Factors predicting for efficacy and safety of docetaxel in a compassionate-use cohort of 825 heavily pretreated advanced breast cancer patients

A Novel Systematic Oxidative Stress Score Predicts the Prognosis of Patients with Operable Breast Cancer

Background

Breast cancer was associated with imbalance between oxidation and antioxidation. Local oxidative stress in tumors is closely related to the occurrence and development of breast cancer. However, the relationship between systematic oxidative stress and breast cancer remains unclear. This study is aimed at exploring the prognostic value of systematic oxidative stress in patients with operable breast cancer.

Methods

A total of 1583 operable female breast cancer patients were randomly assigned into the training set and validation set. The relationship between systematic oxidative stress biomarkers and prognosis were analyzed in the training and validation sets.

Results

The systematic oxidative stress score (SOS) was established based on five systematic oxidative stress biomarkers including serum creatinine (CRE), serum albumin (ALB), total bilirubin (TBIL), lactate dehydrogenase (LDH), and blood urea nitrogen (BUN). SOS was an independent prognostic factor for operable breast cancer patients. A nomogram based on SOS and clinical characteristics could accurately predict the prognosis of operable breast cancer patients, and the area under the curve (AUC) of the nomogram was 0.823 in the training set and 0.872 in the validation set, which was much higher than the traditional prognostic indicators.

Conclusions

SOS is an independent prognostic indicator for operable breast cancer patients. A prediction model based on SOS could accurately predict the outcome of operable breast cancer patients.

Association of post-diagnosis cardiorespiratory fitness with cause-specific mortality in cancer

AIMS

The prognostic importance of post-diagnosis assessment of cardiorespiratory fitness (CRF) in cancer patients is not well established. We sought to examine the association between CRF and mortality in cancer patients.

METHODS AND RESULTS

This was a single-centre cohort analysis of 1632 patients (58% male; 64 ± 12 years) with adult-onset cancer who were clinically referred for exercise treadmill testing a median of 7 [interquartile range (IQR): 3-12] years after primary diagnosis. Cardiorespiratory fitness was defined as peak metabolic equivalents (METs) achieved during standard Bruce protocol and categorized by tertiles. The association between CRF and all-cause and cause-specific mortality was assessed using multivariable Cox proportional hazard models adjusting for important covariates. Median follow-up was 4.6 (IQR: 2.6-7.0) years; a total of 411 deaths (229, 50, and 132 all-cause, cardiovascular (CV), and cancer related, respectively) occurred during this period. Compared with low CRF (range: 1.9-7.6 METs), the adjusted hazard ratio (HR) for all-cause mortality was 0.38 [95% confidence interval (CI): 0.28-0.52] for intermediate CRF (range: 7.7-10.6 METs) and 0.17 (95% CI: 0.11-0.27) for high CRF (range: 10.7-22.0 METs). The corresponding HRs were 0.40 (95% CI: 0.19-0.86) and 0.41 (95% CI: 0.16-1.05) for CV mortality and 0.40 (95% CI: 0.26-0.60) and 0.16 (95% CI: 0.09-0.28) for cancer mortality, respectively. The adjusted risk of all-cause, CV, and cancer mortality decreased by 26%, 14%, and 25%, respectively with each one MET increment in CRF.

CONCLUSION

Cardiorespiratory fitness is a strong, independent predictor of all-cause, CV, and cancer mortality, even after adjustment for important clinical covariates in patients with certain cancers.

Antioxidant and apoptotic effects of Callistemon lanceolatus leaves and their compounds against human cancer cells

Callistemon lanceolatus (Myrtaceae) has been utilized in folk medicine and its pharmacological properties are widely studied. Phytochemicals are effectively recognized as bases of pharmacologically potent drugs for the development of anticancer therapeutics. The free radical scavenging potential of numerous extracts of C. lanceolatus leaves, Hexane leaf extract (HLE), Chloroform leaf extract (CLE), Ethyl acetate leaf extract (ELE), Methanol leaf extract (MLE), and Aqueous leaf extract (ALE)) were determined by Biochemical assay. We evaluated the anticancer activity of C. lanceolatus leaves extracts against different human cancer cell lines viz liver cancer cells (HepG2), breast cancer cells (MCF7), and normal human embryonic kidney (HEK 293) cell line. The ELE and MLE extracts of C. lanceolatus leaves showed potential antiproliferative effects on HepG2 cells. On the basis of free radical scavenging potential and cytotoxicity studies, ELE and MLE extracts of C. lanceolatus leaves are further evaluated in detail for numerous biological activities. ELE and MLE extracts reduced the cell growth, ROS generation, lowering the potential of cell migration and inhibits the metastatic activity in HepG2 cell lines. ELE and MLE extracts treated HepG2 cells showed down-regulation of STAT3 and up-regulation of p53 and inhibition of cdk2 and cyclin A activity. Phytochemicals analysis have shown that the ELE and MLE possess some anticancer compounds like 4-Fluoro-2-trifluoromethylbenzoic acid, neopentyl ester; fumaric acid, di(pent-4-en-2-yl) ester; 2,3-Dihydro-3,5-dihydroxy-6-methyl-4H-pyran-4-one and 2-Furancarboxaldehyde,5-(hydroxymethyl). Molecular docking results demonstrate that interactions of compounds present in ELE and MLE extracts with the SH2 domain of STAT3, might be responsible for their inhibitory effects. We have further concluded that the ELE and MLE extracts of C. lanceolatus arrests the cells at S and G2/M phase and subsequently induced cell death by regulating the DNA damage in HepG2 cells.

Dose Rounding of Biologic and Cytotoxic Anticancer Agents: A Position Statement of the Hematology/Oncology Pharmacy Association

Purpose:

To present a position statement from the Hematology/Oncology Pharmacy Association (HOPA) that pertains to dose rounding of biologic and cytotoxic anticancer agents.

Methods:

The HOPA Standards Committee organized a work group of oncology pharmacist specialists to examine the safety and value of dose rounding of biologic and cytotoxic anticancer agents. Primary literature that describes methods for dose rounding, with clinical or economic data, were analyzed. Relevant pharmacokinetic characteristics and aspects of product formulation were considered. Issues for institutional application were addressed.

Results:

Rounding of biologic and cytotoxic agents within 10% of the ordered dose is designated as acceptable for routine clinical care. Dose changes ≤ 10% are not expected to reduce the safety or effectiveness of therapy. The rounding amount—10%—is rational in the context of standard dose adjustments for patient tolerance and tumor response (≥ 20%), clinical trial deficiency criteria (> 10%), and the influence of interpatient pharmacokinetic variability. HOPA supports the use of the same threshold for dose rounding of anticancer drugs as that used for palliative and curative therapy. Potential exceptions to dose rounding are discussed.

Conclusion:

Dose rounding reduces waste and health care costs. HOPA recommends that each institution develop its own dose-rounding policy that addresses biologic and cytotoxic agents. Institutional guidelines for dose rounding of anticancer agents, including criteria for automatic dose rounding, the allowable percentage, and institutional processes for operationalizing and documenting dose rounding, should be determined by collaborative stakeholder consensus. Exceptions to dose rounding should be determined a priori. Additional studies that evaluate the impact of dose rounding on patient outcome are warranted.

Design, synthesis and biological evaluation of novel pyridine-thiazolidinone derivatives as anticancer agents: Targeting human carbonic anhydrase IX

In order to obtain novel Human carbonic anhydrase IX (CAIX) inhibitors, a series of pyridine-thiazolidinone derivatives was synthesized and characterized by various spectroscopic techniques. The binding affinity of the compounds was measured by fluorescence binding studies and enzyme inhibition activity using esterase assay of CAIX. It was observed that compound 8 and 11 significantly inhibit the CAIX activity with the IC₅₀ value, 1.61 μM and 1.84 μM, respectively. The binding-affinity of compound 8 and 11 for CAIX was significantly high with their K_D values 11.21 μM and 2.32 μM, respectively. Docking studies revealed that compound 8 and 11 efficiently binds in the active site cavity of CA IX by forming sufficient numbers of H-bonds and van der Waals interactions with active side residues. All the compounds were further screened in vitro for anticancer activity and found that compound 8 and 11 exhibit considerable anticancer activity against MCF-7 and HepG-2 cell lines. All these findings suggest that compound 8 and 11 may be further exploited as a novel pharmacophore model for the development of anticancer agents.

Development of a pharmacist-coordinated system of chemotherapy protocols in an integrated healthcare delivery organization

Objectives. To develop and coordinate protocols for chemotherapy regimens in a large integrated healthcare organization; to disseminate protocols in a timely fashion; to maintain protocols for continuous quality improvement; and to promote utilization of protocol-based chemotherapy.

Methods. Two interdisciplinary groups reviewed the acceptability, accessibility, and appropriateness of the existing protocols, and proposed recommendations to be implemented by the Systemic Therapy Program of the agency.

Results. A standard protocol format and a pharmacist-coordinated protocol system were developed. Protocols were relocated from the Intranet to the network computer directory and Internet website for increased accessibility. To date, 172 protocols are available on the network directory and the website, with 87% (150/172) reviewed by pharmacists and physicians of an interdisciplinary review panel. Preliminary analysis shows increased healthcare professionals’ satisfaction and a protocol use in 77% of patients treated.

Conclusion. A pharmacist-coordinated chemotherapy protocol system improves protocol dissemination, protocol compliance, and chemo-therapy delivery and safety. The project enhances the pharmacist profile and credibility within the organization.

Predictors for chemotherapy-related severe or febrile neutropenia: a review of the clinical literature

Purpose. This paper summarizes a literature review of the risk factors and predictors for chemo-therapy-related severe or febrile neutropenia (grades 3 and 4). It explores the extent to which the literature supports the current ASCO guidelines, and assesses the feasibility of developing a predictive algorithm for patients who would benefit from rHuG-CSF (Neupogen).

Methods. An electronic literature search for English articles and abstracts identified 718 abstracts for review. From these, 121 articles were reviewed in depth. The review captured risk factors and predictors for grade 3-4 and/or febrile neutropenia, study design, patient characteristics, chemotherapy treatment, and the incidence of grade 3-4 and/or febrile neutropenia.

Results. Twenty-eight potential risk factors and predictors for severe or febrile neutropenia among cancer patients were identified and could be classified as patient-related, treatment-related, or disease-related characteristics. Some results were inconsistent across studies due to a lack of standardized methods of assessment and reporting. Approximately 1/3 of the factors were mentioned in more than one study and provided information on the statistical significance of findings. Several factors had cross-study support of their value and confirmed previous findings. Strong predictors of severe/febrile neutropenia included advanced age, performance status, myelosuppressive chemotherapy regimen, early low blood counts, the depth of the absolute neutrophil count (ANC) nadir, and a precipitous, early drop in blood counts of all hematopoietic cell types.

Conclusions. This literature review identified several key predictors and risk factors for development of grades 3 and 4 neutropenia in cancer patients. While additional confirmation is needed, there is sufficient consistency in the literature to support use of risk factors to identify patients who may need supportive care. Some of these risk factors were included in the ASCO CSF guidelines for the use of prophylactic support such as G-CSF; however, the ASCO publications have not included other important risk factors, such as age and early reduced ANC levels.

Synthesis, antiamoebic and molecular docking studies of furan-thiazolidinone hybrids

In continuation of our previous work, a series of furan-thiazolidinone hybrids was prepared by Knoevenagel condensation of 3-(furan-2-ylmethyl)-2-(phenylimino)-1, 3-thiazolidin-4-one with different aryl aldehydes in presence of strong base. Some members of the series exhibited remarkable antiamoebic activity and cell viability. Three compounds (3, 6 and 11) showed excellent binding energy for Entamoeba histolytica O-acetyle-l-serine sulfohydrolase and Entamoeba histolytica thioredoxin reductase. These compounds demonstrated significant inhibition of O-acetyle-l-serine sulfohydrolase. The promising antiamoebic activity and enzymatic assay of 3, 6 and 11 make them promising molecules for further lead optimization in the development of novel antiamoebic agents.

Protective effect of astragalus polysaccharides on liver injury induced by several different chemotherapeutics in mice

Side effects are an unavoidable consequence of chemotherapy drugs, during which liver injury often takes place. The current study was designed to investigate the protective effect of Astragalus polysaccharides (APS) against the hepatotoxicity induced by frequently-used chemical therapy agents, cyclophosphamide (CTX), docetaxel (DTX) and epirubicin (EPI)) in mice. Mice were divided into five groups, controls, low or high dose groups (DTXL, CTXL, EPIL or DTXH, CTXH, EPIH), and low or high dose chemotherapeutics+APS groups (DTXL+APS, CTXL+APS, EPIL+APS or DTXH+APS, CTXH+APS, EPIH+APS). Controls were treated with equivalent normal saline for 28 days every other day; low or high dose group were intraperitoneal (i.p) injected with low or high doses of CTX, DTX and EPI for 28 days every other day; low or high dose chemotherapeutics+APS group were separately intraperitoneal (i.p) injected with chemotherapeutics for 28 days every other day and i.p with APS (100 mg/kg) for 7 days continually from the 22th to the 28th days. The body weight, serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), histopathological features, and ultrastructure morphological change of liver tissues, protein expression level of caspase-3 were estimated at different time points. With high dose treatment of DTX, CTX and EPI, weight gain was inhibited and serum levels of ALT and AST were significantly increased. Sections of liver tissue showed massive hepatotoxicity in CTXH group compared to the control group, including hepatic lobule disorder, granular and vacuolar degeneration and necrosis in hepatic cells. These changes were confirmed at ultrastructural level, including obvious pyknosis, heterochromatin aggregation, nuclear membrane resolution, and chondrosome crystal decrease. Western blotting revealed that the protein levels of caspase-3 increased in CTXH group. The low dose groups exhibited trivial hepatotoxicity. More interestingly, after 100 mg/kg APS, liver injury was redecued not only regarding serum transaminase activities (low or high dose chemotherapeutics+APS group), but also from pathological and ultrastructural changes and the protein levels of caspase-3 (CTXH+APS group). In conclusion, DTX, CTX and EPI induce liver damage in a dose dependent manner, whereas APS exerted protective effects.

Prognostic significance of pretreatment serum levels of albumin, LDH and total bilirubin in patients with non-metastatic breast cancer

Liver function tests (LFTs) have been reported as independent predictors of non-liver disease-related morbidity and mortality in general population and cancer patients. In this study, we evaluated the relationship between pretreatment serum LFTs and overall survival (OS) in non-metastatic Caucasian breast cancer patients. Seven LFTs, including albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase (LDH), total bilirubin and total protein, were measured in pretreatment serum from 2425 female Caucasian patients with newly diagnosed, histologically confirmed non-metastatic invasive breast cancer. Multivariate Cox model was used to estimate hazard ratio (HR) and 95% confidence interval (CI) for the association of individual LFTs with 5-year OS while adjusting for age, smoking status, pathological characteristics and treatment regimen. We found that serum albumin, LDH and total bilirubin were significantly associated with 5-year OS in multivariate Cox analyses. Patients with higher albumin level exhibited 45% reduced risk of death (HR = 0.55, 95% CI: 0.40-0.75) compared with those with lower albumin level. Patients with higher total bilirubin level had a nearly 40% reduction in the risk of death (HR = 0.62, 95% CI: 0.45-0.85) and patients with higher LDH levels had a 1.42-fold increased risk of death (HR = 1.42, 95% CI: 1.08-1.88). Furthermore, cumulative analysis showed a significant dose-response trend of significantly increasing risk of death with increasing number of unfavorable LFT levels. Our result highlighted the potential of using pretreatment serum levels of albumin, LDH and total bilirubin as prognostic factors for OS in patients with non-metastatic breast cancer.

Cost effectiveness of integrated medicine in patients with cancer receiving anticancer chemotherapy

PURPOSE

Ambulatory chemotherapy is patient friendly but may result in toxicity-induced unscheduled hospitalizations (TIUHs). This emerging issue may increase health care costs. We studied the cost effectiveness of a hospital-home monitoring program based on systematic iterative telephone calls after chemotherapy.

PATIENTS AND METHODS

We retrospectively evaluated the rates of chemotherapy-induced unscheduled hospitalizations in patients who were treated in August 2008. Patients were contacted by telephone 1 day before chemotherapy and on the second and eighth days after undergoing chemotherapy. Costs associated with TIUHs were calculated and compared with those of a cohort concomitantly treated using the standard follow-up procedure.

RESULTS

A total of 259 patients entered the hospital-home monitoring program. They were compared with 86 patients who had similar characteristics but underwent the standard treatment and follow-up procedure. Inclusion in the hospital-home monitoring program resulted in patients experiencing TIUHs approximately half as frequently as patients in the other group (2.4% v 4.9%; P < .01). Patients in the program experienced TIUHs for a median length of stay of 4 days, representing a nonsignificant reduction in duration of hospitalization (P not significant). Consequently, through a two-fold reduction in TIUH annual incidence, this program represents a reduction in unscheduled hospitalizations per year of 383 days, decreasing hospital costs by €201.468 ($292,468) per year.

CONCLUSION

The hospital-home monitoring program is a cost-effective strategy for offering ambulatory chemotherapy treatment to patients with cancer. This program has become our standard procedure for ambulatory chemotherapy in patients with cancer.

Optimal outcomes for liver-dominant metastatic breast cancer with transarterial chemoembolization with drug-eluting beads loaded with doxorubicin

The purpose of this study was to evaluate the efficacy of image-guided delivery of locoregional chemotherapy to breast cancer hepatic metastases using doxorubicin-loaded drug-eluting beads (DEBDOX). An IRB-approved multi-center, prospective, open, non-controlled repeat treatment registry to investigate the safety and efficacy of doxorubicin microspheres in the treatment of patients with unresectable liver metastasis from breast cancer was reviewed. Statistical analysis was performed with differences of P < 0.05 considered significant. About 40 patients with metastatic breast cancer (MBC) to the liver underwent a total of 75 image-guided procedures with hepatic arterial drug-eluting beads loaded with doxorubicin (DEBDOX). Treatment was well tolerated with a total of eight patients sustaining 13 adverse events within the 30 days of each treatment session. All adverse events were either a grade I or grade II in toxicity. After a median follow-up of 12 months in all patients, the hepatic progression-free survival was a median of 26 months and overall survival was a median of 47 months. The treatment of hepatic metastasis from MBC using DEBDOX is an effective local therapy with very high response rates and a very safe toxicity profile. In comparison to chemotherapy alone, consideration of hepatic-directed therapy is warranted in patients with liver-dominant metastatic disease.

Health-related quality of life as prognostic factor for response, progression-free survival, and survival in women with metastatic breast cancer

The purpose of this study was to, on an exploratory basis, investigate the role of health-related quality of life (HRQoL) at randomization as an independent prognostic factor for response to treatment, progression-free survival (PFS), and survival. In the TEX trial, 287 patients with locally advanced or distant metastatic breast cancer were randomized to either epirubicin and paclitaxel (ET) or epirubicin, paclitaxel, and capecitabine (TEX). Treatment was repeated every 3 weeks. The EORTC QLQ-C30 questionnaire was used to assess HRQoL before randomization. A total of 252 (88%) patients completed EORTC QLQ-C30 before randomization. Clinical conditions included in the multivariate model were age, number of metastases, ECOG performance status, time between diagnosis and randomization, and treatment arm. Univariate analysis revealed an association between prolonged survival and the HRQoL variables global health, physical functioning, role functioning, fatigue, and pain (P < 0.01). After controlling for clinical conditions, only fatigue remained statistically significant. No statistically significant relationships were found between HRQoL and PFS. In the analysis of the association between HRQoL and response to treatment, role functioning, social functioning, fatigue, nausea/vomiting, and appetite loss remained statistically significant. HRQoL variables could act as important predictors of response to treatment, progression-free survival, and overall survival in women with metastatic breast cancer.

Ixabepilone plus capecitabine in metastatic breast cancer patients with reduced performance status previously treated with anthracyclines and taxanes: a pooled analysis by performance status of efficacy and safety data from 2 phase III studies

Patients with metastatic breast cancer (MBC) previously treated with anthracyclines and taxanes often have decreased performance status secondary to extensive tumor involvement. Here, we report the pooled analysis of efficacy and safety data from two similarly designed phase III studies to provide a more precise estimate of benefit of ixabepilone plus capecitabine in MBC patients with Karnofsky's performance status (KPS) 70-80. Across the studies, anthracycline/taxane-pretreated MBC patients were randomized to receive ixabepilone plus capecitabine or capecitabine alone. Individual patient data for KPS 70-80 subset (n = 606) or KPS 90-100 subset (n = 1349) from the two studies were pooled by treatment. Analysis included overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and safety. In patients with reduced performance status (KPS 70-80), ixabepilone plus capecitabine was associated with improvements in OS (median: 12.3 vs. 9.5 months; HR, 0.75; P = 0.0015), PFS (median: 4.6 vs. 3.1 months; HR, 0.76; P = 0.0021) and ORR (35 vs. 19%) over capecitabine alone. Corresponding results in patients with high performance status (KPS 90-100) were median OS of 16.7 versus 16.2 months (HR, 0.98; P = 0.8111), median PFS of 6.0 versus 4.4 months (HR, 0.58; P = 0.0009), and ORR of 45 versus 28%. The safety profile of combination therapy was similar between the subgroups. Ixabepilone plus capecitabine appeared to show superior efficacy compared to capecitabine alone in MBC patients previously treated with anthracyclines and taxanes, regardless of performance status, with a possible OS benefit favoring KPS 70-80 patients (ClinicalTrials.gov identifiers: NCT00080301 and NCT00082433).

Estrogen receptor expression and docetaxel efficacy in patients with metastatic breast cancer: a pooled analysis of four randomized trials

BACKGROUND

Differences in the efficacy of various chemotherapies in patients with estrogen receptor (ER)(+) metastatic breast cancer are not well understood. In the present study, we assessed the efficacy of docetaxel in patients with metastatic breast cancer according to ER expression.

METHODS

The efficacy of docetaxel in terms of the response rate and progression-free survival (PFS) time was analyzed according to ER expression in four randomized trials comparing a docetaxel-based regimen with a nontaxane regimen that included a total of 1,631 patients. The odds ratio for tumor response was estimated with logistic regression and a hazard ratio (HR) for PFS was estimated with Cox proportional hazards models.

FINDINGS

ER expression was assessable in 1,037 patients included in these trials (64%). ER was expressed in 601 tumors (58%). Docetaxel was associated with a similarly higher response rate in both patients with ER(+) (odds ratio, 2.90; 95% confidence interval [CI], 1.72-4.87) and patients with ER(-) (odds ratio, 2.55; 95% CI, 1.44-4.51) disease. The lower hazard for disease progression with docetaxel was also similar in ER(+) (HR, 0.82; 95% CI, 0.67-1.00) and ER(-) (HR, 0.86; 95% CI, 0.70-1.07) cancers. The effect of docetaxel was not different in ER(+) and ER(-) disease, in terms of both the response rate and PFS time (interaction test, p = .77 and p = .93).

INTERPRETATION

Docetaxel produces a higher response rate and lower risk for disease progression to a statistically similar extent in both patients with ER(+) and patients with ER(-) metastatic breast cancer.

Pharmacologic treatment of male breast cancer

Male breast cancer is an uncommon condition. It often occurs in settings in which there is an imbalance between androgens and oestrogens. Genetics plays an important role, as many cases are associated with mutations in BRCA2 or other genes. Male breast cancer occurs at an older age than female breast cancer and is frequently diagnosed at a later stage. Tumors are predominantly oestrogen and progesterone positive. Prognosis is approximately equivalent to that of breast cancer in females when matched for age, stage and hormonal receptors. The recommended treatment for male breast cancer is similar to that for breast cancer in postmenopausal females. However, the presence of androgens in males has a strong effect on the hormonal milieu and the ability of male patients to respond to hormonal agents. When pharmacologic treatment is required, tamoxifen is effective for first-line therapy. Other hormonal approaches such as orchiectomy, aromatase inhibitors and androgen ablation may be useful in later lines of therapy.

Prognostic factors and predictive model in patients with advanced biliary tract adenocarcinoma receiving first-line palliative chemotherapy

BACKGROUND

Advanced biliary tract adenocarcinoma (BTA) has been a rare but fatal cancer. If unresectable, palliative chemotherapy improved the quality and length of life, but to the authors' knowledge, prognostic factors in such patients have not been well established to date. In the current study, prognostic factors were investigated in patients with advanced BTA receiving first-line palliative chemotherapy.

METHODS

Data from 213 patients with advanced BTA who were in prospective phase 2 or retrospective studies from September 2000 through October 2007 were used.

RESULTS

With a median follow-up duration of 29.7 months, the median overall survival (OS) was 7.3 months (95% confidence interval [95% CI], 6.3 months-8.3 months). A Cox proportional hazards model indicated that metastatic disease (hazards ratio [HR], 1.521; P=.011), intrahepatic cholangiocellular carcinoma (HR, 1.368; P=.045), liver metastasis (HR, 1.845; P<.001), Eastern Cooperative Oncology Group performance status (HR, 1.707; P<.001), and alkaline phosphatase level (IU/L) (HR, 1.001; P<.001) were statistically significant independent predictors of poor prognosis. Patients were classified into 3 risk groups based on the prognostic index (PI), which was constructed using the regression coefficients of each variable. The median OS was 11.5 months (95% CI, 9.6 months-13.5 months) for the low-risk group (PI<or=1.5; n=67), 7.3 months (95% CI, 5.7 months-8.9 months) for the intermediate-risk group (PI>1.5 but <or=2.2; n=75), and 3.6 months (95% CI, 2.9 months-4.1 months) for the high-risk group (PI>2.2; n=70 [P<.001]).

CONCLUSIONS

Five prognostic factors in patients with advanced BTA were identified. The predictive model based on PI appears to be promising and may be used for the management of individual patients and to guide the design of future clinical trials, although external validation is needed.

Capecitabine and docetaxel combination for the treatment of breast cancer

The management of breast cancer depends on the tumor and patient's characteristics. Anthracycline-based regimens have been proven to decrease the risk of relapse and prolong survival time in breast cancer. Taxanes have been incorporated not only into metastatic breast cancer but also into adjuvant regimens. Capecitabine, an oral fluoropyrimidine carbamate, has good single-agent activity and, together with docetaxel, demonstrated preclinical synergy and a survival benefit in metastatic breast cancer. Recent analyses show that capecitabine/docetaxel dosing flexibility for managing side effects does not compromise efficacy, and define this combination regimen as an important treatment option for its efficacy, tolerability and cost-effectiveness.

Cancer chemotherapy I: hepatocellular injury

Although hepatotoxicity is a frequent concern with all medications, chemotherapeutic agents are more often implicated in causing liver damage than most other drug classes. In many instances, these reactions are considered dose related because cytotoxic therapy directed at rapidly growing cancer cells may readily impact hepatocytes even though they are dividing more slowly. Because the stakes (remission of cancer) are high, so are the risks that the oncologist and the patient are willing to assume. The dose of many chemotherapeutic agents is limited by the toxic effects on the lungs, bone marrow, kidneys, and gastrointestinal system, including the liver. An awareness of the toxic potential of each chemotherapeutic agent is necessary before initiation of new oncologic treatments.

Factors determining outcome after third line chemotherapy for metastatic breast cancer

Patients with metastatic breast cancer (MBC) are increasingly offered third line chemotherapy. We have reviewed the response rate (RR), time to progression (TTP) and survival of 149 patients in this setting and have investigated factors that influence their outcome. The RR, TTP and survival were 30%, 4 and 8 months, respectively, and should serve as a benchmark for future studies. Response to previous chemotherapy was the only independent variable predicting RR, TTP and survival, p=0.025, 0.04 and 0.004, respectively. Thirty-two percent of patients did not respond to the first two lines of chemotherapy and had a lower RR and a significantly shorter TTP and survival. In conclusion, third line chemotherapy for MBC is sometimes effective in patients who have responded to previous chemotherapy. Patients who do not respond to the first two lines of chemotherapy should be considered for clinical trials or supportive care.

A phase II trial of docetaxel (Taxotere) as second-line chemotherapy in patients with metastatic breast cancer

The efficacy and tolerability of docetaxel 100 mg/m(2) every 3 weeks as second-line chemotherapy in patients with metastatic breast cancer was investigated. In addition, the efficacy of a 3-day prophylaxis against cumulative dose-related fluid retention was examined with methylprednisolone 32 mg twice daily for 3 days starting 12 and 3 h before the docetaxel infusion together with oral cetirizine 10 mg 12 and 3 h before start of docetaxel for prevention of acute hypersensitivity reactions. According to the intent to treat-analysis 35% (95%CI: 25; 46) of the 94 patients entered responded to therapy. Their median survival was 12 months (range 0-20 months). The respective response rate for the 87 patients eligible for response evaluation was 37% (95%CI: 27; 48). Their median duration of response was 8 months (range 3-12 months), their median time to progression was 4 months (range 1-12 months). The corresponding response rate in the eligible patient cohort with anthracycline-resistant disease was 28% (95%CI: 15; 45) and increased to 44% (95%CI: 30; 59) in the cohort with non-anthracycline-resistant disease. Patients with visceral metastases responded in 36% and patients with > or = 3 organs involved in 33%. In a retrospective analysis, the 3-day premedication of corticosteroids and antihistamines proved to be as effective as the established but more toxic 5-day regimen in delaying and preventing the occurrence of docetaxel derived toxicities especially the cumulative fluid retention. In conclusion, docetaxel represents one of the most active agents for second-line treatment of metastatic breast cancer, especially for anthracycline-resistant patients. Due to comparable effectiveness of the 5-day regimen which is widely used by others and the 3-day premedication tested in this trial the latter proved to be more favourable and was therefore recommended for future therapies.

Impact of chemotherapy beyond the first line in patients with metastatic breast cancer

PURPOSE

The goal of this study was to determine which benefit could be brought by the succession of chemotherapy lines in patients treated for metastatic breast cancer and to identify patients who benefit from these treatments.

PATIENTS AND METHODS

Nine hundred and thirty four patients with metastatic breast cancer diagnosed between 1992 and 2002 were studied. A total of 772, 505, 283, 127 and 55 patients received a first, second, third, fourth and fifth line of chemotherapy, respectively. The evaluation of benefit in each chemotherapy lines was based on time of disease control (TDC). TDC is defined as time between the date of the beginning of treatment and the date of progression of disease or death. In case of early progressive disease or progression diagnosed at the first evaluation, TDC value is zero. Cox proportional hazards model was used to identify factors that could influence the TDC in each line of chemotherapy.

RESULTS

Medians duration of TDC are 9.3 [0-120], 5.9 [0-83.6], 4.63 [0-37.2], 4.1 [0-36.7] and 0.23 months [0-15] in first, second, third, fourth and fifth lines, respectively. More interestingly, TDC was longer than 6 months in 50.5% of patients treated with second line, 40% with third line, 35% with fourth line and 23.5% with fifth line. These results justify the therapeutic succession of chemotherapy lines in metastatic breast cancer. Only one factor influences the duration of TDC for each line of treatment: duration of TDC observed in the previous line.

Potentiation of mammary cancer inhibition by combination of antagonists of growth hormone-releasing hormone with docetaxel

Antagonists of growth hormone-releasing hormone (GHRH) are being developed for the treatment of various cancers. In this study, we investigated the effectiveness of treatment with GHRH antagonist JMR-132 alone and in combination with docetaxel chemotherapy in nude mice bearing MX-1 human breast cancers. Specific high-affinity binding sites for GHRH were found on MX-1 tumor membranes using ligand competition assays with (125)I-labeled GHRH antagonist JV-1-42. JMR-132 displaced radiolabeled JV-1-42 with an IC(50) of 0.14 nM, indicating a high affinity of JMR-132 to GHRH receptors. Treatment of nude mice bearing xenografts of MX-1 with JMR-132 at 10 microg per day s.c. for 22 days significantly (P < 0.05) inhibited tumor volume by 62.9% and tumor weight by 47.8%. Docetaxel given twice at a dose of 20 mg/kg i.p. significantly reduced tumor volume and weight by 74.1% and 58.6%, respectively. Combination treatment with JMR-132 (10 microg/day) and docetaxel (20 mg/kg i.p.) led to growth arrest of most tumors as shown by an inhibition of tumor volume and weight by 97.7% and 95.6%, respectively (P < 0.001). Because no vital cancer cells were detected in some of the excised tumors, a total regression of the tumors was achieved in some cases. Treatment with JMR-132 also strongly reduced the concentration of EGF receptors in MX-1 tumors. Our results demonstrate that GHRH antagonists might provide a therapy for breast cancer and could be combined with docetaxel chemotherapy to enhance the efficacy of treatment.

Relationship between cytochrome 3A activity, inflammatory status and the risk of docetaxel-induced febrile neutropenia: a prospective study

BACKGROUND

We hypothesized that cancer-related inflammation might increase the risk of febrile neutropenia (FN) induced by docetaxel (DCX, Taxotere), by both affecting the exposure to DCX and the tissue sensitivity.

PATIENTS AND METHODS

Advanced cancer patients with normal liver function, performance status (PS)<3, were included. Cytochrome P450 3A (CYP 3A) activity was estimated before the first cycle of DCX by a single determination of midazolam plasma concentration, 4 hours after 0.015 mg/kg i.v. bolus. Following the first cycle of 75-100 mg/m2 DCX, clearance and area under the concentration versus time curve (AUC) were estimated using a limited sampling strategy.

RESULTS

Among 56 assessable patients, 7 FNs occurred after first cycle (13%). In univariate analysis, high midazolam concentration and free DCX AUC were associated with severe neutropenia and FN. In addition to DCX exposure-related parameters, the risk of FN was also correlated with poor PS, baseline lymphopenia and lung cancer, while high ferritin level, indicator of an inflammatory state, reached borderline significance (P=0.07). By multivariate analysis, total DCX AUC and baseline lymphopenia were associated with FN. High midazolam concentration was correlated with elevated ferritin level (r=0.32; P=0.02).

CONCLUSION

Inflammatory status and lymphocyte count should be included in the evaluation of the benefice/risk ratio before the initiation of DCX.

The Role of Capecitabine in First‐Line Treatment for Patients with Metastatic Breast Cancer

Capecitabine is an important drug in the therapeutic armamentarium for metastatic breast cancer. A comprehensive worldwide clinical trial program involving >10,000 patients with locally advanced and metastatic breast cancer has provided evidence for the current treatment strategies. On the basis of data demonstrating consistent activity across several trials in patients with heavily pretreated breast cancer, capecitabine was approved in the U.S. in 1998 for the treatment of patients with metastatic disease resistant to paclitaxel and anthracycline-containing therapy, with later European Union approval for single-agent capecitabine in the metastatic setting. Capecitabine plus docetaxel (XT) was approved by the U.S. Food and Drug Administration for the treatment of metastatic breast cancer in 2001 on the basis of the large phase III trial comparing XT with docetaxel alone, which showed a survival advantage for combination therapy compared with single-agent therapy. This was shortly followed by European approval for the combination in metastatic breast cancer. The clinical utility of capecitabine in the management of breast cancer is supported by its convenient oral dosing schedule and favorable safety profile, as well as its excellent clinical activity in primary and metastatic breast cancer. Recently, clinical trials have studied single-agent capecitabine as first-line treatment and evaluated other capecitabine-containing combinations with cytotoxic and novel targeted agents.

Prognostic factors in patients with recently diagnosed incurable cancer: a systematic review

GOALS OF WORK

To review the literature and develop a conceptual framework about prognostic factors for people presenting to medical oncologists with recently diagnosed incurable cancer.

MATERIALS AND METHODS

Medline was searched from January 2000 to October 2003 to identify articles testing associations between clinical or laboratory variables and survival time in adults with advanced solid tumours and median survival of 3 to 24 months. We recorded how frequently prognostic factors were significantly associated with survival in univariable and multivariable analyses.

RESULTS

There were 53 studies included. The factors associated with survival were organised into four categories related to attributes of the host the tumour, the treatment and the interactions between host, tumour and treatment (symptoms, quality of life, performance status and laboratory tests). Co-morbidity was consistently associated with shorter survival. Age and gender were not consistently associated with survival duration, except in lung cancer where females survived longer. Tumour-related factors associated with shorter survival included primary tumour (lung), metastatic site (liver, brain and visceral) and disease extent. Symptoms associated with shorter survival included those of the anorexia-cachexia syndrome, dyspnoea, pain and impaired physical well being. Performance status was strongly associated with survival in most studies. Laboratory tests associated with shorter survival included anaemia, thrombocytopenia, hypoalbuminaemia and elevated serum levels of both alkaline phosphatase and lactate dehydrogenase.

CONCLUSION

Prognostic factors in patients with advanced cancer can be conceptualised as attributes of the host, tumour, treatment and interactions between the three reflected in symptoms, quality of life performance status and laboratory tests.

Docetaxel: a review of its use in metastatic breast cancer

Docetaxel (Taxotere), a cytotoxic taxane, is an antimicrotubule agent effective in the treatment of patients with breast cancer. The clinical profile of docetaxel as an effective cytotoxic agent in the treatment of metastatic breast cancer is well established. As yet, no single standard regimen has been identified as optimal for the treatment of patients with metastatic breast cancer after failure of prior chemotherapy. However, the efficacy of docetaxel monotherapy administered every 3 weeks as a 1-hour infusion is similar to or better than that of doxorubicin, paclitaxel and fluorouracil plus vinorelbine, and better than that of methotrexate plus fluorouracil or mitomycin plus vinblastine. Although docetaxel is associated with neutropenia and other adverse events, its overall tolerability profile is generally acceptable in the majority of patients. Docetaxel, therefore, is an effective option in the treatment of patients with metastatic breast cancer after failure of prior chemotherapy.

Hepatotoxicity of Chemotherapy

The selection of an antineoplastic regimen for an oncology patient is based first on the availability of effective drugs and then on a balancing of potential treatment-related toxicities with the patient's clinical condition and associated comorbidities. Liver function abnormalities are commonly observed in this patient population and identifying their etiology is often difficult. Immunosuppression, paraneoplastic phenomena, infectious diseases, metastases, and poly-pharmacy may cloud the picture. While criteria for standardizing liver injury have been established, dose modifications often rely on empiric clinical judgment. Therefore, a comprehensive understanding of hepatotoxic manifestations for the most common chemotherapeutic agents is essential. We herein review the hepatotoxicity of commonly used antineoplastic agents and regimens.

When will more useful predictive factors be ready for use?

Adjuvant chemotherapy is widely used, but its performance is not optimal. Two subgroups of patients do not get any benefit from adjuvant chemotherapy: the first one comprises patients who are already cured by locoregional treatment alone and the second one patients who do not profit from adjuvant chemotherapy because of resistance to the regimens employed. To improve the cost/benefit of this treatment strategy, we have two means: one is to improve the sensitivity of prognostic factors to be able to select a specific group with a good signature that does not need adjuvant treatment; the second is to identify predictive factors that may help us to select the optimal therapeutic strategy or the optimal regimen or drug for individual patients. New technologies of microarray revealed several genetic profiles. A large randomized trial (Microarray In Node-negative Disease may Avoid ChemoTherapy, MINDACT) will compare the information obtained with the genomic profiling and the classical clinico-pathologic index (St Gallen); the objective is to allow women not to be treated with adjuvant chemotherapy if their genomic signature is good. Another trial (EORTC 10994) is conducted in order to show that in cases of p53 mutated tumors, neoadjuvant chemotherapy with docetaxel is more efficient than an anthracycline-containing regimen. A supplementary study will evaluate gene profile predicting for p53 status. So, new genomic prognostic factors are still in development and seem very promising for optimizing the indications for adjuvant chemotherapy.

Efficacy of weekly paclitaxel in patients with docetaxel-resistant metastatic breast cancer

BACKGROUND

Partial cross-resistance to paclitaxel and docetaxel has been demonstrated in pre-clinical studies.

PATIENTS AND METHODS

We retrospectively evaluated the efficacy of weekly paclitaxel 80 mg/m(2) in 82 patients with docetaxel-resisitant metastatic breast cancer. Docetaxel resistance was classified into primary resistance, defined as progressive disease while receiving docetaxel, and secondary resistance, defined as progression after achievement of a documented clinical response to docetaxel. Secondary resistance was subclassified according to the interval between the final infusion of docetaxel and the start of weekly paclitaxel into: (1) short interval, < or =120 days, and (2) long interval, >120 days.

RESULTS

The response rate of the 82 patients was 19.5% (95% confidence interval, 10.8-27.9%). The response rate according to the docetaxel resistance category was: primary resistance (n = 24), 8.3%; secondary resistance (n = 58), 24.1% (short interval [n = 39], 17.9%, and long interval, [n = 19], 36.8%). The differences in response rates among the three categories were statistically significant (p = 0.0247, Cochran-Mantel-Haenszel test). The interval between from the final docetaxel infusion and disease progression were predictors for response of weekly paclitaxel.

CONCLUSION

Weekly paclitaxel is modestly effective and safe in docetaxel-resistant metastatic breast cancer patients. However, weekly paclitaxel should not be recommended for primary resistance patients with docetaxel.

Patient characteristics compete with dose as predictors of acute treatment toxicity in early phase clinical trials

PURPOSE

The purpose of this study was to identify patient characteristics that may be risk factors or markers of susceptibility to adverse treatment effects in cancer Phase I and II clinical trials.

PATIENTS AND METHODS

A total of 459 patients enrolled in 23 therapeutic Phase I and II studies at the Fox Chase Cancer Center were included in the analysis. Patient-specific characteristics, medical and treatment history, doses of experimental agents, and graded toxicities were extracted from case report forms. We developed a novel summary measure, the toxicity index (TI), to better discriminate patients on the basis of their overall toxicity experiences. Mixed model ANOVA was used to model TI on the basis of data from all trials using a specific agent. Generalized estimating equations in the context of binary logistic regression were used to model dose-limiting toxicity.

RESULTS

Seventeen pretreatment factors, including performance status, alkaline phosphatase, total bilirubin, serum creatinine, and tobacco use, emerged as significant predictors of toxicity as defined by dose-limiting toxicity or TI. Unexpectedly, dose was not always a predictor of toxicity. Even for values within the normal range, the TI identified serum bilirubin and alkaline phosphatase as predictors of toxicity after treatment with docetaxel and alkaline phosphatase as a predictor for toxicity after treatment with irinotecan.

CONCLUSIONS

Independent of dose, certain pretreatment characteristics, including measures of organ function that are in the normal range, were found to be predictors of treatment toxicity. Because of its sensitivity to differences in overall toxicity, the TI should prove to be a useful tool for identifying predictors of chemotherapy-related toxicity.

Capecitabine plus docetaxel combination chemotherapy for metastatic breast cancer

Doxifluridine(5'-DFUR)is converted to its metabolite 5-FU by the enzyme thymidine phosphorylase(TP). TP is expressed significantly higher in tumor tissue than in normal tissue. Capecitabine(N4-pentoxylcarbonyl -5'-deoxy-5-fluorocytidine)is a pro-drug of 5'-DFUR and a novel fluoropyrimidine carbamate that is converted to 5-FU preferentially in tumor tissue through a three-step enzymatic cascade. Expression of TP in tumor tissue may clinically predict efficacy of capecitabine. Induction of TP activity has brought about enhancement of capecitabine efficacy by taxanes in human cancer xenografts. In addition, a phase III study directly comparison docetaxel monotherapy and docetaxel plus capecitabine has been conducted for metastatic breast cancer patients who had received anthracyclines. The overall response rate of the combination group was 42%(n=255), and that of the monotherapy group was 30%(n=256)(p=0.006). The primary endpoints were time to disease progression, and time to treatment failure, and these parameters were superior in the combination arm than in the single arm, suggesting that capecitabine sensitization by docetaxel might be a new approach to breast cancer treatment.

Mitomycin C, 5-fluorouracil and folinic acid (Mi-Fu-Fo) as salvage chemotherapy in breast cancer patients with liver metastases and impaired hepatic function: a phase II study

Patients with measurable liver metastases due to breast cancer and elevated liver enzymes were enrolled into the study. The planned schedule was mitomycin C 8 mg/m2 on day 1, 5-fluorouracil 750 mg/m2 and folinic acid 300 mg/m2 on day 1 and 2 every 4 weeks (Mi-Fu-Fo). Between May 1998 and December 2002, 30 patients with a median age of 51 years (range 33-74) were enrolled. All of them suffered from extensive metastases of the liver resulting in liver dysfunction. Myelosuppression was the most frequent toxicity. Six patients had a partial remission, 12 patients had stable disease and 12 patients progressed during treatment. The median time to progression was 4.5 months in all patients and 7.0 months in patients who responded to the therapy. The median overall survival for the total population was 6.0 months and in the group of responding patients 12.0 months. Mi-Fu-Fo, therefore, provides a valid option for breast cancer patients with liver dysfunction due to liver metastases.

Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients

BACKGROUND

A frequent complication of anticancer treatment, oral and gastrointestinal (GI) mucositis, threatens the effectiveness of therapy because it leads to dose reductions, increases healthcare costs, and impairs patients' quality of life. The Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an international multidisciplinary panel of experts to create clinical practice guidelines for the prevention, evaluation, and treatment of mucositis.

METHODS

The panelists examined medical literature published from January 1966 through May 2002, presented their findings at two separate conferences, and then created a writing committee that produced two articles: the current study and another that codifies the clinical implications of the panel's findings in practice guidelines.

RESULTS

New evidence supports the view that oral mucositis is a complex process involving all the tissues and cellular elements of the mucosa. Other findings suggest that some aspects of mucositis risk may be determined genetically. GI proapoptotic and antiapoptotic gene levels change along the GI tract, perhaps explaining differences in the frequency with which mucositis occurs at different sites. Studies of mucositis incidence in clinical trials by quality and using meta-analysis techniques produced estimates of incidence that are presented herein for what to our knowledge may be a broader range of cancers than ever presented before.

CONCLUSIONS

Understanding the pathobiology of mucositis, its incidence, and scoring are essential for progress in research and care directed at this common side-effect of anticancer therapies.

Metastatic breast cancer: overview of treatment

Patients with metastatic breast cancer have a median survival of 2 to 3 years. Twenty percent of the patients who present with bone-only metastasis will be alive at 5 years from diagnosis. Current therapies are aimed at improving the quality of life, symptom control, and prolongation of survival. Newer endocrine and chemotherapeutic drugs are available to the medical oncologist for care of patients with metastatic breast cancer. We will briefly review the new advances in the treatment of metastatic breast cancer.

A phase I dose-escalation study of docetaxel with granulocyte colony-stimulating factor support in patients with solid tumours

BACKGROUND

Docetaxel is a widely active cytotoxic agent. The principal dose-limiting toxicities (DLTs) of the 3-weekly regimen are neutropenia and febrile neutropenia. Use of prophylactic granulocyte colony-stimulating factor (G-CSF) may allow higher doses of docetaxel to be administered with potentially greater anticancer efficacy. The objectives of this study were to determine the maximum tolerated dose (MTD) and toxicity profile of docetaxel given with G-CSF support.

PATIENTS AND METHODS

Eligible patients had solid tumours and were aged 18-75 years with a WHO performance status of up to 2. Strict criteria for liver function were followed. Patients may have received one previous regimen of chemotherapy in addition to adjuvant chemotherapy. Cohorts of three to six patients received docetaxel over 60-90 min every 3 weeks, commencing at 110 mg/m(2) and escalating at 10 mg/m(2) increments. Patients also received G-CSF 5 micro g/kg/day until neutrophil recovery. A 3-day corticosteroid prophylaxis was given.

RESULTS

Twenty-nine patients with median age 55 years (range 29-75) were included. Fourteen (48%) had previously received chemotherapy. At the 170 mg/m(2) dose level (the MTD), two of three patients had DLTs and 160 mg/m(2) was determined to be the recommended dose. The principal DLTs were skin and neurosensory toxicity. Asthenia was frequent, especially at dose levels >/=140 mg/m(2). Grade 4 neutropenia occurred in only 10 patients (35%) and was not dose related, with febrile neutropenia in three patients (10%).

CONCLUSIONS

Docetaxel may be escalated considerably above standard doses when administered with G-CSF support. The recommended dose for phase II studies is 160 mg/m(2). With escalated-dose docetaxel, DLTs were non-haematological and qualitatively similar to the toxicity profile at standard doses.

Weekly docetaxel in patients with pretreated metastatic breast cancer: a phase II trial

Docetaxel has consistently demonstrated its high activity as an antineoplastic agent in the treatment of metastatic breast cancer. However, 90% of patients receiving the recommended dose of 100 mg/m2 every 3 weeks will develop grade 3 or 4 neutropenia. Recent data suggest that the safety profile of a weekly docetaxel regimen compared favorably with the standard 3-week schedule. Thus, we initiated a phase II study to assess the efficacy and toxicity of weekly docetaxel in pretreated patients with metastatic breast cancer. Twenty patients with advanced, anthra-cycline-refractory breast cancer were included in this phase II trial. Docetaxel was administered at a starting dose of 40 mg/m2, repeated once a week for 3 consecutive weeks followed by a 1-week rest period (1 cycle). Patients were evaluated for tumor response every 8 weeks (after every other cycle). Therapy was continued for a maximum of six courses in patients showing tumor response or stable disease. Twenty patients received a total of 204 weekly infusions of docetaxel. The mean number of treatments was 10.2 (range 1-18). Eighteen patients were assessable for response. Five patients achieved a partial response and six patients showed either stable disease or a minor response. Seven patients had disease progression. The median survival was 7.8 months. Grade 3/4 leukopenia occurred in two patients. No other grade 3 or 4 hematologic toxicities were observed. The following grade 3/4 non-hematologic toxicities were seen: nausea/vomiting (one patient), infection (one patient), mucositis (two patients) and diarrhea (one patient). Three patients withdrew from the study due to dose-limiting toxicities (one due to severe neutropenia and two due to mucositis). We conclude that administration of docetaxel at a dose of 40 mg/m2 was effective and well tolerated even in heavily pretreated patients with metastatic breast cancer. This regimen is associated with only mild myelosuppression.

Evaluation of the nutritional and inflammatory status in cancer patients for the risk assessment of severe haematological toxicity following chemotherapy

BACKGROUND

The toxicity outcome of cancer patients receiving chemotherapy is difficult to predict. In this study the influence of malnutrition and inflammation on acute haematological toxicity was investigated.

PATIENTS AND METHODS

Between January 1999 and January 2000, 48 consecutive cancer patients experienced severe haematological toxicity (SHT), either neutropenic fever or severe thrombocytopenia, following various chemotherapy regimens. Their baseline characteristics were compared with those of 59 control patients. Previous chemotherapy regimens, type of chemotherapy, performance status (PS), calculated creatinine clearance, bilirubin, C-reactive protein (1), alpha-1 acid glycoprotein (2), albumin (3), pre-albumin (4) and the nutritional and inflammatory status (NIS) ratio [NIS = (1 x 2)/(3 x 4)] were studied. Statistical analysis was carried out using either a t-test or a chi-square test. A receiver operating characteristic (ROC) curve determined the cut-off value for NIS.

RESULTS

Patients experiencing SHT had a higher PS (P <0.001), inflammatory serum protein levels (P <0.001) and NIS ratio (P <0.0001), but lower haemoglobin (P <0.05) and serum-albumin levels (P <0.0001). Using a cut-off of 0 or 1 for PS and 1 for NIS, sensitivity was 98%, 43% and 89%; specificity was 38%, 90% and 66%, respectively. In 37 patients treated with topotecan as single agent, the determinants for SHT were PS (P <0.0001) and NIS (P <0.0001).

CONCLUSIONS

Altered nutritional and inflammatory status correlates with increased risk of severe haematological toxicity following anticancer chemotherapy.