints: overall survival, disease-free survival and recurrence, local-regional recurrence, or distant recurrence as first events. When the proportional hazards assumption did not hold, a "change point for the relative risk" technique was used to identify the temporal breakdown of the treatment effect. RESULTS Time-varying treatment effects were observed in nearly half of the trials (nine of 19). In six (B-05, B-11, B-12, B-14, B-16, and B-20), novel treatment benefits diminished statistically significantly at specific time points following surgery. In B-09 and B-31, novel treatment benefits were delayed and emerged more than one year after surgery (1.57 and 1.32 years correspondingly), but the benefit in B-09 reversed after the third year of follow-up. In one trial (B-23), the initial advantage and subsequent disadvantage of one of the regimens was evident. CONCLUSIONS Breast cancer adjuvant systemic therapy can have statistically significant time-varying effects, which should be considered in the design, analysis, reporting, and translation of clinical trials. These time-dependent effects will have greater relevance as the number of long-term breast cancer survivors increases.
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Affiliation(s)
- Ismail Jatoi
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW).
| | - Hanna Bandos
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Jong-Hyeon Jeong
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - William F Anderson
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Edward H Romond
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Eleftherios P Mamounas
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
| | - Norman Wolmark
- NRG Oncology/ National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA (IJ, EHR, EPM, NW); Department of Surgery University of Texas Health Science Center, San Antonio, TX (IJ); NRG Oncology Statistics & Data Management Center, and the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (HB, JHJ); NIH/NCI/Division of Cancer Epidemiology and Genetics, Bethesda, MD (WFA); Markey Cancer Center, University of Kentucky, Lexington, KY (EHR); UF Cancer Center at Orlando Health, Orlando, FL (EPM); Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA (NW)
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Valdivieso M, Corn BW, Dancey JE, Wickerham DL, Horvath LE, Perez EA, Urton A, Cronin WM, Field E, Lackey E, Blanke CD. The Globalization of Cooperative Groups. Semin Oncol 2015; 42:693-712. [PMID: 26433551 DOI: 10.1053/j.seminoncol.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The National Cancer Institute (NCI)-supported adult cooperative oncology research groups (now officially Network groups) have a longstanding history of participating in international collaborations throughout the world. Most frequently, the US-based cooperative groups work reciprocally with the Canadian national adult cancer clinical trial group, NCIC CTG (previously the National Cancer Institute of Canada Clinical Trials Group). Thus, Canada is the largest contributor to cooperative groups based in the United States, and vice versa. Although international collaborations have many benefits, they are most frequently utilized to enhance patient accrual to large phase III trials originating in the United States or Canada. Within the cooperative group setting, adequate attention has not been given to the study of cancers that are unique to countries outside the United States and Canada, such as those frequently associated with infections in Latin America, Asia, and Africa. Global collaborations are limited by a number of barriers, some of which are unique to the countries involved, while others are related to financial support and to US policies that restrict drug distribution outside the United States. This article serves to detail the cooperative group experience in international research and describe how international collaboration in cancer clinical trials is a promising and important area that requires greater consideration in the future.
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Affiliation(s)
- Manuel Valdivieso
- Division of Hematology/Oncology, University of Michigan; and SWOG, Executive Officer, Quality Assurance and International Initiatives, Ann Arbor, MI.
| | - Benjamin W Corn
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv, Israel; and Department of Radiation Oncology, Jefferson Medical College, Philadelphia, PA
| | - Janet E Dancey
- Director, NCIC Clinical Trials Group; Scientific Director Canadian Cancer Clinical Trials Network; Program Leader, High Impact Clinical Trials, Ontario Institute for Cancer Research; Professor of Oncology, Queen's University, Kingston, Ontario, Canada
| | - D Lawrence Wickerham
- Deputy Chairman, NRG Oncology, Pittsburgh, PA; Department of Human Oncology, Pittsburgh Campus, Drexel University School of Medicine; Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA
| | - L Elise Horvath
- Executive Officer, Alliance for Clinical Trials in Oncology, Chicago, IL
| | - Edith A Perez
- Deputy Director at Large, Mayo Clinic Cancer Center; Group Vice Chair, Alliance for Clinical Trials in Oncology; Hematology/Oncology and Cancer Biology Mayo Clinic, Jacksonville, FL
| | - Alison Urton
- Group Administrator, NCIC Clinical Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Walter M Cronin
- Associate Director, NRG Oncology Statistics and Data Management Center (SDMC); Associate Director, Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Erica Field
- Project Specialist III, RTOG, Philadelphia, PA
| | - Evonne Lackey
- Coordinating Center Manager, SWOG Statistical Center, Seattle, WA
| | - Charles D Blanke
- Chair, SWOG; Department of Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University and Knight Cancer Institute, Portland, OR
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Abstract
Dose-dense chemotherapy has made a significant contribution to the adjuvant treatment of breast cancer. One way of achieving dose-density is through the use of sequential therapy with noncross resistant therapies to cause cell kill in tumors composed of heterogeneous cells. Another way to achieve this is to shorten the inter-treatment interval to minimize the re-growth of tumor cells, thus allowing for more effective cell killing. Several trials have tested this concept with the majority demonstrating improved efficacy with a dose-density when compared with the traditional schedule. One such notable trial was CALGB 9741 that showed that when dose size and cycle numbers were kept constant, shortening the interval between each chemotherapy dose, with granulocyte-colony stimulating factor support, significantly improved disease-free and overall survival. This important and practice-changing trial led to the wide adoption of dose-dense chemotherapy and formed the basis of many subsequent studies, including allowing for the addition of biologic and targeted agents with excellent safety profile.
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Affiliation(s)
- Clifford Hudis
- Memorial Sloan Kettering Cancer Center, New York, New York
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25
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Murialdo R, Gallo M, Boy D, Zoppoli G, Tixi L, Gonella R, Ballestrero A, Patrone F. Sequential Dose-dense 5-fluorouracil, Epirubicin and Cyclophosphamide Followed by Docetaxel in Patients with Early Breast Cancer with Four or more Positive Lymph Nodes. TUMORI JOURNAL 2014; 100:128-35. [DOI: 10.1177/030089161410000203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim The aim of present study was to investigate the feasibility of a densified sequence of FEC75 (5-fluorouracil 600 mg/m2, epirubicin 75 mg/m2, cyclophosphamide 600 mg/m2) and docetaxel 100 mg/m2 (D100) in patients with primary operable highrisk breast cancer. Methods Fifty-one consecutive patients with resectable breast cancer and 4 or more positive axillary lymph nodes were enrolled. After a common regimen of 4 cycles of FEC75 given every 14 days, patients received 4 cycles of D100 every 14 days. Prophylactic granulocyte colony-stimulating factor was administered subcutaneously at 5 mg/kg daily from days 5 to 10 to each patient. Results The primary endpoint was the proportion of subjects receiving at least 85% of the relative dose intensity (rDI) both in the FEC and docetaxel parts of the regimen. In view of the high percentage of grade 3–4 skin toxicity (32%) observed in the first 25 patients (Group A) during D100 treatment, it was decided to continue the study using a docetaxel dose reduced by 15% (85 mg/m2; D85). This second group of 26 patients was defined as Group B. Of the total 51 patients, 38 (75%) received docetaxel rDI ≥85%, 23/26 patients (88.5%) and 15/25 patients (60.0%) in Group B and Group A, respectively. The observed grade 3–4 hematological and nonhematological toxicities were in line with data from the literature. The only significant difference was the higher percentage of grade 3–4 skin toxicity experienced with D100. Conclusion This study failed to demonstrate the feasibility of a dose-dense FEC-D regimen with docetaxel 100 mg/m2. Docetaxel 85 mg/m2 seems to allow a higher rDI than docetaxel 100 mg/m2 but this should be confirmed in a larger cohort of patients.
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Affiliation(s)
- Roberto Murialdo
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Maurizio Gallo
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Davide Boy
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Gabriele Zoppoli
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Lucia Tixi
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Roberta Gonella
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Franco Patrone
- Department of Internal Medicine, University of Genoa, Genoa, Italy
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Henderson IC, Bhatia V. Nab-paclitaxel for breast cancer: a new formulation with an improved safety profile and greater efficacy. Expert Rev Anticancer Ther 2014; 7:919-43. [PMID: 17627452 DOI: 10.1586/14737140.7.7.919] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Taxanes, paclitaxel and docetaxel, are among the most effective agents used to treat breast cancer. Nab-paclitaxel (ABI-007, Abraxane) is paclitaxel encapsulated in albumin. This differs from the more conventional formulation which uses cremophor to increase the solubility of paclitaxel (CrEL-paclitaxel). In a randomized trial that formed the basis of its regulatory approval in the USA, 3-weekly nab-paclitaxel induced a higher response rate and longer time to progression than CrEL-paclitaxel in patients with metastatic breast cancer. Except for grade 3 sensory neuropathy, nab-paclitaxel was also safer. An interim analysis from a more recent randomized Phase II trial suggests that weekly nab-paclitaxel is more effective and safer than either 3-weekly nab-paclitaxel or 3-weekly docetaxel. The superior efficacy of nab-paclitaxel is presumably due to the improved safety profile, which allows for the administration of higher doses, a greater proportion of which actually reaches the tumor. Observations on the development of nab-paclitaxel have important implications for our understanding of dose response in the use of cytotoxic drugs to treat all forms of cancer. Although it is not yet clear whether nab-paclitaxel can be routinely substituted for CrEL-paclitaxel or docetaxel in breast cancer treatment regimens, it seems highly likely that this will occur within the next 5 years.
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Affiliation(s)
- I Craig Henderson
- Adjunct Professor of Medicine, University of California, San Francisco, UCSF Comprehensive Cancer Center, San Francisco, CA 94143, USA.
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Rao R. Systemic Therapy. Breast Cancer 2014. [DOI: 10.1007/978-1-4614-8063-1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Joerger M, Thürlimann B. Chemotherapy regimens in early breast cancer: major controversies and future outlook. Expert Rev Anticancer Ther 2013; 13:165-78. [PMID: 23406558 DOI: 10.1586/era.12.172] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The addition of adjuvant chemotherapy in early breast cancer improves overall survival by approximately 10%. Recommendations favor the use of anthracyclines and taxanes in patients with luminal B disease, while the use of an anthracycline, taxane and alkylating agent is recommended in triple-negative disease. In luminal B disease, the addition of chemotherapy to endocrine treatment depends on estrogen receptor expression and overall risk. Chemotherapy is not recommended in most patients with luminal A (highly hormone-sensitive and low proliferation) breast cancer. A major controversy is the addition of adjuvant chemotherapy to endocrine treatment in patients with estrogen receptor-positive breast cancer. In some of these patients, multigene signatures such as the 21-gene recurrence score may be a useful addition to histopathology. The introduction of molecular subtypes and gene signatures improves the complexity of early breast cancer treatment, and individual institutes have to find their policy based on their histopathological information and the availability of gene signatures.
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Affiliation(s)
- Markus Joerger
- Department of Oncology & Hematology, Cantonal Hospital, Rorschacherstrasse 95, 9007 St Gallen, Switzerland.
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Dang C, Hudis C, Norton L. Epoetin Alfa: To Give or Not to Give. J Natl Cancer Inst 2013; 105:1001-3. [DOI: 10.1093/jnci/djt172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kreienberg R, Albert US, Follmann M, Kopp IB, Kühn T, Wöckel A. Interdisciplinary GoR level III Guidelines for the Diagnosis, Therapy and Follow-up Care of Breast Cancer: Short version - AWMF Registry No.: 032-045OL AWMF-Register-Nummer: 032-045OL - Kurzversion 3.0, Juli 2012. Geburtshilfe Frauenheilkd 2013; 73:556-583. [PMID: 24771925 PMCID: PMC3963234 DOI: 10.1055/s-0032-1328689] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | - U.-S. Albert
- Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Klinik
für Gynäkologie, Gynäkologische Endokrinologie und Onkologie,
Marburg
| | - M. Follmann
- Deutsche Krebsgesellschaft e. V., Bereich Leitlinien,
Berlin
| | - I. B. Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, c/o
Philipps-Universität, Marburg
| | - T. Kühn
- Klinikum Esslingen, Klinik für Frauenheilkunde und Geburtshilfe,
Esslingen
| | - A. Wöckel
- Universitätsklinikum Ulm, Klinik für Frauenheilkunde und Geburtshilfe,
Ulm
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Suleiman AA, Nogova L, Fuhr U. Modeling NSCLC progression: recent advances and opportunities available. AAPS JOURNAL 2013; 15:542-50. [PMID: 23404126 DOI: 10.1208/s12248-013-9461-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 01/23/2013] [Indexed: 12/28/2022]
Abstract
Non-small cell lung cancer (NSCLC) is one of the leading causes of death around the world with an estimated 5-year relative survival rate of 16% at diagnosis. Development of drugs treating NSCLC is not easy, and the success rate for an anticancer treatment to pass through the whole clinical development process is as low as 5%. Modeling and simulation lend themselves as tools which can potentially streamline drug development. A critical component of the models developed is a description of how the disease progresses over time and how a treatment would affect its trajectory. Our aim was to review the literature to present the models and growth functions which have been used for describing NSCLC dynamics, and how anticancer treatments can affect such dynamics, both in animals and in humans. Only a limited set of models were identified for such a purpose. Most of the models which have been used were descriptive of tumor growth, yet there were attempts to account for the underlying processes, especially in animals where it is more feasible to collect data needed for developing such models. Moreover, we discuss how modeling and simulation can aid in decision making across the different stages of drug development. Based on some encouraging results from trials of other cancer types where modeling tumor dynamics has played an important role, we propose further exploration of NSCLC using model-based techniques and further use of these techniques in designing and evaluating NSCLC trials.
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Affiliation(s)
- Ahmed Abbas Suleiman
- Department of Pharmacology, University Hospital of Cologne, Gleueler Strasse 24, 50931 Cologne, Germany.
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Abstract
Breast cancer is the most frequent cancer of women in developed countries. Systemic adjuvant chemotherapy has dramatically improved the outcome of patients treated for early stage invasive breast cancer. Among novel chemotherapeutic agents, the taxanes have emerged as the most powerful compounds since anthracycline regimens. Two taxanes are available (paclitaxel and docetaxel) and they share some characteristics, while having a number of significant differences, both in terms of preclinical and pharmacokinetic profiles and, most importantly, clinical consequences. In clinical practice, the taxanes are now standard therapy in metastatic breast cancer. Their role as monochemotherapy or in combination with anthracyclines in advanced breast cancer has suggested their potential therapeutic impact in the treatment of patients with early breast cancer. Available results in the adjuvant and neoadjuvant setting demonstrate that taxanes, used in combination with other chemotherapeutic agents or trastuzumab, or in sequential therapy, possess the capability to induce significant improvements, in particular in terms of survival, confirming the positive impact of taxanes on the natural history of breast cancer.
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Balduzzi A, Castiglione-Gertsch M. Leukemia risk after adjuvant treatment of early breast cancer. WOMENS HEALTH 2012; 1:73-85. [PMID: 19803948 DOI: 10.2217/17455057.1.1.73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Modern cancer treatment has substantially increased the survival and curability of patients with various malignancies. Therefore, favorable prognosis mandates for the evaluation of long-term complications of treatment. Since the late 1970s, adjuvant combination chemotherapy for operable breast cancer has come into widespread use. Several recent studies have estimated the risk of acute myeloid leukemia associated with these regimens. The purpose of this analysis is to discuss the risk of leukemia after early breast cancer therapy, the types of leukemia, and the relationship between the risk of leukemia and treatment with different cytotoxic agents (alkylating agents, antimetabolities, topoisomerase II inhibitors, dose-dense therapy, high-dose therapy and growth factor use) and radiotherapy.
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Affiliation(s)
- Alessandra Balduzzi
- International Breast Cancer Study Group Coordinating Center, Istituto Europeo di Oncologia, via Ripamonti 435, 20141 Milano, Italy.
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Mathieu MC, Mazouni C, Kesty NC, Zhang Y, Scott V, Passeron J, Arnedos M, Schnabel CA, Delaloge S, Erlander MG, André F. Breast Cancer Index predicts pathological complete response and eligibility for breast conserving surgery in breast cancer patients treated with neoadjuvant chemotherapy. Ann Oncol 2012; 23:2046-2052. [PMID: 22112967 DOI: 10.1093/annonc/mdr550] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The aim of neoadjuvant chemotherapy is to increase the likelihood of successful breast conservation surgery (BCS). Accurate identification of BCS candidates is a diagnostic challenge. Breast Cancer Index (BCI) predicts recurrence risk in estrogen receptor+lymph node-breast cancer. Performance of BCI to predict chemosensitivity based on pathological complete response (pCR) and BCS was assessed. METHODS Real-time RT-PCR BCI assay was conducted using tumor samples from 150 breast cancer patients treated with neoadjuvant chemotherapy. Logistical regression and c-index were used to assess predictive strength and additive accuracy of BCI beyond clinicopathologic factors. RESULTS BCI classified 42% of patients as low, 35% as intermediate and 23% as high risk. Low BCI risk group had 98.4% negative predictive value (NPV) for pCR and 86% NPV for BCS. High versus low BCI group had a 34 and 5.8 greater likelihood of achieving pCR and BCS, respectively (P=0.0055; P=0.0022). BCI increased c-index for pCR (0.875-0.924; P=0.017) and BCS prediction (0.788-0.843; P=0.027) beyond clinicopathologic factors. CONCLUSIONS BCI significantly predicted pCR and BCS beyond clinicopathologic factors. High NPVs indicate that BCI could be a useful tool to identify breast cancer patients who are not eligible for neoadjuvant chemotherapy. These results suggest that BCI could be used to assess both chemosensitivity and eligibility for BCS.
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Affiliation(s)
- M C Mathieu
- Breast Cancer Unit; INSERM Unit U981; Department of Pathology
| | - C Mazouni
- Breast Cancer Unit; Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - N C Kesty
- bioTheranostics, Inc., San Diego, USA
| | - Y Zhang
- bioTheranostics, Inc., San Diego, USA
| | | | | | - M Arnedos
- Breast Cancer Unit; INSERM Unit U981; Department of Medical Oncology; Institut Gustave Roussy, Villejuif, France
| | | | - S Delaloge
- Breast Cancer Unit; INSERM Unit U981; Department of Medical Oncology; Institut Gustave Roussy, Villejuif, France
| | | | - F André
- Breast Cancer Unit; INSERM Unit U981; Department of Medical Oncology; Institut Gustave Roussy, Villejuif, France.
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Pathologic response to short intensified taxane-free neoadjuvant chemotherapy in patients with highly proliferative operable breast cancer. Am J Clin Oncol 2012; 35:242-6. [PMID: 21358298 DOI: 10.1097/coc.0b013e318209d34c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Breast cancer treatment relies on 3 major phenotypical subtypes, including the triple-negative (TN), HER2-positive, and hormone receptor-positive (estrogen receptor/progesterone receptor) ones. We retrospectively determined the clinical and pathologic response rates to intensified taxane-free neoadjuvant chemotherapy according to these phenotypical classes in a series of patients with highly proliferative operable breast cancer, and examined the patterns of recurrence. METHODS Patients with early breast cancer with highly proliferative (S-phase fraction >4%) operable tumors of >3 cm received 4 cycles of intensified neoadjuvant chemotherapy with high-dose cyclophosphamide (doxorubicin 70 mg/m d1, cyclophosphamide 700 mg/m d1/d8, and 5 FU 700 mg/m d1-d5) every 3 weeks. RESULTS Fifty-five patients were included in the analysis. Patients with TN phenotype experienced a high pathologic complete response (pCR) rate to intensified chemotherapy in comparison with patients with HER2-positive and estrogen receptor/progesterone receptor tumors (47%, 0%, and 12%, respectively). Forty percent of patients with TN breast cancer recurred after a median follow-up of nearly 11 years, but only 22% of those achieving a pCR. CONCLUSIONS A high pCR rate to short intensified neoadjuvant chemotherapy with high-dose cyclophosphamide was achieved in patients with operable highly proliferative TN breast cancer, and pCR was associated with a low rate of recurrence.
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Abe H, Kawai Y, Mori T, Cho H, Kubota Y, Umeda T, Tani T. Feasibility of prior administration of cyclophosphamide in TC combination treatment. Breast Cancer 2012; 21:202-7. [PMID: 22696251 DOI: 10.1007/s12282-012-0381-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 05/17/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND TC (docetaxel 75 mg/m(2) and cyclophosphamide 600 mg/m(2) q3w) combination is used for neoadjuvant/adjuvant chemotherapy in primary breast cancer. The incidence of allergic reaction is reportedly more common in patients who receive docetaxel before cyclophosphamide. This study aims to determine the significance of cyclophosphamide and docetaxel administration sequence. METHODS Prospective analysis was performed of 49 consecutive patients treated with TC for stage I-IIB breast cancer from March 2010 to June 2011. Premedication was administered with granisetron, dexamethasone, and chlorpheniramine. Patient charts were reviewed for completion rate and adverse events. Two-tailed Fisher exact test was used to evaluate adverse events between prior cyclophosphamide and prior docetaxel. RESULTS Of 49 patients, 26 received docetaxel prior to cyclophosphamide and 23 received cyclophosphamide before docetaxel. There were no differences in patient characteristics between the two groups. Completion rates were 95.6 % in the prior cyclophosphamide group, and 100 % in the prior docetaxel group. The relative dose intensities of docetaxel and cyclophosphamide were 94.5 and 94.8 % in the prior cyclophosphamide group, and 98.5 and 98.7 % in the prior docetaxel group (p < 0.01). In the prior cyclophosphamide group, severe neutropenia occurred in 96 % of patients, but in only 46 % of patients in the prior docetaxel group (p < 0.01). Significantly fewer cases of skin eczema (27 versus 61 %), nausea (8 versus 48 %), stomatitis (23 versus 61 %), and diarrhea (4 versus 30 %) were observed in the prior docetaxel group as compared with the prior cyclophosphamide group (p < 0.01). Decreased incidences of fatigue (50 versus 65 %) and edema (19 versus 35 %) were found in the prior docetaxel group (p < 0.05). No difference was observed in allergic reaction or neuropathy between the two groups. CONCLUSION Patients receiving cyclophosphamide prior to docetaxel were at increased risk of several toxicities as compared with patients receiving docetaxel prior to cyclophosphamide in TC combination therapy.
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Affiliation(s)
- Hajime Abe
- Division of Breast and General Surgery, Shiga University of Medical Science Hospital, Seta-Tsukinowa, Otsu, Shiga, 520-2192, Japan,
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Chan A, Ng TRD, Yap KYL. Clinically–relevant anticancer-antidepressant drug interactions. Expert Opin Drug Metab Toxicol 2011; 8:173-99. [DOI: 10.1517/17425255.2012.645804] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Postoperative dose-dense sequential versus concomitant administration of epirubicin and paclitaxel in patients with node-positive breast cancer: 5-year results of the Hellenic Cooperative Oncology Group HE 10/00 phase III Trial. Breast Cancer Res Treat 2011; 132:609-19. [PMID: 22187126 DOI: 10.1007/s10549-011-1913-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 12/03/2011] [Indexed: 10/14/2022]
Abstract
To explore the impact of dose intensity (DI) in the adjuvant setting of breast cancer, a randomized phase III trial was conducted comparing postoperative dose-dense sequential chemotherapy with epirubicin, paclitaxel, and cyclophosphamide, methotrexate and fluorouracil (CMF)in high-risk breast cancer patients. From Oct 2000 to June 2005, 1,121 node-positive patients were randomized to dose-dense sequential epirubicin 110 mg/m(2) and paclitaxel (Taxol, Bristol Myers-Squibb, Princeton, NJ) 250 mg/m(2) (group A), or concurrent epirubicin 83 mg/m(2) and paclitaxel 187 mg/m(2) (group B), both followed by three cycles of "intensified" combination chemotherapy with CMF. By protocol design total cumulative dose and duration of treatment were identical in both groups. Dose intensity of epirubicin and paclitaxel was double in the dose-dense arm. Prophylactic treatment with granulocyte colony-stimulating factor was given with the dose-dense treatments. Disease-free survival (DFS) was the primary endpoint. At a median follow-up of 76 months, 253 patients (23%) had documented disease relapse (123 vs. 130 in groups A and B, respectively) and 208 deaths (101, group A and 107, group B) had been observed. The 5-year DFS rate of 74 and 74% and OS rate of 86 and 85% were observed for group A and group B, respectively. No differences were found in DFS or OS between the two treatment groups (P = 0.78 and P = 0.45 for DFS and OS, respectively). Safety analysis results showing that both regimens were well tolerated and safe have been previously published (Fountzilas et al. Ann Oncol 2008). No DFS or OS benefit from the dose-dense sequential epirubicin and paclitaxel was detected when compared to the concurrent administration of the same drugs. No additional safety issues were raised with long-term follow-up.
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Arun BK, Dhinghra K, Valero V, Kau SW, Broglio K, Booser D, Guerra L, Yin G, Walters R, Sahin A, Ibrahim N, Buzdar AU, Frye D, Sneige N, Strom E, Ross M, Theriault RL, Vadhan-Raj S, Hortobagyi GN. Phase III randomized trial of dose intensive neoadjuvant chemotherapy with or without G-CSF in locally advanced breast cancer: long-term results. Oncologist 2011; 16:1527-34. [PMID: 22042783 DOI: 10.1634/theoncologist.2011-0134] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To compare the pathologic complete response (pCR) rate of patients treated with 5-fluorouracil (5-FU), doxorubicin, and cyclophosphamide (FAC) versus dose-intense FAC plus G-CSF in the neoadjuvant setting and to compare the delivered dose intensity, disease-free survival (DFS) and overall survival (OS) times, and toxicity between treatment arms in patients with breast cancer. METHODS Patients were randomized to receive preoperative FAC (5-FU, 500 mg/m(2); doxorubicin, 50 mg/m(2); cyclophosphamide, 500 mg/m(2)) every 21 days for four cycles or dose-intense FAC (5-FU, 600 mg/m(2); doxorubicin, 60 mg/m(2); cyclophosphamide, 1,000 mg/m(2)) plus G-CSF every 18 days for four cycles. RESULTS Two hundred two patients were randomly assigned. The median follow-up was 7.5 years. Patients randomized to FAC plus G-CSF had a higher pCR rate as well as clinical complete response rate; however, these differences were not statistically different from those with the FAC arm. Patients in the FAC + G-CSF arm had a higher delivered dose intensity of doxorubicin in the neoadjuvant and adjuvant settings than those in the standard FAC arm. DFS and OS times were not significantly different between the two groups. However, the OS and DFS rates were significantly higher for patients who achieved a pCR than for those who did not. Thrombocytopenia, febrile neutropenia, and infection rates were higher in the FAC + G-CSF arm. CONCLUSIONS A higher delivered dose intensity of doxorubicin with the FAC + G-CSF regimen did not result in a statistically significant higher pCR rate. However, patients who achieved a pCR experienced longer DFS and OS times.
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Affiliation(s)
- Banu K Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Lee M, Cronin KA, Gail MH, Dignam JJ, Feuer EJ. Multiple imputation methods for inference on cumulative incidence with missing cause of failure. Biom J 2011; 53:974-93. [DOI: 10.1002/bimj.201000175] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 07/11/2011] [Accepted: 08/11/2011] [Indexed: 11/07/2022]
Affiliation(s)
- Minjung Lee
- Data Analysis and Interpretation Branch, Division of Cancer Control and Population Studies, National Cancer Institute, Bethesda, MD 20852, USA
| | - Kathleen A. Cronin
- Data Analysis and Interpretation Branch, Division of Cancer Control and Population Studies, National Cancer Institute, Bethesda, MD 20852, USA
| | - Mitchell H. Gail
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA
| | - James J. Dignam
- Department of Health Studies, University of Chicago, Chicago, IL 60637, USA
| | - Eric J. Feuer
- Statistical Methodology and Applications Branch, Division of Cancer Control and Population Studies, National Cancer Institute, Bethesda, MD 20852, USA
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Prognostic value of chemotherapy-induced neutropenia in early-stage breast cancer. Breast Cancer Res Treat 2011; 131:483-90. [PMID: 21971729 DOI: 10.1007/s10549-011-1799-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/21/2011] [Indexed: 01/18/2023]
Abstract
Neutropenia is one of the most important dose-limiting toxicities and often the reason for dose reduction. In this study we aimed to assess whether chemotherapy-induced neutropenia could be a marker of efficacy and associate with increased survival. Data from a retrospective survey for early breast cancer patients in our hospital were reviewed. Three hundred and thirty-five patients who had been treated with six cycles of cyclophosphamide, epirubicin, and fluorouracil (CEF) were studied. The association between chemotherapy-induced neutropenia and overall survival (OS) was assessed. According to a multivariate Cox model with time-varying covariates, hazard ratios of death were 0.434 (95% confidence interval (CI), 0.298-0.634; P < 0.001) for patients with mild neutropenia, and 0.640 (95% CI, 0.42-0.975; P = 0.038) for those with severe neutropenia. Neutropenia occurring in early breast cancer patients is an independent predictor of increased survival. These findings suggest that neutropenia in patients who receive chemotherapy is strongly associated with a better prognosis.
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Incidence of febrile neutropenia among early-stage breast cancer patients receiving anthracycline-based chemotherapy. Support Care Cancer 2011; 20:1525-32. [PMID: 21818641 DOI: 10.1007/s00520-011-1241-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 07/17/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the incidence of febrile neutropenia (FN) with adjuvant AC (doxorubicin and cyclophosphamide) chemotherapy among Asian early-stage breast cancer (ESBC) patients, to evaluate the impact of FN on chemotherapy delivery, and to identify specific risk factors that would predispose ESBC patients to FN. METHODS This was a single-center, observational, retrospective cohort study conducted in Singapore. All ESBC patients who have received the AC regimen as adjuvant chemotherapy between January 2007 and July 2010 were included into the study. Patients did not receive granulocyte colony-stimulating factors (G-CSF) as primary prophylaxis. RESULTS One hundred and eighty-nine patients and 729 cycles of chemotherapy were analyzed in this study, of which, majority were Chinese (84%). Median age of the patients was 54 years old (IQR 49-58). In total, 26 patients (13.8%) manifested at least one episode of FN, of which 17 patients developed FN during the first cycle of treatment. Patients who manifested FN received similar dose intensities of chemotherapy, compared to those patients who did not manifest FN (100% versus 98%, p = 0.95). After adjusting for age, race, and presence of comorbidities, low body mass index (BMI) (<23 kg/m(2)) was found to be associated with a higher risk of FN (OR 4.4, 95% CI = 1.65-12.01, p = 0.003). CONCLUSIONS Asian patients are at moderate risk for FN when they receive the AC regimen for treatment of ESBC. Further studies should evaluate the role of G-CSF to reduce the occurrence of FN in Asian patients with low BMI.
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Berry DA, Ueno NT, Johnson MM, Lei X, Caputo J, Rodenhuis S, Peters WP, Leonard RC, Barlow WE, Tallman MS, Bergh J, Nitz UA, Gianni AM, Basser RL, Zander AR, Coombes RC, Roché H, Tokuda Y, de Vries EGE, Hortobagyi GN, Crown JP, Pedrazzoli P, Bregni M, Demirer T. High-dose chemotherapy with autologous stem-cell support as adjuvant therapy in breast cancer: overview of 15 randomized trials. J Clin Oncol 2011; 29:3214-23. [PMID: 21768471 DOI: 10.1200/jco.2010.32.5910] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Adjuvant high-dose chemotherapy (HDC) with autologous hematopoietic stem-cell transplantation (AHST) for high-risk primary breast cancer has not been shown to prolong survival. Individual trials have had limited power to show overall benefit or benefits within subsets. METHODS We assembled individual patient data from 15 randomized trials that compared HDC versus control therapy without stem-cell support. Prospectively defined primary end points were relapse-free survival (RFS) and overall survival (OS). We compared the effect of HDC versus control by using log-rank tests and proportional hazards regression, and we adjusted for clinically relevant covariates. Subset analyses were by age, number of positive lymph nodes, tumor size, histology, hormone receptor (HmR) status, and human epidermal growth factor receptor 2 (HER2) status. RESULTS Of 6,210 total patients (n = 3,118, HDC; n = 3,092 control), the median age was 46 years; 69% were premenopausal, 29% were postmenopausal, and 2% were unknown menopausal status; 49.5% were HmR positive; 33.5% were HmR negative, and 17% were unknown HmR status. The median follow-up was 6 years. After analysis was adjusted for covariates, HDC was found to prolong relapse-free survival (RFS; hazard ratio [HR], 0.87; 95% CI, 0.81 to 0.93; P < .001) but not overall survival (OS; HR, 0.94; 95% CI, 0.87 to 1.02; P = .13). For OS, no covariates had statistically significant interactions with treatment effect, and no subsets evinced a significant effect of HDC. Younger patients had a significantly better RFS on HDC than did older patients. CONCLUSION Adjuvant HDC with AHST prolonged RFS in high-risk primary breast cancer compared with control, but this did not translate into a significant OS benefit. Whether HDC benefits patients in the context of targeted therapies is unknown.
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Affiliation(s)
- Donald A Berry
- Division of Quantitative Sciences, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA.
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Traina TA, Dugan U, Higgins B, Kolinsky K, Theodoulou M, Hudis CA, Norton L. Optimizing chemotherapy dose and schedule by Norton-Simon mathematical modeling. Breast Dis 2011; 31:7-18. [PMID: 20519801 DOI: 10.3233/bd-2009-0290] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND to hasten and improve anticancer drug development, we created a novel approach to generating and analyzing preclinical dose-scheduling data so as to optimize benefit-to-toxicity ratios. METHODS we applied mathematical methods based upon Norton-Simon growth kinetic modeling to tumor-volume data from breast cancer xenografts treated with capecitabine (Xeloda®, Roche) at the conventional schedule of 14 days of treatment followed by a 7-day rest (14-7). RESULTS the model predicted that 7 days of treatment followed by a 7-day rest (7-7) would be superior. Subsequent preclinical studies demonstrated that this biweekly capecitabine schedule allowed for safe delivery of higher daily doses, improved tumor response, and prolonged animal survival. CONCLUSIONS we demonstrated that the application of Norton-Simon modeling to the design and analysis of preclinical data predicts an improved capecitabine dosing schedule in xenograft models. This method warrants further investigation and application in clinical drug development.
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Affiliation(s)
- Tiffany A Traina
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Láng I, Kahán Z, Pintér T, Dank M, Boér K, Pajkos G, Faluhelyi Z, Pikó B, Eckhardt S, Horváth Z. [Pharmaceutical therapy of breast cancer]. Magy Onkol 2010; 54:237-254. [PMID: 20870601 DOI: 10.1556/monkol.54.2010.3.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Saurel CA, Patel TA, Perez EA. Changes to adjuvant systemic therapy in breast cancer: a decade in review. Clin Breast Cancer 2010; 10:196-208. [PMID: 20497918 DOI: 10.3816/cbc.2010.n.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Breast cancer is the second most common cause of cancer death in women among the United States. Fortunately, it continues to be an active area of research. Today, it is well recognized that breast cancer can often be a systemic disease, with micrometastatic involvement at diagnosis in many patients. Over the past decade, adjuvant systemic therapy has been used to eradicate micrometastatic disease, and it has been shown to decrease the rates of recurrence and improve the survival of patients with early-stage, resected breast cancer. Some of the success of modern adjuvant systemic therapy has come from the advent of new chemotherapy and endocrine agents but also from the development of targeted therapies, which have improved the efficacy of conventional, cytotoxic therapy. There has also been increasing awareness that the dosing and schedule of administration of systemic therapies are equally important factors in achieving better outcomes in patients with early-stage breast cancer. Growing research into the biology and genomics of breast cancer has fueled the development of more accurate risk stratification tools and helped individualize the decision to recommend adjuvant systemic therapy. Herein, we present a review of salient developments over the past decade that have helped shape the adjuvant systemic therapy of today.
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A phase I trial of dose-dense (biweekly) carboplatin combined with paclitaxel and pegfilgrastim: a feasibility study in patients with untreated Stage III and IV ovarian, tubal or primary peritoneal cancer: a Gynecologic Oncology Group study. Gynecol Oncol 2010; 118:303-7. [PMID: 20547415 DOI: 10.1016/j.ygyno.2010.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 05/17/2010] [Accepted: 05/20/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE Dose-dense regimens have been shown to improve outcome when given as adjuvant therapy to patients with breast cancer compared with their three weekly counterparts. We investigated the feasibility of a dose-dense regimen with carboplatin/paclitaxel followed by pegfilgrastim in patients with advanced ovarian cancer. We also investigated the toxicities including the percentage of patients with grade 2 or greater peripheral neurotoxicity and the clinical response of this regimen. PATIENTS AND METHODS Women with untreated Stage III or IV epithelial ovarian, (fallopian) tubal, or primary peritoneal cancer were treated with carboplatin area under the curve (AUC) 5 and paclitaxel 175 mg/m(2) day one, and pegfilgrastim 6 mg day two every 2 weeks for six cycles. RESULTS Between 9/06 and 9/08, 43 patients enrolled. Thirty-one patients completed six or more cycles of therapy. The dose limiting toxicities resulting in treatment discontinuation included: grade 3 and 4 neuropathy, grade 4 thrombocytopenia, grade 4 thrombocytopenia/grade 3 febrile neutropenia, and grade 4 supraventricular tachycardia. Twelve patients (30%) had >or=grade 2 neuropathy from this regimen. The overall response rate in patients with measurable disease was 58% (11 out of 19). CONCLUSION Dose-dense carboplatin/paclitaxel appears to be effective. However, based on dose limiting toxicities occurring when administering 6 cycles of treatment, it is not feasible. Given the neuropathy and thrombocytopenia, we do not recommend 6 cycles of this regimen without modification.
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Ejlertsen B, Mouridsen HT, Jensen MB, Andersen J, Andersson M, Kamby C, Knoop AS. Cyclophosphamide, methotrexate, and fluorouracil; oral cyclophosphamide; levamisole; or no adjuvant therapy for patients with high-risk, premenopausal breast cancer. Cancer 2010; 116:2081-9. [PMID: 20186830 DOI: 10.1002/cncr.24969] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The Danish Breast Cancer Cooperative Group (DBCG) 77B trial examined the relative efficacy of levamisole, single-agent oral cyclophosphamide, and the classic combination of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) against no adjuvant systemic therapy in high-risk breast cancer patients. The authors report the results from that trial after a potential follow-up of 25 years. METHODS Between 1977 and 1983, 1146 premenopausal patients who had tumors >5 cm or positive axillary lymph nodes were assigned randomly to 1 of 4 options: no systemic therapy, levamisole 5 mg weekly for 48 weeks (the levamisole arm), oral cyclophosphamide 130 mg/m(2) on Days 1 through 14 every 4 weeks for 12 cycles (the C arm), or oral cyclophosphamide 80 mg/m(2) on Days 1 through 14 plus methotrexate 30 mg/m(2) and fluorouracil 500 mg/m(2) intravenously on Days 1 and 8 every 4 weeks for 12 cycles (the CMF arm). RESULTS The 10-year invasive disease-free survival (IDFS) rate was 38.6% in the control arm compared with 55.5% in the C arm, 48.8% in the CMF arm, and 35.2% in the levamisole arm. Compared with the control arm, the hazard ratio for an IDFS event was 0.62 in the C arm (P = .001) and 0.70 in the CMF arm (P = .01). The hazard ratio for death was 0.70 in both the C arm (P = .02) and the CMF arm (P = .02) at 10 years, and the overall survival (OS) benefit was maintained during 25 years of follow-up. No significant differences were observed in IDFS or OS between the C arm and the CMF arm or between the levamisole arm and the control arm. CONCLUSIONS Compared with controls, both cyclophosphamide and CMF significantly improved disease-free survival and OS, and the benefits persisted for at least 25 years in premenopausal patients who had high-risk breast cancer.
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Affiliation(s)
- Bent Ejlertsen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark.
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Hayes DF. Is there a standard type and duration of adjuvant chemotherapy for early stage breast cancer? Breast 2010; 18 Suppl 3:S131-4. [PMID: 19914531 DOI: 10.1016/s0960-9776(09)70287-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Adjuvant chemotherapy clearly reduces the odds of subsequent breast cancer recurrence, metastases, and mortality. There are three main areas of interest regarding adjuvant chemotherapy: (1) Should everyone receive it? (2) Is there an optimal regimen for everyone or selected individuals at this time? And (3) Can we improve on existing regimens? A multitude of investigations from around the world have addressed the three questions raised above. Increasingly we are able to identify both those patients most likely to need adjuvant chemotherapy (prognosis) and, perhaps, those most likely to benefit from it (prediction). In this regard, web-based, multi-factorial calculators, best exemplified by Adjuvant!, permit a patient and her caregiver to estimate her absolute odds of benefit from chemotherapy, thus better informing women in their assessment of benefits and risks (http://www.adjuvantonline.com/index.jsp). The answer to the next question, whether there is an optimal regimen, dose, and schedule of adjuvant chemotherapy, is, frankly, "no". Clinical research over the last four decades has strongly suggested the following principles: In summary, it is clear that adjuvant chemotherapy is beneficial for women with early stage breast cancer, and it is clear that selected regimens, based on specific agents, cumulative and cycle-specific dose, and schedule may affect the relative efficacy. It is not clear which patients are most likely to benefit from any adjuvant chemotherapy at all, or from specific strategies. Thus, at this time there is no single standard type or duration of adjuvant chemotherapy, and physicians should choose from regimens that have proven benefit as demonstrated in randomized Phase III trials.
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Affiliation(s)
- Daniel F Hayes
- University of Michigan Comprehensive Cancer Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
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