Dose-dense doxorubicin, docetaxel, and granulocyte colony-stimulating factor support with or without tamoxifen as preoperative therapy in patients with operable carcinoma of the breast: a randomized, controlled, open phase IIb study

Role of imaging based response assesment for adapting neoadjuvant systemic therapy for breast cancer: A systematic review

PURPOSE

The objective of this systematic review is to investigate the role of imaging in response monitoring during neoadjuvant systemic therapy (NST) for breast cancer and assess whether treatment modifications based on imaging response are implemented in clinical practice.

METHODS

A systematic review was conducted, analyzing five clinical practice guidelines and 147 clinical trial publications involving NST for breast cancer. The snowballing technique was employed, using a "start set" of clinical guidelines to trace relevant trials. Additionally, a PubMed search was conducted to identify trials published between 2023-2024. The review analyzed the use of imaging modalities, timing, and response criteria, and whether escalation, de-escalation, or change of treatment occurred based on imaging response.

RESULTS

Imaging was utilized in 81 % (119/147) of the trials, with ultrasound, MRI, and mammography being the most frequently employed modalities. Mid-treatment imaging was applied in 56 % (83/147) of the trials. However, only 15 % (22/147) of the trials implemented treatment modifications based on imaging response, highlighting the limited application of imaging response-guided therapy. No standardized imaging protocols or consistent response-guided treatment strategies were identified across the trials or clinical practice guidelines, with considerable variability in imaging methods, timing, and response criteria.

CONCLUSION

This systematic review underscores the critical need for standardized imaging protocols, response assessment criteria and image-guided treatment decisions. It is therefore evident that imaging for response monitoring during treatment should preferably be performed within clinical trials.

Outcomes of Triple-Negative Breast Cancer Patients in Response to Taxane and Nontaxane-Based Neoadjuvant Chemotherapies

Introduction Neoadjuvant chemotherapy (NAC) is the standard of care for locally advanced breast cancer. The achievement of pathological complete response (pCR) in response to NAC is of clinical significance as it correlates with improved long-term outcome. pCR rate varies with different chemotherapeutic agents and a higher rate may be associated with higher treatment cost and more toxicity.

Triple-negative breast cancer (TNBC) has poorer prognosis than non-TNBC (estrogen receptor, progesterone receptor, and/or human epidermal growth factor receptor 2 expressing tumors), but patients achieving pCR may have similar outcome. We evaluated the response of TNBC after taxane and nontaxane-based NAC and its correlation with survival outcome.

Materials and Methods This was a retrospective study comparing the efficacy of “taxotere, Adriamycin and cyclophosphamide TAC” versus “cyclophosphamide, epirubicin, 5-fluorouracil/cyclophosphamide, Adriamycin, 5-fluorouracil (CEF/CAF)” NAC regimens in patients with locally advanced TNBC. The efficacy and safety of both the regimens were compared. Overall and disease-free survival were analyzed.

Results Two-hundred and forty-nine eligible patients were included and divided into two groups: taxane group receiving “TAC” regimen (123 patients) and nontaxane group receiving “CEF/CAF” regimen (126 patients). A higher pCR rate was achieved with taxane compared with nontaxane NAC (28 vs. 12%) (p = 0.0001). Although taxane addition did not lead to survival advantage for the entire group, significantly better survival rates were achieved for patients who had pCR compared with similar subgroup of patients in nontaxane group. Both the NAC regimens were well tolerable.

Conclusion Taxane-based NAC was although costlier than anthracycline-based regimen but was more effective, resulting in a higher pCR rate and an improved survival outcome in patients who achieved pCR.

Predictive and Prognostic Roles of Pathological Indicators for Patients with Breast Cancer on Neoadjuvant Chemotherapy

Currently, neoadjuvant chemotherapy is a standard therapeutic strategy for breast cancer, as it can provide timely and individualized chemo-sensitivity information and is beneficial for custom-designing subsequent treatment strategies. To accurately select candidates for neoadjuvant chemotherapy, the association between various immunohistochemical biomarkers of primary disease and tumor response to neoadjuvant chemotherapy has been investigated, and results have shown that certain pathological indicators evaluated after neoadjuvant chemotherapy are associated with long-term prognosis. The Food and Drug Administration (FDA) has recommended that complete pathological response can be used as a surrogate endpoint for neoadjuvant chemotherapy, which is related to better prognosis. Considering that residual tumor persists in the majority of patients after neoadjuvant chemotherapy, the value of various pathological indicators of residual disease in predicting the long-term outcomes is being extensively investigated. This review summarizes and compares various predictive and prognostic indicators for patients who have received neoadjuvant chemotherapy, and analyzes their efficacy in different breast cancer subtypes.

Neoadjuvant chemotherapy among patients treated for nonmetastatic breast cancer in a population with a high HIV prevalence in Johannesburg, South Africa

Background

Neoadjuvant (primary) chemotherapy (NACT) is the standard of care for locally advanced breast cancer. It also allows for the short-term assessment of chemotherapy response; a pathological complete responses correspond to improved long-term breast cancer outcomes. In sub-Saharan Africa, many patients are diagnosed with large nonresectable tumors. We examined NACT use in breast cancer patients who visited public hospitals in Johannesburg, South Africa.

Methods

We assessed demographic characteristics, tumor stage and grade, hormone receptor status, and human immunodeficiency virus (HIV) status of female patients diagnosed with nonmetastatic invasive carcinoma of the breast at Chris Hani Baragwanath Academic Hospital between January 1, 2009, and December 31, 2011. The patients received neoadjuvant, adjuvant, or no chemotherapy. Trastuzumab was unavailable. We developed logistic regression models to analyze the factors associated with NACT receipt in these patients.

Results

Of 554 women with nonmetastatic breast cancer, the median age at diagnosis was 52 years (range: 28–88 years). Only 5.8% of patients were diagnosed with stage I disease; 49.3% and 44.9% were diagnosed with stages II and III, respectively. Most patients had hormone-responsive tumors: luminal A, 38.1%; luminal B₁ (human epidermal growth factor receptor 2 [HER2]-negative and high grade), 12.5%, and luminal B₂ (HER2-positive any grade), 11.6%; 11.6% had a HER2-enriched tumor and 20.6% a triple-negative tumor. Eighty (14.4%) patients were HIV-positive. In total, 195 patients (35.2%) received NACT, 264 (47.7%) patients received adjuvant chemotherapy, and 95 patients (17.1%) received no chemotherapy, including 62 (11.2%) patients who received only hormonal therapy. Of patients receiving NACT, 125 (64.1%) were evaluable for clinical response. Eighty (64.0%) patients had a clinically significant response; 19 (15.2%) patients had a stable disease, and 26 (20.8%) patients had a progressive disease. Multivariate analysis showed age <40 years and disease stage to be independently associated with the receipt of NACT.

Conclusion

Most women receiving NACT with available response data showed a clinical benefit. Stage III disease at diagnosis and age <40 years were predictors of neoadjuvant versus adjuvant chemotherapy treatment.

Neoadjuvant Treatment of Stage IIB/III Triple Negative Breast Cancer with Cyclophosphamide, Doxorubicin, and Cisplatin (CAP Regimen): A Single Arm, Single Center Phase II Study (GBECAM 2008/02)

Background

The DNA damaging platinum salts have been explored in the treatment of triple negative breast cancer (TNBC) based on preclinical, and, more recently, clinical evidence of specific susceptibility of TNBC to these agents. Despite the increased toxicity, treatment intensification with polychemotherapy improves response and might be of interest in patients presenting with large primaries. In this trial, we aimed at exploring the efficacy and tolerability of the addition of cisplatin to standard anthracycline–cyclophosphamide backbone in patients with stage IIB/III TNBC.

Patients and methods

This is a single arm, single center, non-randomized, phase II trial of stage IIB/III TNBC. Patients received neoadjuvant chemotherapy with cisplatin (50 mg/m²) in combination with doxorubicin (50 mg/m²) and cyclophosphamide (500 mg/m²) every 21 days and for a total of six cycles (CAP). After surgery, adjuvant chemotherapy consisting of docetaxel (75 mg/m²) every 21 days was further provided for four cycles. Primary outcome was pathological complete response in the breast and axilla (pCR; ypT0ypN0). Secondary outcomes were safety, disease-free survival (DFS), and overall survival (OS).

Results

Eight (19.5%) out of 41 patients reached a pCR and 35 (85.4%) had a clinical complete or partial response. After a median follow-up of 47.4 months (interquartile range 30.9–61.9), the proportion of patients free of recurrence or death at 3 years was of 51.8% [95% confidence interval (CI) 34.6–66.5%], while the proportion of patients alive at 3 years was of 55.5% (95% CI 37.8–70.1%). Patients with a pCR rate or family history of breast and/or ovarian cancer showed a numerical but statistically non-significant trend for improved DFS and OS. The majority of patients received six cycles of CAP (82.9%). The three most common grade ≥3 adverse events were nausea (16.3%), vomiting (14.0%), and neutropenia (9.3%). Febrile neutropenia occurred in three patients (7.0%).

Conclusion

Cisplatin in association with doxorubicin and cyclophosphamide was associated with a pCR rate of 19.5% in a cohort of patients with predominantly stage III tumors. The tolerability profile of this combination poses clinical challenges to its general use in clinical practice.

Unique Identifier Number

GBECAM 2008/02.

NCT Identifier Number

NCT03304756.

Outcome after neoadjuvant chemotherapy in estrogen receptor-positive and progesterone receptor-negative breast cancer patients: a pooled analysis of individual patient data from ten prospectively randomized controlled neoadjuvant trials

PURPOSE

The estrogen receptor (ER) is involved in control of progesterone receptor (PgR) expression and lack of PgR may be also a surrogate of altered growth factor signaling. The aim of this study was therefore to investigate PgR expression as predictive factor for response to neoadjuvant therapy and long-term outcome.

METHODS

Five thousand and six hundred and thirteen patients with primary breast cancer and positive ER expression from ten German neoadjuvant trials of anthracycline and taxane-based chemotherapy were included. Pathologic complete response (pCR), disease-free survival (DFS), distant disease-free survival (DDFS), overall survival (OS), and local recurrence-free survival (LRFS) were compared according to PgR expression.

RESULTS

The lack of PgR expression (1172 patients) was associated with grade 3 (38.4 vs. 26.3%; p < 0.001), nodal involvement (>cN2) (6.8% vs. 4.7%; p = 0.004), and HER2 positivity (36.2 vs. 22.3%; p < 0.001). pCR rates of PgR-negative tumors were higher in the entire cohort (13.8 vs. 7.5%; p < 0.001) and in the HER2-negative subgroup (11.2 vs. 5.8%; p < 0.001). In multivariable logistic regression, PgR negativity was an independent predictive factor for pCR overall (OR 1.76; p < 0.001) and in the HER2-negative patients (OR 1.99; p < 0.001). Patients with PgR-negative disease had significantly worse outcome (p < 0.001, respectively). Multivariable Cox regression analysis revealed that PgR was an independent prognostic factor for DFS, OS, DDFS, and LRFS.

CONCLUSION

ER-positive/PgR-negative breast carcinomas are associated with higher response but also worse long-term outcome after neoadjuvant therapy. PgR negativity is an independent predictive factor for pCR after neoadjuvant chemotherapy in ER-positive HER2-negative breast cancer.

An Acetamide Derivative as a Camptothecin Sensitizer for Human Non-Small-Cell Lung Cancer Cells through Increased Oxidative Stress and JNK Activation

In recent years, combination chemotherapy is a primary strategy for treating lung cancer; however, the issues of antagonism and side effects still limit its applications. The development of chemosensitizer aims to sensitize chemoresistant cancer cells to anticancer drugs and therefore improve the efficacy of chemotherapy. In this study, we examined whether N-[2-(morpholin-4-yl)phenyl]-2-{8-oxatricyclo[7.4.0.0,2,7]trideca-1(9),2(7),3,5,10,12-hexaen-4-yloxy}acetamide (NPOA), an acetamide derivative, sensitizes human non-small-cell lung cancer (NSCLC) H1299 cells towards camptothecin- (CPT-) induced apoptosis effects. Our results demonstrate that the combination of CPT and NPOA enhances anti-lung-cancer effect. The cytometer-based Annexin V/propidium iodide (PI) staining showed that CPT and NPOA cotreatment causes an increased population of apoptotic cells compared to CPT treatment alone. Moreover, Western blotting assay showed an enhancement of Bax expression and caspase cascade leading to cell death of H1299 cells. Besides, CPT and NPOA cotreatment-mediated disruption of mitochondrial membrane potential (MMP) in H1299 cells may function through increasing the activation of the stressed-associated c-Jun N-terminal kinase (JNK). These results showed that NPOA treatment sensitizes H1299 cells towards CPT-induced accumulation of cell cycle S phase and mitochondrial-mediated apoptosis through regulating endogenous ROS and JNK activation. Accordingly, NPOA could be a candidate chemosensitizer of CPT derivative agents such as irinotecan or topotecan in the future.

Outcome after neoadjuvant chemotherapy in young breast cancer patients: a pooled analysis of individual patient data from eight prospectively randomized controlled trials

Young women with breast cancer (BC) have a worse survival partly due to more aggressive tumor characteristics; however, their response to chemotherapy seems better. We investigated to what extent the prognostic factor pathological complete remission (pCR) after neoadjuvant chemotherapy is applicable to young women. 8949 patients with primary BC and follow-up from eight German neoadjuvant trials were included. A subgroup of 1453 patients <40 years was compared with women aged 40-49 and ≥50 years regarding pCR (ypT0 ypN0), as well as disease free survival (DFS), local recurrence free survival (LRFS), distant disease free survival (DDFS), and overall survival (OS) overall, according to pCR status and subtypes defined by hormone-receptor (HR) status and HER2. pCR was strongly associated with age without a clear age cut-off. The pCR rate was significantly higher in the young compared with other age groups (20.9 vs. 17.7 vs. 13.7 %; p < 0.001). This difference was confined to triple-negative breast cancer (TNBC) and HR +/HER2-. DFS, DDFS, LRFS, and OS were significantly worse for young women. Age was independently prognostic for survival in HR +/HER2-, with women <40 years without pCR having a worse DFS compared to their counterparts with pCR. Young women are more likely to achieve pCR after neoadjuvant chemotherapy, especially in HR +/HER2- and TNBC. Age is not an important prognostic factor in TNBC and HR-/HER2 + but is in HR +/HER2-. Young women with a luminal-like BC seem to benefit more from neoadjuvant chemotherapy than older women, which needs to be taken into account.

Can pathologic complete response (pCR) be used as a surrogate marker of survival after neoadjuvant therapy for breast cancer?

Breast cancer is heterogeneous in clinical, morphological, immunohistochemical and biological features, as reflected by several different prognostic subgroups. Neoadjuvant approaches are currently used for the "in vivo" efficacy assessment of treatments. Pathological complete response (pCR) has been reported as a reliable predictive factor of survival in that setting. However, pCR remains a subject of controversy in terms of definition and its evaluation methods. In addition, its predictive value for patient outcome in various breast cancer biological subtypes has been under debate. In this review, we will present the existing definitions of pCR, the impact of its evaluation methods on its rate and the assessment of its predictive value for patient outcome in the molecular subtypes of breast cancer (luminal A and B, Triple Negative and HER2-positive).

Surgical treatment of primary breast cancer in the neoadjuvant setting

Background

Neoadjuvant chemotherapy (NACT) is a standard treatment option for primary operable breast cancer when adjuvant chemotherapy is indicated.

Methods

This article reviews the use of NACT in breast cancer treatment.

Results

Pathological complete response (pCR) rates of up to 60 per cent have been reached for certain breast cancer subgroups. Patients achieving a pCR have a lower locoregional recurrence rate. Nevertheless, the rate of breast-conserving surgery seems to be stable at around 65–70 per cent, although more than 80 per cent of patients respond to NACT. The risk of local relapse does not appear to be higher after NACT, which supports the recommendation to operate within the new margins, as long as there is no tumour in the inked area of the surgical specimen. However, tumours do not shrink concentrically and the re-excision rate is higher after NACT. Mastectomy rates for lobular carcinomas remain high irrespective of tumour response. The role of sentinel lymph node biopsy (SLNB) in the context of NACT has been studied in recent years, and it is not yet completely clear which type of axillary staging is the most suitable. SLNB before NACT in clinically node-negative patients has been the preferred option. However, this practice is currently changing, and it seems advisable to have the SLNB after NACT to reduce the risk of a false-negative SLNB.

Conclusion

Overall, patients do benefit from NACT, especially those with human epidermal growth factor receptor 2-positive and triple-negative breast cancer, but surgical/local procedures need to be adapted.

Meta-analysis of magnetic resonance imaging in detecting residual breast cancer after neoadjuvant therapy

BACKGROUND

It has been proposed that magnetic resonance imaging (MRI) be used to guide breast cancer surgery by differentiating residual tumor from pathologic complete response (pCR) after neoadjuvant chemotherapy. This meta-analysis examines MRI accuracy in detecting residual tumor, investigates variables potentially affecting MRI performance, and compares MRI with other tests.

METHODS

A systematic literature search was undertaken. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate (relative) diagnostic odds ratios ([R]DORs). Summary sensitivity (correct identification of residual tumor), specificity (correct identification of pCR), and areas under the SROC curves (AUCs) were derived. All statistical tests were two-sided.

RESULTS

Forty-four studies (2050 patients) were included. The overall AUC of MRI was 0.88. Accuracy was lower for "standard" pCR definitions (referent category) than "less clearly described" (RDOR = 2.41, 95% confidence interval [CI] = 1.11 to 5.23) or "near-pCR" definitions (RDOR = 2.60, 95% CI = 0.73 to 9.24; P = .03.) Corresponding AUCs were 0.83, 0.90, and 0.91. Specificity was higher when negative MRI was defined as contrast enhancement less than or equal to normal tissue (0.83, 95% CI = 0.64 to 0.93) vs no enhancement (0.54, 95% CI = 0.39 to 0.69; P = .02), with comparable sensitivity (0.83, 95% CI = 0.69 to 0.91; vs 0.87, 95% CI = 0.80 to 0.92; P = .45). MRI had higher accuracy than mammography (P = .02); there was only weak evidence that MRI had higher accuracy than clinical examination (P = .10). No difference in MRI and ultrasound accuracy was found (P = .15).

CONCLUSIONS

MRI accurately detects residual tumor after neoadjuvant chemotherapy. Accuracy was lower when pCR was more rigorously defined, and specificity was lower when test negativity thresholds were more stringent; these definitions require standardization. MRI is more accurate than mammography; however, studies comparing MRI and ultrasound are required.

Neoadjuvant chemotherapy: early response as a guide for further treatment: clinical, radiological, and biological

Neoadjuvant chemotherapy (NACT) was initially developed as a treatment strategy for patients with locally advanced breast cancer to improve operability and locoregional control. Today, NACT has become an equivalent option along with adjuvant treatment, and it is regarded as standard treatment approach for patients with locally advanced cancer because it enables breast-conserving therapy to these patients. In addition, there is increasing information on NACT in operable breast disease that supports its use in routine practice for operable tumor stages. According to the German S3 and AGO guidelines, NACT is indicated for every patient with breast cancer, who would need adjuvant chemotherapy after evaluation of radiological, histological, and clinical prognostic factors. Based on a broad range of clinical studies during the last 10 years, it has been demonstrated that NACT leads to an increasing rate of breast-conserving operations, reduced mortality, and less toxicity. A very important issue is to obtain early information about the responsiveness of the primary tumor to chemotherapy, so that individualized therapeutical strategies can be developed. The decision to proceed with NACT is depending on several considerations including surgical aspects, pretreatment diagnostic evaluations, and efficacy monitoring as well as biological aspects to predict response.

Neoadjuvant Therapy - What Have We Achieved in the Last 20 Years?

Neoadjuvant chemotherapy is the standard of care for patients with large, inoperable tumors or inflammatory breast cancer, but it is also increasingly considered for women with operable disease. Several randomized trials have demonstrated that anthracycline- and taxane-containing regimens in operable breast cancer were equally effective in terms of disease-free or overall survival regardless of whether they were administered postoperatively or preoperatively. Further neoadjuvant treatment allows for a higher rate of breast conserving surgery. Tumor responses in terms of pathologic complete remission after short-term chemotherapy will probably only serve as a surrogate marker for long-term outcome in some molecular breast cancer subtypes like the triple-negative, HER2-positive, and some luminal B subsets. Recent trials showed that in HER2-positive disease pCR rates were as high as 70% when 2 HER2-targeted agents were added to chemotherapy.

Phase III study of doxorubicin/cyclophosphamide with concomitant versus sequential docetaxel as adjuvant treatment in patients with human epidermal growth factor receptor 2-normal, node-positive breast cancer: BCIRG-005 trial

PURPOSE

Anthracyclines, taxanes, and alkylating agents are among the most active agents in treatment of adjuvant breast cancer (BC), but the optimal schedule for their administration is unknown. We performed an adjuvant trial to compare the sequential regimen of doxorubicin with cyclophosphamide (AC) followed by docetaxel (ie, AC>T) with the combination regimen of TAC.

PATIENTS AND METHODS

Women with node-positive, human epidermal growth factor receptor 2-nonamplified, operable BC were stratified by number of axillary nodes and hormone receptor status and were randomly assigned to adjuvant chemotherapy with six cycles of TAC (75/50/500 mg/m² every 3 weeks) or four cycles of AC (60/600 mg/m² every 3 weeks) followed by four doses of docetaxel at 100 mg/m² every 3 weeks (AC>T). After completion of chemotherapy, radiation therapy was given as indicated, and patients with hormone receptor (HR) -positive disease received adjuvant hormonal therapy with tamoxifen and/or aromatase inhibitors.

RESULTS

In 30 months, 3,298 patients were enrolled (n = 1,649 in each arm). The major baseline characteristics were well balanced between the groups. At a median follow-up of 65 months, estimated 5-year disease-free survival rates were 79% in both groups (log-rank P = .98; hazard ratio [HR], 1.0; 95%CI, 0.86 to 1.16), and 5-year overall survival rates for both arms were 88% and 89%, respectively (log-rank P = .37; HR, 0.91; 95% CI, 0.75 to 1.11). TAC was associated with more febrile neutropenia and thrombocytopenia, and AC>T was associated with more sensory neuropathy, nail changes, and myalgia. The incidence of neutropenic infection was similar in both groups.

CONCLUSION

The sequential and combination regimens incorporating three drugs were equally effective but differed in toxicity profile.

Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials

BACKGROUND

As trials of 5 years of tamoxifen in early breast cancer mature, the relevance of hormone receptor measurements (and other patient characteristics) to long-term outcome can be assessed increasingly reliably. We report updated meta-analyses of the trials of 5 years of adjuvant tamoxifen.

METHODS

We undertook a collaborative meta-analysis of individual patient data from 20 trials (n=21,457) in early breast cancer of about 5 years of tamoxifen versus no adjuvant tamoxifen, with about 80% compliance. Recurrence and death rate ratios (RRs) were from log-rank analyses by allocated treatment.

FINDINGS

In oestrogen receptor (ER)-positive disease (n=10,645), allocation to about 5 years of tamoxifen substantially reduced recurrence rates throughout the first 10 years (RR 0·53 [SE 0·03] during years 0-4 and RR 0·68 [0·06] during years 5-9 [both 2p<0·00001]; but RR 0·97 [0·10] during years 10-14, suggesting no further gain or loss after year 10). Even in marginally ER-positive disease (10-19 fmol/mg cytosol protein) the recurrence reduction was substantial (RR 0·67 [0·08]). In ER-positive disease, the RR was approximately independent of progesterone receptor status (or level), age, nodal status, or use of chemotherapy. Breast cancer mortality was reduced by about a third throughout the first 15 years (RR 0·71 [0·05] during years 0-4, 0·66 [0·05] during years 5-9, and 0·68 [0·08] during years 10-14; p<0·0001 for extra mortality reduction during each separate time period). Overall non-breast-cancer mortality was little affected, despite small absolute increases in thromboembolic and uterine cancer mortality (both only in women older than 55 years), so all-cause mortality was substantially reduced. In ER-negative disease, tamoxifen had little or no effect on breast cancer recurrence or mortality.

INTERPRETATION

5 years of adjuvant tamoxifen safely reduces 15-year risks of breast cancer recurrence and death. ER status was the only recorded factor importantly predictive of the proportional reductions. Hence, the absolute risk reductions produced by tamoxifen depend on the absolute breast cancer risks (after any chemotherapy) without tamoxifen.

FUNDING

Cancer Research UK, British Heart Foundation, and Medical Research Council.

Phase II trial of combination of pegylated liposomal doxorubicin, cisplatin, and infusional 5-fluorouracil (CCF) plus trastuzumab as preoperative treatment for locally advanced and inflammatory breast cancer

BACKGROUND

Pegylated liposomal doxorubicin (PLD) was shown as active but less toxic compared to doxorubicin in advanced breast cancer. Given its low cardiotoxicity, the combination of PLD and trastuzumab appears most attractive in the treatment of human epidermal factor receptor 2 (HER2)-positive breast cancer.

PATIENTS AND METHODS

We investigated the activity of 8 courses of PLD in combination with cisplatin and infusional 5-fluorouracil (CCF) plus 3-week trastuzumab in patients with primary or recurrent cT2-T4 a-d, N0-3, M0 any estrogen receptor (ER), HER2-positive breast cancer. Patients with ER and/or progesterone receptor (PgR) ≥ 10% tumors received also letrozole (plus triptorelin if premenopausal). The principal endpoint was clinical response rate; secondary endpoints were the pathologic complete response rate (pCR) and the cardiac safety of the combination.

RESULTS

Thirty-two patients were enrolled in the study and all are evaluable for response and toxicity. Fifteen patients (47%) had ER-positive tumors, 15 patients and 2 patients had ER absent and ER poor tumors, respectively. Thirteen patients (41%) had inflammatory breast cancer (IBC) and 84% of patients had clinically positive nodes. A clinical response rate of 94% (95% CI, 79%-99%) and a pCR rate of 41% (95% CI, 24%-59%) were observed. Fifty-four percent of patients with IBC obtained a pCR. Eleven patients discontinued treatment before completing 8 courses as planned. No patient developed relevant cardiac toxicity.

CONCLUSION

In this series of very locally advanced breast cancer, the combination of CCF and trastuzumab was very active obtaining an impressive rate of pCR, particularly in IBC, which merits further investigation in larger series.

Second-line neoadjuvant vinorelbine and gemcitabine combination in locally advanced breast cancer showing no early response to TAC

Due to socioeconomic issues, locally advanced breast cancer (LABC) is still a common presentation of breast cancer in the third world. It was found that LABC patients showing a clinical response after two to four cycles of neoadjuvant chemotherapy have a higher probability of obtaining a pathological complete response at surgery than patients without an early response. In the present work, the short-term effects and toxicity of the neoadjuvant second-line vinorelbine and gemcitabine combination were evaluated in the treatment of LABC who did not show early response to anthracyclines and taxanes-containing regimen. The use of vinorelbine and gemcitabine was based on their use in metastatic breast cancer cases who had been treated before with anthracyclines and taxanes. This was a prospective phase II study accomplished at the Clinical Oncology and Nuclear Medicine Department of Mansoura University, Egypt. Seventy LABC patients not suitable for breast conservative surgery who failed to achieve early response to two cycles of a combination of docetaxel, doxorubicin, and cyclophosphamide (TAC) were treated with a 3-weekly regimen of vinorelbine 30 mg/m(2) plus gemcitabine 1,200 mg/m(2) given on days 1 and 8 by intravenous infusion as a second-line neoadjuvant chemotherapy. Response was assessed after the second cycle. Stable and progressed patients were operated upon while responding cases received up to four cycles before the operation. Patient accrual was from June 20, 2007, to October 20, 2009. The objective response was evaluated clinically with breast sonography before every new cycle and before operation while the pathological response was determined postoperatively. The toxicity was evaluated according to the National Cancer Institute--Common Toxicity criteria version 3. The end points of this study were clinical response rate, pathological response rate, and treatment toxicity. Clinical response rate was achieved in 35 cases (50%) while pathological response rate was reported in 4 cases (5.7%). Breast conservative surgery (BCS) became possible in 31 cases (44%). The most common severe toxicities (grades 3 and 4) were neutropenia and thrombocytopenia in 25.7 and 22.8% of cases, respectively. Toxicities were reversible and did not cause death. It is possible to achieve objective clinical and pathological responses of LABC with potentially non-cross-resistant neoadjuvant second-line therapy, leading to BCS in a high proportion of patients. Thus, preoperative second-line chemotherapy appears to be justified when breast conservation is an important treatment goal.

[Predictive factors of response to anthracyclines neoadjuvant chemotherapy in breast cancer]

OBJECTIVES

Anthracyclines chemotherapy remains primordial and impossible to circumvent in the treatment of breast cancer, in the adjuvant, metastatic and neoadjuvant setting. But some breast invasive tumors are resistant to anthracyclines. The neoadjuvant model is ideal to test the chemosensibility by selecting the well-responder patients and identifying the predictive factors of this response.

PATIENTS AND METHODS

We report a retrospective study of 126 patients treated at our institute during 2 years (January 2003-December 2004) for a breast cancer with primary chemotherapy. All the patients received anthracyclines according to protocol AC60 (doxorubicine plus cyclophosphamide).

RESULTS

The clinical objective response rate (RO) was 67 % with a complete clinical response (RC) of 11 %. We found a pathological complete response (pCR) in seven patients (5,6 %) of the 126 cases. The statistical study identifies only two clinical factors as predictive of RC and pCR: tumoral size T2-T3 and clinical nodal status N0-N1, while the SBR grading and the hormonal receptors were not correlated.

DISCUSSION AND CONCLUSION

Some clinical and histological factors are recognized as predictive for the benefit of anthracyclines neoadjuvant chemotherapy, and correlated to the pCR; we discuss our results through those of the literature, by exposing the current data.

A phase II trial of dose-dense neoadjuvant gemcitabine, epirubicin, and albumin-bound paclitaxel with pegfilgrastim in the treatment of patients with locally advanced breast cancer

BACKGROUND

Neoadjuvant anthracycline/taxane combinations, with or without gemcitabine, produce pathologic complete responses (pCRs) in 15%-25% of patients. In this multicenter phase II study, we attempted to increase efficacy and decrease toxicity of a 3-drug gemcitabine-containing neoadjuvant regimen by administering dose-dense therapy with pegfilgrastim, and including albumin-bound paclitaxel as the taxane.

PATIENTS AND METHODS

A total of 123 patients with locally advanced breast cancer were enrolled. Patients were treated with 6 doses of neoadjuvant gemcitabine 2000 mg/m2, epirubicin 50 mg/m2, and albumin-bound paclitaxel 175 mg/m2 intravenously administered at 14-day intervals. Following neoadjuvant chemotherapy, patients underwent either mastectomy or breast conservation surgery; pathologic response to treatment was assessed. Postoperatively, patients received 4 doses of gemcitabine 2000 mg/m2 with albumin-bound paclitaxel 220 mg/m2 at 14-day intervals. Pegfilgrastim 6 mg was administered subcutaneously on day 2 following each dose of chemotherapy.

RESULTS

A total of 116 patients (95%) completed neoadjuvant chemotherapy and had subsequent surgical resection. Twenty-three patients (20%) had a pCR. The estimated 3-year progression-free survival (PFS) and overall survival rates were 48% and 86%, respectively. Neoadjuvant treatment was well tolerated; only 11% of the patients had grade 3/4 neutropenia, with 1 episode of neutropenic fever. Other grade 3/4 toxicities occurred in < 10% of the patients.

CONCLUSION

Neoadjuvant biweekly chemotherapy with gemcitabine/epirubicin/albumin-bound paclitaxel with pegfilgrastim is feasible and well tolerated. The pCR rate of 20% and the 3-year PFS rate of 48% are similar to results achieved with other commonly used neoadjuvant regimens.

Letrozole plus GnRH analogue as preoperative and adjuvant therapy in premenopausal women with ER positive locally advanced breast cancer

Patients with large ER positive tumors candidate to preoperative chemotherapy may also benefit from a concurrent endocrine intervention, but this issue has been scarcely investigated due to concerns arising from unfavorable results emerged from an adjuvant trial of concurrent tamoxifen and chemotherapy. We retrospectively investigated the activity of letrozole plus GnRH analogue (GnRH-a) administered concurrently with preoperative chemotherapy and as adjuvant treatment in premenopausal women with locally advanced ER positive breast cancer consecutively admitted at the European Institute of Oncology. Results were compared with those of a non-randomized unmatched control group of premenopausal women with locally advanced ER positive breast cancer receiving preoperative chemotherapy, followed by tamoxifen and GnRH-a after surgery. Primary endpoints were pathological complete response (pCR) rate, decrease of Ki67 and disease free survival (DFS). One-hundred and nineteen women constituted the study group, while 95 patients served as controls. The pCR rate was 5.0 vs 1.1% in the study and control group, respectively. A statistically significant greater suppression of Ki67 was observed in patients receiving chemoendocrine therapy as compared with controls (P = 0.003). At a median follow up of 59 months, 26 events occurred in the chemoendocrine group and 48 in the control group. Five-year DFS was 78 vs 41% in the study and in the control group, respectively [adjusted HR 0.46, 95% CI 0.27-0.79, P = 0.0047]. The concurrent administration of letrozole and GnRH-a with preoperative chemotherapy was highly effective in premenopausal women with large ER positive breast cancer in terms of decreased proliferation and of improved DFS. Randomized studies are warranted to establish the role of the addition of endocrine therapy to chemotherapy as standard preoperative approach for ER positive locally advanced breast cancer as well as of letrozole in combination with GnRH-a for the treatment of premenopauasal women with early breast cancer.

Impact of treatment characteristics on response of different breast cancer phenotypes: pooled analysis of the German neo-adjuvant chemotherapy trials

Pathological complete response (pCR) to neoadjuvant treatment correlates with outcome in breast cancer. We determined whether characteristics of neoadjuvant therapy are associated with pCR. We used multi-level models, which accounted for heterogeneity in pCR across trials and trial arms, to analyze individual patient data from 3332 women included in 7 German neoadjuvant trials with uniform protocols. PCR was associated with an increase in number of chemotherapy cycles (odds ratio [OR] 1.2 for every two additional cycles; P = 0.009), with higher cumulative anthracycline doses (OR 1.6; P = 0.002), higher cumulative taxane doses (OR 1.6; P = 0.009), and with capecitabine containing regimens (OR 1.62; P = 0.022). Association of pCR with increase in number of cycles appeared more pronounced in hormone receptor (HR)-positive tumors (OR 1.35) than in HR-negative tumors (OR 1.04; P for interaction = 0.046). Effect of anthracycline dose was particularly pronounced in HER2-negative tumors (OR 1.61), compared to HER2-positive tumors (OR 0.83; P for interaction = 0.14). Simultaneous trastuzumab treatment in HER2-positive tumors increased odds of pCR 3.2-fold (P < 0.001). No association of pCR and number of trastuzumab cycles was found (OR 1.20, P = 0.39). Dosing characteristics appear important for successful treatment of breast cancer. Longer treatment, higher cumulative doses of anthracyclines and taxanes, and the addition of capecitabine and trastuzumab are associated with better response. Tailoring according to breast cancer phenotype might be possible: longer treatment in HR-positive tumors, higher cumulative anthracycline doses for HER2-negative tumors, shorter treatment at higher cumulative doses for triple-negative tumors, and limited number of preoperative trastuzumab cycles in HER2-positive tumors.

Neoadjuvant endocrine therapy for postmenopausal patients with hormone receptor-positive early breast cancer: a new concept

Patients with resectable, nonmetastatic (stage I-IIIA) breast cancer usually receive adjuvant (postoperative) systemic therapy to control micrometastasis and prevent recurrence. Neoadjuvant (preoperative) chemotherapy is a standard treatment for resectable breast cancer, potentially enabling patients to undergo partial dissection. However, it has been reported that neoadjuvant chemotherapy has a limited effect in patients with hormone receptor-positive disease in terms of pathologic complete response rate, and in elderly patients there may be safety concerns. Furthermore, the appropriateness of chemotherapy for luminal early breast cancer [defined as hormone receptor-positive and human epidermal growth factor receptor-2 (HER2)-negative tumors] is an important clinical issue. We determine the need for chemotherapy in postmenopausal patients with hormone receptor-positive, HER2-negative, lymph node-negative early breast cancer according to clinicopathologic factors, including multigene signature. The National Surgical Adjuvant Study of Breast Cancer (N-SAS-BC06) New primary Endocrine-therapy Origination Study (NEOS) is a randomized phase III trial conducted in Japanese centers. It is evaluating adjuvant endocrine therapy, with or without chemotherapy, in patients with postmenopausal breast cancer that has responded to neoadjuvant letrozole. The aims of this trial are to: define patients who might not require chemotherapy by using their response to neoadjuvant endocrine therapy; analyze the relationship between neoadjuvant endocrine therapy and long-term prognosis; and analyze the correlation between clinical and pathologic response to neoadjuvant hormonal therapy with additional postoperative chemotherapy. We hope that the results of this trial will lead to the development of a new clinical strategy of pre- and postsurgical treatment for luminal breast cancer.

Neoadjuvant therapy for locally advanced breast cancer: Focus on chemotherapy and biological targeted treatments' armamentarium

Despite progress achieved in diagnosis and therapy in recent years, locally advanced breast cancer (LABC) remains a major clinical issue. Biological characteristics and clinical behavior varies widely, ranging from indolent to locally aggressive or generalized disease. In depth knowledge of biology of cancer progression and cancer could lead to the identification of tumor characteristics associated with outcome. Neoadjuvant chemotherapy (NCT) integrated into a multimodality program is nowadays the established treatment in LABC. Although our efforts in this research task are ongoing, of special clinical interest is the integration of anti-HER2 and other biological therapies, as anti-angiogenesis targeted treatments, that may further improve the long term control of LABC. Clinical management of LABC could be modified based on molecular biology and an approach tailored to each patient will optimize therapy.

Predictors of complete pathological response after neoadjuvant systemic therapy for breast cancer

BACKGROUND

The aim of the current study was to identify predictors of pathologic complete response (pCR) following neoadjuvant therapy.

METHODS

From 2000 to 2007, 518 breast cancer patients received neoadjuvant therapy. Data were compared using chi(2) and Fisher's exact tests and multivariate analysis of variance, as appropriate.

RESULTS

Of 518 breast cancer patients receiving neoadjuvant therapy, 81 (16%) had pCR (77 of 456 [17%] with chemotherapy, 4 of 62 [6%] with endocrine therapy; P < .05). Four factors were associated with pCR: higher tumor grade (P = .015), lack of estrogen receptor (ER) and progesterone receptor (PR) expression (P < .0001), HER2/neu amplification (P = .025), and negative lymph node status (P < .0001). On multivariate analysis, ER and PR negativity, HER2/neu amplification, and negative lymph node status were found to significantly correlate with pCR.

CONCLUSIONS

Patients with ER-negative and PR-negative and HER2/neu-amplified breast cancer phenotypes are more likely to experience pCR to neoadjuvant therapy. Although pCR is more frequently observed following neoadjuvant chemotherapy, it is rare following neoadjuvant endocrine therapy.

[Neoadjuvant systemic therapy in breast cancer]

Neoadjuvant (preoperative) systemic therapy is a good possibility for the treatment of symptomatic breast cancers of the locoregional stage. Chemotherapy or hormone therapy chosen according to the characteristics of the primary tumor, result in the regression of the tumor in the majority of the cases, favoring breast conserving surgery thereafter. The long-term effects of neoadjuvant systemic therapy are equivalent to that of adjuvant therapy, and the in vivo observed efficiency of the treatment reflects prognosis. Finally, systemic therapy introduced prior to surgery is not delayed by the possible adverse effects of the surgery. Detailed examination of the tumor and the patient is mandatory before starting systemic therapy. Besides breast imaging and histological examinations, staging is necessary. Pathological characterization of the tumor will enhance treatment choice based on the features of chemo- or hormone-sensitivity. For the treatment of chemosensitive tumors, taxane- and anthracycline-based polychemotherapy is the most efficacious. Data on neoadjuvant hormone therapy have been provided by studies on postmenopausal patients. Since the aromatase inhibitors are more efficient than tamoxifen, their use is the first option in this patient population. Among the molecular targeted agents, trastuzumab combined with chemotherapy produces extending therapeutic response rate. Following the completion of the neoadjuvant systemic therapy, breast imaging is required once more before performing breast and lymph node surgery. Postoperative radiotherapy is generally needed. The use of a common language and professional guidelines by the members of the multidisciplinary breast team is a condition for neoadjuvant systemic therapy.

Preoperative bevacizumab combined with letrozole and chemotherapy in locally advanced ER- and/or PgR-positive breast cancer: clinical and biological activity

The antiangiogenic agent bevacizumab showed synergistic effects when combined with chemotherapy in advanced breast cancer. We presently investigated the activity of bevacizumab in combination with chemotherapy, including capecitabine and vinorelbine, and endocrine therapy, including letrozole (+triptorelin in premenopausal women), as primary therapy for patients with ER and/or PgR ⩾10% T2–T4a-c, N0–N2, M0 breast cancer. Biological end point included the proliferative activity (Ki67), whereas clinical end points were clinical response rate, pathological complete response (pCR) and tolerability. Circulating endothelial cells (CECs) and their progenitors, as surrogate markers of antiangiogenic activity, were measured at baseline and at surgery.Thirty-six women are evaluable. A clinical response rate of 86% (95% CI, 70–95) and no pCR were observed; Ki67 was significantly decreased by 71% (interquartile range, −82%, −62%). Toxicity was manageable: two grade 3 hypertension, four grade 3 deep venous thrombosis and no grade >2 proteinuria were observed. Treatment significantly decreased the percentage of viable CECs and prevented the chemotherapy-induced mobilisation of circulating progenitors. Basal circulating progenitors were positively associated with clinical response. In conclusion, bevacizumab is feasible and active in association with primary chemoendocrine therapy for ER-positive tumours in terms of proliferation inhibition, clinical response and antiangiogenic activity.

Biweekly docetaxel-containing chemotherapy may be the optimal schedule

The dosing schedule of docetaxel may affect its clinical activity and toxicity profile. Although triweekly docetaxel has higher antitumor activity but more severe hematological toxicity, weekly docetaxel seems to have less activity or fewer adverse events. To evaluate the efficacy and toxicity of biweekly docetaxel and mitoxantrone in patients with advanced breast cancer, the regimen consisting of docetaxel (60 mg/m), and mitoxantrone (8 mg/m) was administered intravenously to 59 patients every 2 weeks. Most (54.2%) of the patients experienced objective responses. The median time to progression for the whole group was 6.8 months. The median time to progression for patients with complete or partial response was 10.3 months, but only 3.6 months for patients with stable or progressive disease (P<0.001). Grade III/IV adverse events of neutropenia, thrombocytopenia, anemia, febrile neutropenia, and nausea/vomiting were documented in 61.0, 6.8, 3.4, 3.4, and 3.4% of the patients, respectively. The median overall survival was 16.9 months. In conclusion, biweekly use of docetaxel and mitoxantrone is a highly effective and well-tolerated regimen for patients with advanced breast cancer. The optimal dosage of docetaxel in combination with chemotherapeutic regimen may be given every 2 weeks.

Clinical response after two cycles compared to HER2, Ki-67, p53, and bcl-2 in independently predicting a pathological complete response after preoperative chemotherapy in patients with operable carcinoma of the breast

Introduction

To investigate the predictive value of clinical and biological markers for a pathological complete remission after a preoperative dose-dense regimen of doxorubicin and docetaxel, with or without tamoxifen, in primary operable breast cancer.

Methods

Patients with a histologically confirmed diagnosis of previously untreated, operable, and measurable primary breast cancer (tumour (T), nodes (N) and metastases (M) score: T2-3(≥ 3 cm) N0-2 M0) were treated in a prospectively randomised trial with four cycles of dose-dense (bi-weekly) doxorubicin and docetaxel (ddAT) chemotherapy, with or without tamoxifen, prior to surgery. Clinical and pathological parameters (menopausal status, clinical tumour size and nodal status, grade, and clinical response after two cycles) and a panel of biomarkers (oestrogen and progesterone receptors, Ki-67, human epidermal growth factor receptor 2 (HER2), p53, bcl-2, all detected by immunohistochemistry) were correlated with the detection of a pathological complete response (pCR).

Results

A pCR was observed in 9.7% in 248 patients randomised in the study and in 8.6% in the subset of 196 patients with available tumour tissue. Clinically negative axillary lymph nodes, poor tumour differentiation, negative oestrogen receptor status, negative progesterone receptor status, and loss of bcl-2 were significantly predictive for a pCR in a univariate logistic regression model, whereas in a multivariate analysis only the clinical nodal status and hormonal receptor status provided significantly independent information. Backward stepwise logistic regression revealed a response after two cycles, with hormone receptor status and lymph-node status as significant predictors. Patients with a low percentage of cells stained positive for Ki-67 showed a better response when treated with tamoxifen, whereas patients with a high percentage of Ki-67 positive cells did not have an additional benefit when treated with tamoxifen. Tumours overexpressing HER2 showed a similar response to that in HER2-negative patients when treated without tamoxifen, but when HER2-positive tumours were treated with tamoxifen, no pCR was observed.

Conclusion

Reliable prediction of a pathological complete response after preoperative chemotherapy is not possible with clinical and biological factors routinely determined before start of treatment. The response after two cycles of chemotherapy is a strong but dependent predictor. The only independent factor in this subset of patients was bcl-2.

Trial registration number

NCT00543829

Histological features of breast cancer, highly sensitive to chemotherapy

BACKGROUND

To establish tailor-made therapy for breast cancer, we investigated the possibility of predicting chemotherapy sensitive cases based on pre-therapeutic histological features.

METHODS

A total of 87 breast cancer patients underwent neoadjuvant chemotherapy with a paclitaxel (80 mg/m(2)/q1w, 12 courses)or an epirubicin regimen (90 mg/m(2)/q3wks, 4 courses). We investigated the chemo-sensitivity of invasive ductal carcinoma, solid-tubular carcinoma consisting of highly malignant cancer cells with many mitoses. We refer to this type of carcinoma as " chemo-sensitive carcinoma " and compared the histological therapeutic effects of chemo-sensitive and chemo-insensitive carcinomas.

RESULTS

1) Out of 87 patients, 20 cases (23%) showed the histological features of chemo-sensitive carcinomas on pre-therapeutic needle biopsy specimens. The remaining 67 cases (77%) were classified as chemo-insensitive carcinoma. 2) Histologically marked or complete response were observed in 50% (10/20) of chemo-sensitive carcinomas and 10% (7/67) of chemo-insensitive carcinomas (chi(2)=15.33, p=0.0001). Multivariate analysis of chemo-sensitive carcinoma, including HER2, hormone receptor and p53 status, revealed that chemo-sensitive carcinoma had a significant correlation with the histological therapeutic effects (p=0.01119). 3) Pathological complete response (pCR) was achieved in 35% (7/20) of chemo-sensitive carcinomas and 1.5% (1/67)of chemo-insensitive carcinomas (chi(2)=20.71, p<0.0001). Multivariate analysis revealed that chemo-sensitive carcinoma had a significant correlation with pCR (p=0.0091).

CONCLUSION

The histological features of chemo-sensitive carcinoma were significant predictive factors for chemotherapeutic efficacy.