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Salem AM, Smith T, Wilkes J, Bailly DK, Heyrend C, Profsky M, Yellepeddi VK, Gopalakrishnan M. Pharmacokinetic Modeling Using Real-World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement-Clinical Outcomes Relationship. J Clin Pharmacol 2024; 64:30-44. [PMID: 37565528 DOI: 10.1002/jcph.2333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO), but evidence is lacking on the ideal dosing. We aimed to (1) develop a population pharmacokinetic (PK) model for UFH, measured through anti-factor Xa assay; (2) optimize UFH starting infusions and dose titrations through simulations; and (3) explore UFH exposure-clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A 1-compartment PK model with time-varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first-order rate constant to reach steady-state CL were 0.57 L/(h·10 kg) and 0.02/h. Comparable to non-ECMO patients, the typical steady-state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 and 20 IU/h/kg for patients aged younger than 6 years and 6 years or older, respectively, achieved the therapeutic target in 56.6% of all patients, whereas only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in more than 90% of patients while less than 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti-factor Xa target rapidly and safely.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Trey Smith
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Analytics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caroline Heyrend
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Michael Profsky
- Mechanical Circulatory Support, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Venkata K Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Salem AM, Dvergsten E, Karovic S, Maitland ML, Gopalakrishnan M. Model-based approach to identify predictors of paclitaxel-induced myelosuppression in "real-world" administration. CPT Pharmacometrics Syst Pharmacol 2023; 12:929-940. [PMID: 37101403 PMCID: PMC10349185 DOI: 10.1002/psp4.12963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/11/2023] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
Taxanes are currently the most frequently used chemotherapeutic agents in cancer care, where real-world use has focused on minimizing adverse events and standardizing the delivery. Myelosuppression is a well-characterized, adverse pharmacodynamic effect of taxanes. Electronic health records (EHRs) comprise data collected during routine clinical care that include patients with heterogeneous demographic, clinical, and treatment characteristics. Application of pharmacokinetic/pharmacodynamic (PK/PD) modeling to EHR data promises new insights on the real-world use of taxanes and strategies to improve therapeutic outcomes especially for populations who are typically excluded from clinical trials, including the elderly. This investigation: (i) leveraged previously published PK/PD models developed with clinical trial data and addressed challenges to fit EHR data, and (ii) evaluated predictors of paclitaxel-induced myelosuppression. Relevant EHR data were collected from patients treated with paclitaxel-containing chemotherapy at Inova Schar Cancer Institute between 2015 and 2019 (n = 405). Published PK models were used to simulate mean individual exposures of paclitaxel and carboplatin, which were linearly linked to absolute neutrophil count (ANC) using a published semiphysiologic myelosuppression model. Elderly patients (≥70 years) constituted 21.2% of the dataset and 2274 ANC measurements were included in the analysis. The PD parameters were estimated and matched previously reported values. The baseline ANC and chemotherapy regimen were significant predictors of paclitaxel-induced myelosuppression. The nadir ANC and use of supportive treatments, such as growth factors and antimicrobials, were consistent across age quantiles suggesting age had no effect on paclitaxel-induced myelosuppression. In conclusion, EHR data could complement clinical trial data in answering key therapeutic questions.
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Affiliation(s)
- Ahmed M. Salem
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
| | | | | | - Michael L. Maitland
- Inova Schar Cancer InstituteFairfaxVirginiaUSA
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Mathangi Gopalakrishnan
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
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Purcell SA, Kok DE, Ketterl T, Garcia MB, Joffe L, Brown JC, Dieli-Conwright CM, Williams GR. Pharmacokinetics of cancer therapeutics and energy balance: the role of diet intake, energy expenditure, and body composition. J Natl Cancer Inst Monogr 2023; 2023:3-11. [PMID: 37139976 PMCID: PMC10157766 DOI: 10.1093/jncimonographs/lgad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/06/2023] [Accepted: 02/17/2023] [Indexed: 05/05/2023] Open
Abstract
Energy balance accounts for an individual's energy intake, expenditure, and storage. Each aspect of energy balance has implications for the pharmacokinetics of cancer treatments and may impact an individual's drug exposure and subsequently its tolerance and efficacy. However, the integrated effects of diet, physical activity, and body composition on drug absorption, metabolism, distribution, and excretion are not yet fully understood. This review examines the existing literature on energy balance, specifically the role of dietary intake and nutritional status, physical activity and energy expenditure, and body composition on the pharmacokinetics of cancer therapeutics. As energy balance and pharmacokinetic factors can be influenced by age-related states of metabolism and comorbidities, this review also explores the age-related impact of body composition and physiologic changes on pharmacokinetics among pediatric and older adult populations with cancer.
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Affiliation(s)
- Sarah A Purcell
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, Canada
- Irving K. Barber Faculty of Science, Department of Biology, University of British Columbia Okanagan, Kelowna, Canada
| | - Dieuwertje E Kok
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, the Netherlands
| | - Tyler Ketterl
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplant, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA, USA
| | - Miriam B Garcia
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lenat Joffe
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New Hyde Park, NY, USA
| | - Justin C Brown
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Christina M Dieli-Conwright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Grant R Williams
- Institute for Cancer Outcomes and Survivorship, Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Williams GR, Outlaw D, Harvey RD, Lichtman SM, Zamboni WC, Giri S. Chemotherapy dosing in older adults with cancer: One size does NOT fit all. J Geriatr Oncol 2023; 14:101363. [PMID: 36030172 DOI: 10.1016/j.jgo.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/01/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Grant R Williams
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Darryl Outlaw
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - R Donald Harvey
- Winship Cancer Institute, Emory University, Atlanta, GA, United States of America
| | - Stuart M Lichtman
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - William C Zamboni
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Smith Giri
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
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Lichtman SM, Cohen HJ, Muss H, Tew WP, Korc-Grodzicki B. From Assessment to Implementation and Beyond in Cancer and Aging Research. J Clin Oncol 2021; 39:2217-2225. [PMID: 34043443 PMCID: PMC8260919 DOI: 10.1200/jco.21.00317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Hyman Muss
- Department of Medicine and UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
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Yoshida Y, Inoue D. Clinical management of chemotherapy for elderly gynecological cancer patients. J Obstet Gynaecol Res 2021; 47:2261-2270. [PMID: 33880829 DOI: 10.1111/jog.14804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/18/2021] [Accepted: 04/10/2021] [Indexed: 12/14/2022]
Abstract
AIM Since there are no established guidelines for the treatment of gynecological cancer in the elderly, medical treatment policy is currently decided by discussion with patients and their families based on doctors' experiences, referring to data from nonelderly patients and healthy elderly patients. The aim of this review was to clarify the current position of chemotherapy for elderly gynecological cancer patients and discuss the problems to be addressed in the future. METHODS Little evidence has been accumulated for anticancer drug treatment in elderly individuals with gynecological cancer. This review presents outlines and representative papers on general cancer chemotherapy for the elderly, and problems that need to be solved in gynecological cancer fields in the future are identified. RESULTS In 2018, the American Society of Clinical Oncology (ASCO) published guidelines for "Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology Summary". This guideline emphasizes that, when administering chemotherapy to patients over 65 years of age, vulnerabilities should be identified using geriatric assessment (GA). However, there have been no reports of clinical studies using GA in patients with cervical or uterine cancers, and only a few clinical studies using GA have been reported in patients with ovarian cancer. CONCLUSIONS Scoring systems suitable for elderly Japanese patients remain lacking. A Japanese gynecological GA needs to be developed in cooperation with other disciplines.
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Affiliation(s)
- Yoshio Yoshida
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Daisuke Inoue
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
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Does Older Age Lead to Higher Risk for Neutropenia in Patients Treated with Paclitaxel? Pharm Res 2019; 36:163. [PMID: 31617004 DOI: 10.1007/s11095-019-2697-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 09/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE There is ongoing concern regarding increased toxicity from paclitaxel in elderly patients, particularly of severe neutropenia. Yet, data so far is controversial and this concern is not supported by a clinically relevant age-dependent difference in pharmacokinetics (PK) of paclitaxel. This study assessed whether age is associated with increased risk for paclitaxel-induced neutropenia. METHODS Paclitaxel plasma concentration-time data, pooled from multiple different studies, was combined with available respective neutrophil count data during the first treatment cycle. Paclitaxel pharmacokinetic-pharmacodynamic (PK-PD) data was modeled using a non-linear mixed effects approach and a semiphysiological neutropenia model, where systemic paclitaxel exposure was linked to reduced proliferation of neutrophils. The impact of age was evaluated on relevant variables in the model, using a significance threshold of p < 0.005. RESULTS Paclitaxel PK-PD data was evaluated from 300 patients, with a median age of 65 years (range 23-84 years), containing 116 patients ≥70 years (39%). First cycle neutrophil counts were adequately described by a threshold effect model of paclitaxel on the proliferation rate of neutrophils. Age as a continuous or dichotomous variable (≥70 versus <70 years) did not significantly impact sensitivity of the bone marrow to paclitaxel nor the average maturation time of neutrophils (both p > 0.005), causing a decline in the respective interindividual variability of <1%. CONCLUSION Results from this large retrospective patient cohort do not suggest elderly patients to be at an increased risk of developing paclitaxel-associated neutropenia during the first treatment cycle. Reflexive dose reductions of paclitaxel in elderly patients are unlikely to improve the risk of severe neutropenia and may be deleterious.
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Chon HS, Sehovic M, Marchion D, Walko C, Xiong Y, Extermann M. Biologic Mechanisms Linked to Prognosis in Ovarian Cancer that May Be Affected by Aging. J Cancer 2019; 10:2604-2618. [PMID: 31258768 PMCID: PMC6584919 DOI: 10.7150/jca.29611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 04/27/2019] [Indexed: 12/20/2022] Open
Abstract
The increase of both life expectancy of the Western industrialized population and cancer incidence with aging is expected to result in a rapid expansion of the elderly cancer population, including patients with epithelial ovarian cancer (EOC). Although the survival of patients with EOC has generally improved over the past three decades, this progress has yet to provide benefits for elderly patients. Compared with young age, advanced age has been reported as an adverse prognostic factor influencing EOC. However, contradicting results have been obtained, and the mechanisms underlying this observation are poorly defined. Few papers have been published on the underlying biological mechanisms that might explain this prognosis trend. We provide an extensive review of mechanisms that have been linked to EOC prognosis and/or aging in the published literature and might underlie this relationship in humans.
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Affiliation(s)
- Hye Sook Chon
- Department of Gynecology Oncology, Moffitt Cancer Center and Research Institute, Tampa FL, USA
- University of South Florida, Tampa FL, USA
| | - Marina Sehovic
- Senior Adult Oncology Program, Moffitt Cancer Center and Research Institute, Tampa FL, USA
- Department of Individualized Cancer Management, Moffitt Cancer Center and Research Institute, Tampa FL, USA
| | - Douglas Marchion
- Department of Pathology, Moffitt Cancer Center and Research Institute, Tampa FL, USA
| | - Christine Walko
- Department of Individualized Cancer Management, Moffitt Cancer Center and Research Institute, Tampa FL, USA
| | - Yin Xiong
- Department of Pathology, Moffitt Cancer Center and Research Institute, Tampa FL, USA
| | - Martine Extermann
- Senior Adult Oncology Program, Moffitt Cancer Center and Research Institute, Tampa FL, USA
- Department of Individualized Cancer Management, Moffitt Cancer Center and Research Institute, Tampa FL, USA
- University of South Florida, Tampa FL, USA
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9
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Impact of Older Age on the Exposure of Paclitaxel: a Population Pharmacokinetic Study. Pharm Res 2019; 36:33. [PMID: 30617624 DOI: 10.1007/s11095-018-2563-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Limited available data suggest that older patients are more prone to develop paclitaxel-induced toxicity than their younger peers. It remains unclear whether this is related to age-dependent pharmacokinetics (PK) of paclitaxel. Primary objective of this study was to determine the influence of older age on the PK of paclitaxel. METHODS PK data of patients aged ≥70 years who received paclitaxel intravenously at the Netherlands Cancer Institute (NKI) and the Radboud University Medical Center between September 2012 and May 2017 were collected. These prospectively collected data were pooled with previously published databases from multiple clinical trials conducted at the NKI and Erasmus MC Cancer Institute. A previously developed 3-compartment population PK model with saturable distribution and elimination was used to describe paclitaxel plasma concentration-time data. Hereafter, influence of age on paclitaxel PK was assessed in a previously established full covariate model. RESULTS In total, paclitaxel PK data from 684 patients were available, consisting of 166 patients ≥70 years (24%). Median age of the cohort was 61 years (range 18 to 84 years). The impact of age, either treated as a continuous or dichotomous covariate (<70 versus ≥70 years), on the elimination of paclitaxel was only marginal but statistically significant (both p < 0.001 with no clinically relevant decrease in interindividual variability). For a typical patient, maximal elimination capacity decreased by only 5% for a 10-year increment of age. CONCLUSION In this extensive multi-center dataset, which included a considerable number of older patients, older age had no clinically relevant impact on paclitaxel PK.
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Singh H, Hurria A, Klepin HD. Progress Through Collaboration: An ASCO and U.S. Food and Drug Administration Workshop to Improve the Evidence Base for Treating Older Adults With Cancer. Am Soc Clin Oncol Educ Book 2018; 38:392-399. [PMID: 30231338 DOI: 10.1200/edbk_201133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Older adults represent the majority of patients diagnosed with cancer, yet the evidence base used to guide therapy for this growing segment of the population is limited compared with data available for younger adults. Information is particularly limited for adults commonly seen in practice, including those over age 75 and those with comorbidity or frailty. Efforts have been underway to raise awareness of this substantial gap in evidence and identify strategies to build an evidence base for older adults. Recently, the ASCO and the U.S. Food and Drug Administration convened a public workshop to address this issue. There is a need for innovative trial design to test the efficacy and tolerability of therapies among generalizable older adult populations. Incorporation of endpoints such as functional independence and quality of life as well as investigation of geriatric assessment-based treatment allocation strategies will be needed to individualize care planning. Strategies to increase trial enrollment need to be emphasized, including modernizing eligibility criteria, addressing patient and provider barriers to clinical trial enrollment, and consideration of incentives for patients, providers, and sponsors. Finally, investigation of real-world data and incorporation of patient-reported outcomes into the drug-development process may provide opportunities to build evidence related to treatment benefit and tolerance with an emphasis on the patient experience among older adults in diverse treatment settings.
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Affiliation(s)
- Harpreet Singh
- From the U.S. Food and Drug Administration, Silver Spring, MD; City of Hope Center for Cancer and Aging, Duarte, CA; Wake Forest School of Medicine, Winston-Salem, NC
| | - Arti Hurria
- From the U.S. Food and Drug Administration, Silver Spring, MD; City of Hope Center for Cancer and Aging, Duarte, CA; Wake Forest School of Medicine, Winston-Salem, NC
| | - Heidi D Klepin
- From the U.S. Food and Drug Administration, Silver Spring, MD; City of Hope Center for Cancer and Aging, Duarte, CA; Wake Forest School of Medicine, Winston-Salem, NC
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Barginear M, Dueck AC, Allred JB, Bunnell C, Cohen HJ, Freedman RA, Hurria A, Kimmick G, Le-Rademacher JG, Lichtman S, Muss HB, Shulman LN, Copur MS, Biggs D, Ramaswamy B, Lafky JM, Jatoi A. Age and the Risk of Paclitaxel-Induced Neuropathy in Women with Early-Stage Breast Cancer (Alliance A151411): Results from 1,881 Patients from Cancer and Leukemia Group B (CALGB) 40101. Oncologist 2018; 24:617-623. [PMID: 30409792 PMCID: PMC6516126 DOI: 10.1634/theoncologist.2018-0298] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/31/2018] [Indexed: 01/28/2023] Open
Abstract
PURPOSE A few previous studies report a direct relationship between older age and chemotherapy-induced neuropathy. This study further evaluated this adverse event's age-based risk. METHODS CALGB 40101 investigated adjuvant paclitaxel (80 mg/m2 once per week or 175 mg/m2 every 2 weeks) in patients with breast cancer and served as a platform for the current study that investigated age-based differences in neuropathy. Grade 2 or worse neuropathy, as per Common Terminology Criteria for Adverse Events version 4, was the primary endpoint; patients were assessed at baseline, every 6 months for 2 years, and then annually for 15 years. RESULTS Among these 1,881 patients, 230 were 65 years of age or older, 556 were 55-64 years, and 1,095 were younger than 55; 1,226 neuropathy events (commonly grade 1 or 2) were reported in 65% of the cohort. The number of grade 2 or worse events was 63 (27%), 155 (28%), and 266 (24%) within respective age groups (p = .14). In univariate analysis, only motor neuropathy had a higher age-based incidence: 19 (8%), 43 (8%), and 60 (5%), respectively (p = .04); in multivariate analyses, this association was no longer statistically significant. Other endpoints, such as time to onset of neuropathy (time from trial enrollment to neuropathy development) and time to improvement (time from maximal grade sensory neuropathy to a one-category improvement), showed no statistically significant age-based differences. In contrast, obesity was associated with neuropathy, and every 2-week paclitaxel was associated with trends toward neuropathy. CONCLUSION Although paclitaxel-induced neuropathy is common, older age is not an independent risk factor. Clinical trial identification number. NCT00041119 (CALGB 40101). IMPLICATIONS FOR PRACTICE Age alone is not an independent risk factor for paclitaxel-induced neuropathy.
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Affiliation(s)
- Myra Barginear
- Northwell Health Cancer Institute, New York New York, USA
| | - Amylou C Dueck
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jacob B Allred
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Craig Bunnell
- Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Harvey J Cohen
- Center for the Study of Aging and Human Development and, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Gretchen Kimmick
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer G Le-Rademacher
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Stuart Lichtman
- Memorial Sloan Kettering Cancer Center, Commack, New York, USA
| | - Hyman B Muss
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M Sitiki Copur
- Saint Francis Cancer Treatment Center, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David Biggs
- Christiana Care Health System-Christiana Hospital, Newark, Delaware, USA
| | | | | | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Baldini C, Le Saux O, Helissey C, Aspeslagh S, Castanon E, Varga A, Gazzah A, Bahleda R, Mir O, Massard C, Soria JC, Hollebecque A. Are phase I trials safe for older patients? J Geriatr Oncol 2018; 9:87-92. [DOI: 10.1016/j.jgo.2017.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/13/2017] [Accepted: 08/23/2017] [Indexed: 02/06/2023]
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13
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Advancing Treatment Approach to the Older Patient with Cancer Through Clinical Trials Participation. Surg Oncol Clin N Am 2017; 26:719-728. [DOI: 10.1016/j.soc.2017.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Background The number of individuals aged 65 years and older is growing rapidly, and the majority of cancers are diagnosed in this age group. Age-related changes in physiology can affect chemotherapy pharmacokinetics and pharmacodynamics in older patients. Methods We review the literature regarding the impact of age on the pharmacokinetics of commonly used chemotherapy drugs and discuss age-related changes in physiology and pharmacology that can affect chemotherapy tolerance in older patients. Results The data on age-related changes in chemotherapy pharmacokinetics are conflicting. While a few studies report age-related differences in chemotherapy pharmacokinetics, most found no significant difference or subtle differences in pharmacokinetics with aging. A difference in pharmacodynamics was commonly seen, however, with older patients at increased risk of myelosuppression and toxicity from age-related decline in organ function. The majority of these studies were performed in a small cohort of patients, thus limiting the generalizability of these results. Conclusions Additional studies are needed to address the pharmacokinetics and pharmacodynamics of cancer therapies in the older patient. Multicenter pharmacokinetic studies of adequate sample size, which include a thorough evaluation of physiologic factors and geriatric assessment parameters, would provide further insight into the factors affecting treatment tolerance. These studies would also help to guide appropriate chemotherapy dosing and interventions in order to maximize efficacy and minimize toxicity in the older patient.
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Affiliation(s)
- Arti Hurria
- Cancer and Aging Research Program, City of Hope National Medical Center, Duarte, CA 91010, USA.
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15
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Wedding U, Honecker F, Bokemeyer C, Pientka L, Höffken K. Tolerance to Chemotherapy in Elderly Patients with Cancer. Cancer Control 2017; 14:44-56. [PMID: 17242670 DOI: 10.1177/107327480701400106] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Due to demographic changes, the number of elderly people with cancer will increase in the next decades. In the past, elderly patients with cancer were often excluded from clinical trials. Chronological age has been considered a risk factor for increased toxicity and reduced tolerance to chemotherapy. Methods We present a review on toxicity of chemotherapy and factors associated with toxicity in elderly patients with cancer, and we discuss chemotherapeutic agents and treatment options in treating this patient population. Results Age is a risk factor for increased toxicity to chemotherapy and decreased tolerance. However, few trials have been reported with adjustment for age-associated changes such as impairment of functional status and increased comorbidity, which also show an independent association with increased toxicity. Published data may include several biases, such as referral and publication bias. Conclusions Decision making in elderly cancer patients should be based on the results of a geriatric assessment. Patients with few or no limitations should be treated as younger patients are treated. Data with a high level of evidence are unavailable for patients showing moderate or severe limitations in a geriatric assessment.
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Affiliation(s)
- Ulrich Wedding
- Klinik und Poliklinik fur Innere Medizin II, Department of Hematology and Oncology, Friedrich Schiller Universitat, Erlanger Allee 101, D-07747 Jena, Germany.
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Henrich A, Joerger M, Kraff S, Jaehde U, Huisinga W, Kloft C, Parra-Guillen ZP. Semimechanistic Bone Marrow Exhaustion Pharmacokinetic/Pharmacodynamic Model for Chemotherapy-Induced Cumulative Neutropenia. J Pharmacol Exp Ther 2017; 362:347-358. [DOI: 10.1124/jpet.117.240309] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/05/2017] [Indexed: 11/22/2022] Open
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von Gruenigen VE, Huang HQ, Beumer JH, Lankes HA, Tew W, Herzog T, Hurria A, Mannel RS, Rizack T, Landrum LM, Rose PG, Salani R, Bradley WH, Rutherford TJ, Higgins RV, Secord AA, Fleming G. Chemotherapy completion in elderly women with ovarian, primary peritoneal or fallopian tube cancer - An NRG oncology/Gynecologic Oncology Group study. Gynecol Oncol 2017; 144:459-467. [PMID: 28089376 PMCID: PMC5570471 DOI: 10.1016/j.ygyno.2016.11.033] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/16/2016] [Accepted: 11/20/2016] [Indexed: 01/07/2023]
Abstract
PURPOSE A simple measure to predict chemotherapy tolerance in elderly patients would be useful. We prospectively tested the association of baseline Instrumental Activities of Daily Living (IADL) score with ability to complete 4 cycles of first line chemotherapy without dose reductions or >7days delay in elderly ovarian cancer patients. PATIENTS AND METHODS Patients' age ≥70 along with their physicians chose between two regimens: CP (Carboplatin AUC 5, Paclitaxel 135mg/m2) or C (Carboplatin AUC 5), both given every 3weeks either after primary surgery or as neoadjuvant chemotherapy (NACT) with IADL and quality of life assessments performed at baseline, pre-cycle 3, and post-cycle 4. RESULTS Two-hundred-twelve women were enrolled, 152 selecting CP and 60 selecting C. Those who selected CP had higher baseline IADL scores (p<0.001). After adjusting for age and PS, baseline IADL was independently associated with the choice of regimen (p=0.035). The baseline IADL score was not found to be associated with completion of 4 cycles of chemotherapy without dose reduction or delays (p=0.21), but was associated with completion of 4 cycles of chemotherapy regardless of dose reduction and delay (p=0.008) and toxicity, with the odds ratio (OR) of grade 3+ toxicity decreasing 17% (OR: 0.83; 95%CI: 0.72-0.96; p=0.013) for each additional activity in which the patient was independent. After adjustment for chemotherapy regimen, IADL was also associated with overall survival (p=0.019) for patients receiving CP. CONCLUSION Patients with a higher baseline IADL score (more independent) were more likely to complete 4 cycles of chemotherapy and less likely to experience grade 3 or higher toxicity.
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Affiliation(s)
- Vivian E von Gruenigen
- Division of Gynecologic Oncology, Summa Akron City Hospital, NEOMED, Akron, OH 44304, United States.
| | - Helen Q Huang
- NRG Oncology Statistics & Data Center, Roswell Park Cancer Institute, Buffalo, NY 14263, United States.
| | - Jan H Beumer
- Cancer Therapeutics Program, University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15213, United States; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States.
| | - Heather A Lankes
- NRG Oncology Statistics & Data Center, Roswell Park Cancer Institute, Buffalo, NY 14263, United States.
| | - William Tew
- Memorial Sloan Kettering Cancer Center, Department of Medicine, Gynecologic Medical Oncology Service, New York, NY 10065, United States.
| | - Thomas Herzog
- Department of Obstetrics and Gynecology, Columbia University Cancer Center, New York NY, 10032, United States.
| | - Arti Hurria
- Department of Obstetrics and Gynecology, Columbia University Cancer Center, New York NY, 10032, United States.
| | - Robert S Mannel
- Division of Obstetrics & Gynecology, The Peggy and Charles Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, United States.
| | - Tina Rizack
- Dept. of Gynecologic Oncology, Women & Infants Hospital, Alpert Medical School of Brown University, Providence, RI 02905, United States.
| | - Lisa M Landrum
- Division of Obstetrics & Gynecology, The Peggy and Charles Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, United States.
| | - Peter G Rose
- Dept. of Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, OH 44109, United States
| | - Ritu Salani
- Dept. of Gynecologic Oncology, Ohio State University Medical Center, Columbus, OH 43210, United States.
| | - William H Bradley
- Dept. of OB/GYN, Medical College of Wisconsin, Milwaukee, WI 53226, United States.
| | - Thomas J Rutherford
- Dept. of OB/GYN, Western Connecticut Health Network, Norwalk, CT 06856, United States.
| | - Robert V Higgins
- Dept. of Gynecologic Oncology, Carolinas Medical Center, Blumenthal Cancer Center, Charlotte, NC 28203, United States.
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC 27710, United States; Dept. of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, United States.
| | - Gini Fleming
- Section of Hematology-Oncology, Department of Medicine, The University of Chicago, Chicago, IL 60637, United States.
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Calvo E, Walko C, Dees EC, Valenzuela B. Pharmacogenomics, Pharmacokinetics, and Pharmacodynamics in the Era of Targeted Therapies. Am Soc Clin Oncol Educ Book 2017; 35:e175-84. [PMID: 27249721 DOI: 10.1200/edbk_159061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The complex nature of the pharmacologic aspects of cancer therapeutics has become more apparent in the past several years with the arrival of a cascade of target-based agents and the difficult challenge of bringing individualized precision medicine to oncology. Interpatient variability in drug action, singularly in novel agents, is in part caused by pharmacogenomic (PG), pharmacokinetic, and pharmacodynamic (PD) factors, and drug selection and dosing should take this into consideration to optimize the benefit for our patients in terms of antitumor activity and treatment tolerance. In this regard, somatic genetic evaluation of tumors is useful in not only predicting response to initial targeted therapies but also in anticipating and guiding therapy after the development of acquired resistance; therapeutic drug monitoring of novel small molecules and monoclonal antibodies must be incorporated in our day-to-day practice to minimize the negative effect on clinical outcome of interindividual variability on pharmacokinetic processes of these drugs for all patients, but especially for fragile patient populations and those with organ dysfunction or comorbidities. For these populations, incorporating frailty assessment tools into trials of newer agents and validating frailty-based dose adjustment should be an important part of further drug development.
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Affiliation(s)
- Emiliano Calvo
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Christine Walko
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - E Claire Dees
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Belén Valenzuela
- From the DeBartolo Family Personalized Medicine Institute, H. Lee Moffitt Cancer Center, Tampa, FL; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Platform of Oncology, Hospital Quirón, Torrevieja, Alicante, Spain; START Madrid, Early Clinical Drug Development Program, Centro Integral Oncológico Clara Campal, Madrid, Spain
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Palumbo R, Sottotetti F, Bernardo A. Targeted chemotherapy with nanoparticle albumin-bound paclitaxel (nab-paclitaxel) in metastatic breast cancer: which benefit for which patients? Ther Adv Med Oncol 2016; 8:209-29. [PMID: 27239239 DOI: 10.1177/1758834016639873] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The therapeutic goals in metastatic breast cancer (MBC) remain palliative in nature, aimed at controlling symptoms, improving or maintaining quality of life and prolonging survival. The advent of new drugs and new formulations of standard agents has led to better outcomes in patients with advanced or metastatic disease. These developments have also allowed a tailored therapeutic approach, in which the molecular biology of the tumour, the treatment history, and patient attitudes are taken into account in the decision-making process. Targeting drug delivery to the tumour is a promising mean of increasing the therapeutic index of highly active agents such as the taxanes, and nanoparticle albumin-bound paclitaxel (nab-paclitaxel), the first nanotechnology-based drug developed in cancer treatment, is one such advance. Data from randomized trials support the efficacy of single-agent nab-paclitaxel as first-line and further treatment lines in MBC at the registered 3-weekly schedule of 260 mg/m(2), but emerging evidence suggests its activity as a weekly regimen or combined with other agents in various clinical scenarios. Thus, nab-paclitaxel seems to offer flexibility in terms of dosing schedules, allowing physicians to tailor the dose according to different clinical situations. This paper reviews the clinical trial background for nab-paclitaxel in MBC, focusing on specific 'difficult-to-treat' patient populations, such as taxane-pretreated or elderly women, as well as those with triple-negative, HER2-positive and poor-prognostic-factors disease. Moving beyond evidence-based information, 'real life' available experiences are also discussed with the aim of providing an update for daily clinical practice.
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Affiliation(s)
- Raffaella Palumbo
- Departmental Unit of Oncology, Fondazione Salvatore Maugeri, Via Maugeri 10, 27100 Pavia, Italy
| | - Federico Sottotetti
- Departmental Unit of Oncology, IRCCS-Fondazione Salvatore Maugeri, Pavia, Italy
| | - Antonio Bernardo
- Departmental Unit of Oncology, IRCCS-Fondazione Salvatore Maugeri, Pavia, Italy
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20
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Biganzoli L, Aapro M, Loibl S, Wildiers H, Brain E. Taxanes in the treatment of breast cancer: Have we better defined their role in older patients? A position paper from a SIOG Task Force. Cancer Treat Rev 2016; 43:19-26. [DOI: 10.1016/j.ctrv.2015.11.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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Abstract
Epithelial ovarian cancer is primarily a disease of older women. Advanced age is risk factor for decreased survival. Optimal surgery and the safe and effective administration of chemotherapy are essential for prolonged progression-free and overall survival (OS). In this article, the available regimens in both the primary treatment and relapsed setting are reviewed.
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Affiliation(s)
| | - Stuart M Lichtman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 11725, USA
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22
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Pharmacokinetics of Selected Anticancer Drugs in Elderly Cancer Patients: Focus on Breast Cancer. Cancers (Basel) 2016; 8:cancers8010006. [PMID: 26729170 PMCID: PMC4728453 DOI: 10.3390/cancers8010006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/30/2015] [Accepted: 12/29/2015] [Indexed: 01/07/2023] Open
Abstract
Background: Elderly patients receiving anticancer drugs may have an increased risk to develop treatment-related toxicities compared to their younger peers. However, a potential pharmacokinetic (PK) basis for this increased risk has not consistently been established yet. Therefore, the objective of this study was to systematically review the influence of age on the PK of anticancer agents frequently administered to elderly breast cancer patients. Methods: A literature search was performed using the PubMed electronic database, Summary of Product Characteristics (SmPC) and available drug approval reviews, as published by EMA and FDA. Publications that describe age-related PK profiles of selected anticancer drugs against breast cancer, excluding endocrine compounds, were selected and included. Results: This review presents an overview of the available data that describe the influence of increasing age on the PK of selected anticancer drugs used for the treatment of breast cancer. Conclusions: Selected published data revealed differences in the effect and magnitude of increasing age on the PK of several anticancer drugs. There may be clinically-relevant, age-related PK differences for anthracyclines and platina agents. In the majority of cases, age is not a good surrogate marker for anticancer drug PK, and the physiological state of the individual patient may better be approached by looking at organ function, Charlson Comorbidity Score or geriatric functional assessment.
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23
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Duska LR, Tew WP, Moore KN. Epithelial ovarian cancer in older women: defining the best management approach. Am Soc Clin Oncol Educ Book 2015:e311-21. [PMID: 25993191 DOI: 10.14694/edbook_am.2015.35.e311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Epithelial ovarian cancer is a cancer of older women. In fact, almost half of women diagnosed with ovarian cancer will be older than age 64, and 25% will be older than age 74. Therefore, it is crucial to examine the available data in older populations to optimize the therapeutic approach without negatively affecting the quality of life permanently. Unfortunately, little prospective data are available in this under-represented population of women. Although ovarian cancer traditionally has been approached with aggressive cytoreductive surgery, older patients may benefit from a less aggressive surgical approach and, in some cases, may be candidates for neoadjuvant chemotherapy followed by an interval cytoreduction. Modalities do exist for assessing an older woman's ability to tolerate surgery and chemotherapy, and these tools should be familiar to clinicians who are caring for this population of women in making treatment decisions. Ongoing planned trials to evaluate pretreatment assessment for older patients will provide objective, feasible, clinical tools for applying our treatment-based knowledge. Future trials of both surgery and chemotherapy, including a focus on the sequence of these two treatment modalities, are crucial to guide decision making in this vulnerable population and to improve outcomes for all.
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Affiliation(s)
- Linda R Duska
- From the University of Virginia, Charlottesville, VA; Memorial Sloan Kettering Cancer Center, New York NY; University of Oklahoma, Oklahoma City, OK
| | - William P Tew
- From the University of Virginia, Charlottesville, VA; Memorial Sloan Kettering Cancer Center, New York NY; University of Oklahoma, Oklahoma City, OK
| | - Kathleen N Moore
- From the University of Virginia, Charlottesville, VA; Memorial Sloan Kettering Cancer Center, New York NY; University of Oklahoma, Oklahoma City, OK
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24
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Hurria A, Blanchard MS, Synold TW, Mortimer J, Chung CT, Luu T, Katheria V, Rotter AJ, Wong C, Choi A, Feng T, Ramani R, Doan CM, Brown J, Somlo G. Age-related changes in nanoparticle albumin-bound paclitaxel pharmacokinetics and pharmacodynamics: influence of chronological versus functional age. Oncologist 2015; 20:37-44. [PMID: 25492923 PMCID: PMC4294604 DOI: 10.1634/theoncologist.2014-0202] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 11/06/2014] [Indexed: 12/27/2022] Open
Abstract
PURPOSE This study evaluated age-related changes in pharmacokinetic and pharmacodynamic parameters of nanoparticle albumin-bound paclitaxel (nab-paclitaxel) in patients with metastatic breast cancer. METHODS Forty patients received nab-paclitaxel (100 mg/m(2) weekly for 3 weeks followed by a 1-week break) as first- or second-line chemotherapy. Blood samples were collected for analysis, and response was assessed every two cycles. Planned statistical analyses included linear regression to examine the relationship between age and pharmacokinetic variables (ln clearance [CL] and ln area under the curve [AUC]) and two-sided two-sample t tests to evaluate age differences in pharmacodynamic variables. The association between chemotherapy toxicity risk scores and pharmacokinetic and pharmacodynamic variables including grade ≥ 3 toxicity were examined post hoc. RESULTS Of 40 patients enrolled, 39 (98%) were evaluable (mean age: 60 years; range: 30-81 years). A partial response was achieved in 31%, and 38% had stable disease. There was a borderline positive association between age and 24-hour ln AUC (slope = 0.011; SE = 0.006; p = .055). Grade 3 toxicity was experienced by 26% (8% hematologic, 18% nonhematologic). There were no differences in age based on the presence of grade 3 toxicity (p = .75), dose reductions (p = .38), or dose omissions (p = .15). A significant association was noted between chemotherapy toxicity risk score category and presence of grade 3 toxicity (toxicity rate by risk score category: low, 5 of 30 patients; medium, 3 of 6 patients; high, 2 of 3 patients; p = .041). CONCLUSION A borderline significant relationship exists between age and 24-hour AUC, but no differences were noted for pharmacodynamic variables (grade 3 toxicity, dose reductions, or dose omissions) based on age. There is an association between toxicity risk score and grade ≥ 3 chemotherapy toxicity and pharmacokinetic variables. The treatment is well tolerated across all age groups.
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Affiliation(s)
- Arti Hurria
- City of Hope National Medical Center, Duarte, California, USA
| | | | | | - Joanne Mortimer
- City of Hope National Medical Center, Duarte, California, USA
| | - Cathie T Chung
- City of Hope National Medical Center, Duarte, California, USA
| | - Thehang Luu
- City of Hope National Medical Center, Duarte, California, USA
| | - Vani Katheria
- City of Hope National Medical Center, Duarte, California, USA
| | - Arnold J Rotter
- City of Hope National Medical Center, Duarte, California, USA
| | - Carol Wong
- City of Hope National Medical Center, Duarte, California, USA
| | - Anthony Choi
- City of Hope National Medical Center, Duarte, California, USA
| | - Tao Feng
- City of Hope National Medical Center, Duarte, California, USA
| | - Rupal Ramani
- City of Hope National Medical Center, Duarte, California, USA
| | - Caroline M Doan
- City of Hope National Medical Center, Duarte, California, USA
| | - Jaycen Brown
- City of Hope National Medical Center, Duarte, California, USA
| | - George Somlo
- City of Hope National Medical Center, Duarte, California, USA
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25
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Hurria A, Dale W, Mooney M, Rowland JH, Ballman KV, Cohen HJ, Muss HB, Schilsky RL, Ferrell B, Extermann M, Schmader KE, Mohile SG. Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations. J Clin Oncol 2014; 32:2587-94. [PMID: 25071116 DOI: 10.1200/jco.2013.55.0418] [Citation(s) in RCA: 237] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
A majority of cancer diagnoses and deaths occur in patients age ≥ 65 years. With the aging of the US population, the number of older adults with cancer will grow. Although the coming wave of older patients with cancer was anticipated in the early 1980s, when the need for more research on the cancer-aging interface was recognized, many knowledge gaps remain when it comes to treating older and/or frailer patients with cancer. Relatively little is known about the best way to balance the risks and benefits of existing cancer therapies in older patients; however, these patients continue to be underrepresented in clinical trials. Furthermore, the available clinical trials often do not include end points pertinent to the older adult population, such as preservation of function, cognition, and independence. As part of its ongoing effort to advance research in the field of geriatric oncology, the Cancer and Aging Research Group held a conference in November 2012 in collaboration with the National Cancer Institute, the National Institute on Aging, and the Alliance for Clinical Trials in Oncology. The goal was to develop recommendations and establish research guidelines for the design and implementation of therapeutic clinical trials for older and/or frail adults. The conference sought to identify knowledge gaps in cancer clinical trials for older adults and propose clinical trial designs to fill these gaps. The ultimate goal of this conference series is to develop research that will lead to evidence-based care for older and/or frail adults with cancer.
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Abstract
Minimizing toxicity while maximizing efficacy is a common goal in the treatment of any condition but its importance is underscored in the discipline of oncology because of the serious nature of many chemotherapeutic toxicities and the risk of cancer recurrence or disease progression. The challenge of achieving an optimal therapeutic index is especially augmented in the elderly population because of age-related metabolism changes and interacting concurrent medications. Additional factors, such as germline mutations in drug-metabolizing enzymes and other pharmacogenomic alterations, may have more pronounced effects in elderly patients, given their predisposition to altered pharmacokinetics and pharmacodynamics with resulting increased risk of toxicity. Examples of the possible interplay of these factors will be discussed using tamoxifen, paclitaxel, codeine, and fluorouracil as starting points. Limited participation of the elderly in many cancer trials, especially trials assessing drug exposure, makes much knowledge on the interaction of these patient and environmental factors speculative in nature but presents an opportunity for future research to achieve better optimization of chemotherapeutic agents in the elderly.
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Bertagnolli MM, Canetta R, Nass SJ. Expanding public-private collaborations to enhance cancer drug development: a report of the Institute of Medicine's workshop series, "Implementing a National Cancer Clinical Trials System for the 21st Century". Oncologist 2014; 19:1179-85. [PMID: 25326161 PMCID: PMC4221375 DOI: 10.1634/theoncologist.2014-0240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/10/2014] [Indexed: 11/17/2022] Open
Abstract
Since their inception in the 1950s, the National Cancer Institute-funded cancer cooperative groups have been important contributors to cancer clinical and translational research. In 2010, a committee appointed by the Institute of Medicine (IOM) of the National Academy of Sciences completed a consensus review on the status of the U.S. publicly funded cancer clinical trials system. This report identified a need to reinvigorate the cooperative groups and provided recommendations for improving their effectiveness. Follow-up workshops to monitor progress were conducted by the IOM's National Cancer Policy Forum and the American Society of Clinical Oncology (ASCO) in 2011 and 2013. One of the key recommendations of the IOM report was a call for greater collaboration among stakeholders in cancer research. In particular, more active engagement and better alignment of incentives among the cooperative groups, the National Cancer Institute, the U.S. Food and Drug Administration, and the biopharmaceutical industry were identified as essential to achieving the promise of oncology drug development. This review, based on presentations and discussion during the IOM-ASCO workshops, outlines the progress and remaining challenges of these collaborations.
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Affiliation(s)
- Monica M Bertagnolli
- Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Bristol-Myers Squibb, Wallingford, Connecticut, USA; National Cancer Policy Forum, Institute of Medicine of the National Academies, Washington, D.C., USA
| | - Renzo Canetta
- Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Bristol-Myers Squibb, Wallingford, Connecticut, USA; National Cancer Policy Forum, Institute of Medicine of the National Academies, Washington, D.C., USA
| | - Sharyl J Nass
- Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA; Bristol-Myers Squibb, Wallingford, Connecticut, USA; National Cancer Policy Forum, Institute of Medicine of the National Academies, Washington, D.C., USA
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28
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How I treat ovarian cancer in older women. J Geriatr Oncol 2014; 5:223-9. [DOI: 10.1016/j.jgo.2014.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/29/2014] [Accepted: 06/02/2014] [Indexed: 11/17/2022]
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Ren X, Zhang Y, Li C, Wang H, Jiang Z, Zhang Z, Guo Q, Song G, Bi K, Jiang G. Enhancement of baicalin by hexamethylene bisacetamide on the induction of apoptosis contributes to simultaneous activation of the intrinsic and extrinsic apoptotic pathways in human leukemia cells. Oncol Rep 2013; 30:2071-80. [PMID: 23970138 DOI: 10.3892/or.2013.2684] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 06/21/2013] [Indexed: 11/06/2022] Open
Abstract
Hexamethylene bisacetamide (HMBA) and natural flavanoid baicalin both exert potent antileukemic activity. However, there is currently no data on the anti-leukemic effects of baicalin in combination with HMBA. In the present study, we demonstrated that the combination of baicalin and HMBA synergistically inhibited the proliferation of acute myeloid leukemia (AML) cell lines. In addition, a slight G0/G1 phase arrest and significant apoptosis were observed. The combination treatment triggered apoptosis through the intrinsic pathway, which involved loss of MMP, decreased Bcl‑2/Bax ratio and Bcl‑XL/Bax ratio, caspase‑9 activation, as well as through the extrinsic pathway mediated by Fas and caspase‑8 activation. On the other hand, combination of baicalin and HMBA showed little toxic effect on peripheral blood mononuclear cells from healthy volunteers. Our results raise the possibility that the novel combination of baicalin and HMBA may be a promising regimen for the treatment of AML.
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Affiliation(s)
- Xia Ren
- Key Laboratory for Rare and Uncommon Diseases, Key Laboratory for Tumor Immunology and Chinese Medicine Immunology of Shandong Province, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
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Considerations regarding the administration of systemic therapy for elderly patients with ovarian cancer. Curr Treat Options Oncol 2013; 14:1-11. [PMID: 23307065 DOI: 10.1007/s11864-012-0219-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
To improve the benefit and tolerability of cancer treatment, we must develop new geriatric-specific trials, better assessment tools, and encourage enrollment of older patients in clinical trials. Age is a strong predictor of survival in ovarian cancer and often influences the treatment plan. Elderly patients, broadly defined as older than age 65 years, are commonly not offered participation in clinical research or provided with substandard chemotherapy or surgical options. Because first-line, platinum-based chemotherapy with cytoreductive surgery is a potentially curative modality, all standard treatment options should be explored (intravenous, neoadjuvant, and/or intraperitoneal chemotherapy). However, one must balance the specific needs of the older patient and be aware of the increased risk of side effects. To be mindful and respectful, the oncologist should clearly define the goals (palliative vs. curative) and specific risks of treatment to patients and their families. As the field of geriatric oncology evolves and prospective trials tailored to older women with ovarian cancer are developed, specific guidelines will ultimately assist in these difficult decisions.
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Abstract
There have been conflicting results regarding a correlation between CD133 expression and disease outcome. To assess CD133 expression in patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) and to evaluate its correlation with the different clinical and laboratory data as well as its relation to disease outcome, the present study included 60 newly diagnosed acute leukemic patients; 30 ALL patients with a male to female ratio of 1.5:1 and their ages ranged from 9 months to 48 years, and 30 AML patients with a male to female ratio of 1:1 and their ages ranged from 17 to 66 years. Flow cytometric assessment of CD133 expression was performed on blast cells. In ALL, no correlations were elicited between CD133 expression and some monoclonal antibodies, but in AML group, there was a significant positive correlation between CD133 and HLA-DR, CD3, CD7 and TDT, CD13 and CD34. In ALL group, patients with negative CD133 expression achieved complete remission more than patients with positive CD133 expression. In AML group, there was no statistically significant association found between positive CD133 expression and treatment outcome. The Kaplan-Meier curve illustrated a high significant negative correlation between CD133 expression and the overall survival of the AML patients. CD133 expression is an independent prognostic factor in acute leukemia, especially ALL patients and its expression could characterize a group of acute leukemic patients with higher resistance to standard chemotherapy and relapse. CD133 expression was highly associated with poor prognosis in acute leukemic patients.
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Elderly Patients with Advanced NSCLC in Phase III Clinical Trials: Are the Elderly Excluded from Practice-Changing Trials in Advanced NSCLC? J Thorac Oncol 2013; 8:366-8. [DOI: 10.1097/jto.0b013e31827e2145] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Ovarian cancer (OC) is a disease of elderly women. The disease spreads insidiously and presents at an advanced stage at initial diagnosis for most patients. Several groups reported at least a two-fold increased risk of death in women older than 65. Various theories have been proposed to explain this survival disparity in older women, including: (1) more aggressive cancer with advanced age, (2) inherent resistance to chemotherapy, (3) individual patient factors such as multiple concurrent medical problems, and (4) physician and health-care biases toward the elderly that lead to inadequate surgery, less than optimal chemotherapy, and poor enrollment in clinical trials. As a result of this high clinical variability, oncologists need to be more familiar with the comprehensive geriatric assessment to better identify vulnerable patients at higher risk of complications. Several geriatric tools are available to assess the physiologic and functional capacities of older patients and to better individualize treatment. This paper gives an overview of the management of elderly patients with OC, in particular the integration of chemotherapy, surgery, and geriatric assessment to improve treatment tolerance and survival outcomes.
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Affiliation(s)
- G Freyer
- From the Lyon 1 University and Department of Medical Oncology, Lyon Sud Hospital, Lyon, France; Memorial Sloan-Kettering Cancer Center, New York, NY; Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK
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Abstract
PURPOSE This project aimed to identify common drug-related problems (DRP) among elderly cancer patients, to determine the effectiveness of medication therapy management (MTM) service in resolving DRP, to determine the clinical significance of pharmacist interventions, and to determine patients' satisfaction level of MTM service. METHOD Elderly cancer patients (age ≥65) who were at least on one chronic medication would be eligible for the MTM service. Any DRP that was detected would be recorded and steps to resolve it were taken. Pre- and post-service patient satisfaction surveys (PSS) were conducted before and after MTM. All interventions performed by MTM pharmacists were subjected to independent evaluation by a panel of three judges. RESULTS One hundred eighteen patients received at least one session of MTM. We identified and attempted to resolve 361 DRPs, and the most common DRPs were drug interactions (117 cases, 32.4 %), adverse effects (114 cases, 31.6 %), and non-adherence (48 cases, 13.3 %). Forty-four interventions were performed by pharmacists and forty cases (91 %) were accepted by physicians. Almost two third of these interventions were deemed significant (or higher) by the judges. Seventy-two patients completed PSS. There was statistically significant improvement in patients' satisfaction level after the service was provided. CONCLUSION MTM is an important platform in identifying and managing DRPs. Patients are generally satisfied with MTM services.
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Lichtman SM. Clinical trial design in older adults with cancer—The need for new paradigms. J Geriatr Oncol 2012. [DOI: 10.1016/j.jgo.2012.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Teo MY, Power DG, Tew WP, Lichtman SM. Doublet chemotherapy in the elderly patient with ovarian cancer. Oncologist 2012; 17:1450-60. [PMID: 22915061 PMCID: PMC3500367 DOI: 10.1634/theoncologist.2012-0155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/25/2012] [Indexed: 11/17/2022] Open
Abstract
The aging of the population has focused on the need to evaluate older patients with cancer. Approximately 50% of patients with ovarian cancer will be older than age 65 years. Increasing age has been associated with decreased survival. It is uncertain whether this relates to biologic factors, treatment factors, or both. There is concern that undertreatment may be associated with decreased survival. Older patients with ovarian cancer have been underrepresented in clinical trials. Therefore, the evidence base on which make decisions is lacking. Clinicians need to be aware of the currently available data to aid in treatment decisions. Doublet therapy is the most common standard treatment in epithelial ovarian cancer. It usually consists of a taxane and a platinum compound. A series of cooperative group studies in both the United States and Europe established intravenous paclitaxel and carboplatin as the most common standard in optimally debulked patients. The recent introduction of intraperitoneal therapy has complicated decision making in terms of which older patients would benefit from this more toxic therapy. In relapsed patients, the issue of platinum sensitivity is critical in deciding whether to reutilize platinum compounds. It is unclear whether single agents or combinations are superior, particularly in older patients. Geriatric assessment is an important component of decision making. Prospective studies are needed to develop strategies to determine the optimal treatment for older patients with ovarian cancer.
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Affiliation(s)
- Min Y. Teo
- Department of Medical Oncology, Cork/Mercy University Hospitals, Cork, Ireland
| | - Derek G. Power
- Department of Medical Oncology, Cork/Mercy University Hospitals, Cork, Ireland
| | | | - Stuart M. Lichtman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Griggs JJ, Mangu PB, Anderson H, Balaban EP, Dignam JJ, Hryniuk WM, Morrison VA, Pini TM, Runowicz CD, Rosner GL, Shayne M, Sparreboom A, Sucheston LE, Lyman GH. Appropriate chemotherapy dosing for obese adult patients with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2012; 30:1553-61. [PMID: 22473167 DOI: 10.1200/jco.2011.39.9436] [Citation(s) in RCA: 353] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To provide recommendations for appropriate cytotoxic chemotherapy dosing for obese adult patients with cancer. METHODS The American Society of Clinical Oncology convened a Panel of experts in medical and gynecologic oncology, clinical pharmacology, pharmacokinetics and pharmacogenetics, and biostatistics and a patient representative. MEDLINE searches identified studies published in English between 1996 and 2010, and a systematic review of the literature was conducted. A majority of studies involved breast, ovarian, colon, and lung cancers. This guideline does not address dosing for novel targeted agents. RESULTS Practice pattern studies demonstrate that up to 40% of obese patients receive limited chemotherapy doses that are not based on actual body weight. Concerns about toxicity or overdosing in obese patients with cancer, based on the use of actual body weight, are unfounded. RECOMMENDATIONS The Panel recommends that full weight-based cytotoxic chemotherapy doses be used to treat obese patients with cancer, particularly when the goal of treatment is cure. There is no evidence that short- or long-term toxicity is increased among obese patients receiving full weight-based doses. Most data indicate that myelosuppression is the same or less pronounced among the obese than the non-obese who are administered full weight-based doses. Clinicians should respond to all treatment-related toxicities in obese patients in the same ways they do for non-obese patients. The use of fixed-dose chemotherapy is rarely justified, but the Panel does recommend fixed dosing for a few select agents. The Panel recommends further research into the role of pharmacokinetics and pharmacogenetics to guide appropriate dosing of obese patients with cancer.
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Dale W, Mohile SG, Eldadah BA, Trimble EL, Schilsky RL, Cohen HJ, Muss HB, Schmader KE, Ferrell B, Extermann M, Nayfield SG, Hurria A. Biological, clinical, and psychosocial correlates at the interface of cancer and aging research. J Natl Cancer Inst 2012; 104:581-9. [PMID: 22457474 DOI: 10.1093/jnci/djs145] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In September 2010, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, conducted the first of three planned conferences to discuss research methodology to generate the highest quality research in older adults with cancer and then disseminate these findings among those working in the fields of cancer and aging. Conference speakers discussed the current level of research evidence in geriatric oncology, outlined the current knowledge gaps, and put forth principles for research designs and strategies that would address these gaps within the next 10 years. It was agreed that future oncology research trials that enroll older adults should include: (1) improved standardized geriatric assessment of older oncology patients, (2) substantially enhanced biological assessment of older oncology patients, (3) specific trials for the most vulnerable and/or those older than 75 years, and (4) research infrastructure that specifically targets older adults and substantially strengthened geriatrics and oncology research collaborations. This initial conference laid the foundation for the next two meetings, which will address the research designs and collaborations needed to enhance therapeutic and intervention trials in older adults with cancer.
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Affiliation(s)
- William Dale
- Department of Medical Oncology and Therapeutics Research, City of Hope, 1500 E Duarte Rd, Duarte, CA 91010, USA
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Lichtman SM, Hurria A, Cirrincione CT, Seidman AD, Winer E, Hudis C, Cohen HJ, Muss HB. Paclitaxel efficacy and toxicity in older women with metastatic breast cancer: combined analysis of CALGB 9342 and 9840. Ann Oncol 2012; 23:632-638. [PMID: 21693770 PMCID: PMC3331731 DOI: 10.1093/annonc/mdr297] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 04/24/2011] [Accepted: 04/26/2011] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Two Cancer and Leukemia Group B (CALGB) studies were utilized to determine the efficacy and tolerability of paclitaxel (Taxol) in older patients with metastatic breast cancer. PATIENTS AND METHODS CALGB 9840 evaluated weekly paclitaxel (80 mg/m(2)) versus paclitaxel every 3 weeks (175 mg/m(2)); CALGB 9342 evaluated three doses of paclitaxel as follows: 175, 210 and 250 mg/m(2) each over 3 h every 3 weeks. Of the 1048 patients, paclitaxel was used first line in 57%. The groups: (i) <55 years (45%), (ii) 55-64 years (29%), and (iii) ≥65 years (26%). RESULTS Tumor response was also similar among age groups. First-line therapy (P = 0.0001) and better performance status (PS) (P = 0.018) were significantly related to higher response. Age did not significantly relate to overall survival (OS) or progression-free survival (PFS). First-line therapy, better PS, estrogen receptor positive status and a fewer number of metastatic sites were significantly related to improved OS and PFS. The grade ≥3 toxic effects that increased linearly with age were leucopenia (P = 0.0099), granulocytopenia (P = 0.022), anorexia (P = 0.028), bilirubin elevation (P = 0.0035) and neurotoxicity (P < 0.0001). Patients over 65 years receiving second-line therapy had the shortest time to neurotoxicity. CONCLUSIONS Older women with breast cancer derive similar efficacy from treatment with paclitaxel as younger women. Older women are at increased risk for specific toxic effects.
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Affiliation(s)
- S M Lichtman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York.
| | - A Hurria
- Department of Medical Oncology and Therapeutics Research and Department of Population Sciences, City of Hope, Duarte
| | | | - A D Seidman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York
| | - E Winer
- Breast Oncology Center, Dana-Farber Cancer Institute, Boston
| | - C Hudis
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York
| | - H J Cohen
- Center for the Study of Aging and Human Development, Duke University, Durham
| | - H B Muss
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, USA
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Pal SK, Vanderwalde A, Hurria A, Figlin RA. Systemic therapies for metastatic renal cell carcinoma in older adults. Drugs Aging 2011; 28:635-49. [PMID: 21812499 PMCID: PMC5333645 DOI: 10.2165/11592880-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The introduction of targeted therapies has radically changed the treatment paradigm for metastatic renal cell carcinoma (mRCC). However, multiple clinical dilemmas have emerged. For instance, limited data are available to juxtapose the safety and efficacy profile of targeted therapies between older and younger adults. Herein, pivotal trials of vascular endothelial growth factor (VEGF)- and mammalian target of rapamycin (mTOR)-directed therapies are assessed in the context of their implications in treating older adults with mRCC. In general, subset analyses from these pivotal studies suggest similar efficacy of targeted therapies amongst older adults. Aging is accompanied by a multitude of physiological changes, as well as an increased prevalence of co-morbidities. The age-related toxicity profiles of targeted agents for mRCC are detailed to provide a framework for the risks and benefits of these therapies in older adults. Ultimately, tools such as the Comprehensive Geriatric Assessment (CGA) that account for physiological (as opposed to chronological) age may prove useful in the evaluation and treatment of older adults with mRCC.
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Affiliation(s)
- Sumanta K. Pal
- Division of Genitourinary Malignancies, Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ari Vanderwalde
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Arti Hurria
- Department of Medical Oncology & Experimental Therapeutics, Cancer Control and Population Sciences Program, and Cancer and Aging Research Program, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Robert A. Figlin
- Department of Medicine, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, USA
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Spazzapan S, Crivellari D, Bedard P, Lombardi D, Miolo G, Scalone S, Veronesi A. Therapeutic management of breast cancer in the elderly. Expert Opin Pharmacother 2011; 12:945-60. [DOI: 10.1517/14656566.2011.540570] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pal SK, Hurria A. Impact of age, sex, and comorbidity on cancer therapy and disease progression. J Clin Oncol 2010; 28:4086-93. [PMID: 20644100 DOI: 10.1200/jco.2009.27.0579] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A theme of personalized medicine was highlighted at the 2009 Annual Meeting of the American Society of Clinical Oncology. To this end, the current review focuses on the impact of host characteristics (such as age, sex, and comorbidity) as they pertain to cancer biology, treatment efficacy, and tolerance. Increasing age is associated with complex changes in physiology, including alterations in renal and hepatic function, and decreased bone marrow reserve. These may in turn result in alterations in pharmacokinetics and toxicity related to many commonly used anticancer agents. Using tools, such as the geriatric assessment, may help to elucidate the physiologic age of the patient as opposed to the chronologic age. Increasing age is paralleled by an increase in comorbidity, and comorbidity may have independent prognostic implications and substantially impact medical decision making in the patient with cancer. Numerous biologic ties between cancer and comorbidity exist, one example being an association of diabetes with an increased risk of disease recurrence and mortality in the setting of colon cancer. Biologic features can also vary by sex; several biomarkers with either prognostic or predictive value (ie, excisionrepair cross-complementation group 1 expression, epidermal growth factor receptor mutation, or dihydropyrimidine dehydrogenase polymorphism) may differentiate efficacy or toxicity in males and females. Taken together, age, sex, and comorbidity each encompass a complex array of physiologic and molecular variations that may each aid in personalizing care for the patient with cancer.
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Affiliation(s)
- Sumanta Kumar Pal
- Experimental Therapeutics and Cancer Control and Population Sciences Program, Cancer and Aging Research Program, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd, Duarte, CA, USA
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AC133 expression in egyptian children with acute leukemia: impact on treatment response and disease outcome. J Pediatr Hematol Oncol 2010; 32:286-93. [PMID: 20224439 DOI: 10.1097/mph.0b013e3181c80c08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AC133 antigen is expressed restrictively in the immature subset of the CD34 cells. Hence, it is expected to be a valuable prognostic marker in acute leukemia. Sixty Egyptian children with acute leukemia were enrolled into this prospective study divided into 2 groups: 30 acute myeloblastic leukemia (AML) and 30 acute lymphoblastic leukemia (ALL) patients. Flow cytometric assessment of AC133 expression was performed on CD34 blast cells. AC133 was expressed in 66.7% and 40% of AML and ALL patients, respectively. AC133-positive expression was not associated with any of the studied standard prognostic factors. In AML, 80% of patients with poor clinical outcome (relapse or death) were positive for AC133 expression, whereas, all ALL patients who developed resistance as well as those who displayed poor clinical outcome had AC133-positive expression (P<0.05). Patients with positive AC133 expression had significantly shorter overall and disease-free survival times compared with AC133-negative patients in both ALL (P<0.001) and AML (P<0.05) groups. AC133 expression percentage was a reliable poor prognostic marker in ALL patients (P<0.0001). AC133-positive expression is an independent poor prognostic factor in childhood acute leukemia and could characterize a group of patients with resistance to standard chemotherapy, as well as high incidence of relapse and death.
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Lalami Y, de Castro G, Bernard-Marty C, Awada A. Management of head and neck cancer in elderly patients. Drugs Aging 2010; 26:571-83. [PMID: 19655824 DOI: 10.2165/11316340-000000000-00000] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Head and neck cancer (HNC) represents a heterogeneous group of tumours requiring multimodality approaches. It is debatable whether HNC treatment in geriatric patients should be different to that delivered for younger patients. Furthermore, the risk of death seems to be higher in HNC patients with higher co-morbidity status. Despite the fact that there is no significant difference in outcome in younger versus older patients, older HNC patients are more likely to receive nonstandard, less aggressive therapies than younger patients. Age alone should not be the basis for selecting treatment options in older HNC patients. A thorough pretreatment evaluation of co-morbidities should always be performed, and radical surgical options should not be excluded in older HNC patients treated with curative intent, as postoperative complications occur no more frequently in older patients than in younger patients. Locoregional control and disease-free survival in older patients treated with radiation therapy (either with curative intent or in the palliative setting) are comparable to the results seen in younger HNC patients, with the same acute toxicity profile. In patients receiving systemic therapies, special attention must be given to modification of chemotherapy dosages according to renal and hepatic function. Molecular-targeted therapies appear to be very useful in such patients because of their favourable tolerability. In conclusion, once all physiological and biological risk factors have been addressed, a large proportion of geriatric patients can and should be offered the same HNC treatment as is offered to younger patients.
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Affiliation(s)
- Yassine Lalami
- Medical Oncology Clinic, Institut Jules Bordet, Brussels, Belgium
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Dawood S, Leyland-Jones B. Pharmacology and pharmacogenetics of chemotherapeutic agents. Cancer Invest 2009; 27:482-8. [PMID: 19479485 DOI: 10.1080/07357900802574660] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The last decade the field of oncology has seen the introduction of several efficacious chemotherapeutic agents. However the benefits achieved have been modest at best. The choice of chemotherapeutic agent is often empirical and geared to fit the average patient with the result that approximately 40% of patients may be receiving the wrong drug. With greater understanding of the mechanisms behind the heterogeneity observed across patient populations, both in terms of efficacy and toxicity of a variety of therapeutic agents, research has now focused on individualizing treatment strategies by incorporating a combination of physiological variables, genetic characteristics and environmental factors together with the traditional tumor characteristics that currently drives clinical decision making. This review focuses on defining some of the principle components of personalized medicine. In addition we will review the pharmacological and pharmacogenetic predictors of toxic effects of chemotherapeutic agents drawing on examples of commonly used agents in oncology.
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Affiliation(s)
- Shaheenah Dawood
- Department of Oncology, Dubai Hospital, Dubai, United Arab Emirates.
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Abstract
Members of the Cancer and Leukemia Group B (CALGB) have been striving to improve cancer therapies for more than 50 years. The organization began in the mid 1950s as a multi-institutional collaboration between investigators at the National Cancer Institute, Roswell Park Memorial Institute, and the Children's Hospital in Buffalo New York. In 1956 the group was officially designated as the Acute Leukemia Group B (ALGB) and for most of its first decade focused largely on leukemia research. Reflecting an expansion of its research portfolio during the 1960s and 70s, the name was changed in 1976 to Cancer and Leukemia Group B. Currently, the organization has hundreds of members, including nurses, clinical research associates, statisticians, physicians, translational scientists, and an administrative staff from a nationwide network of academic and community based organizations and medical practices. Disease areas within the scope of CALGB research include hematologic malignancies, as well as breast, gastrointestinal, genitourinary, and respiratory cancers. Modality expertise includes quality of life, medical oncology, surgery, radiation oncology, pathology, imaging, oncology nursing, health outcomes, geriatrics, biostatistics, data management, and an extensive array of correlative sciences. Some of the major accomplishments of CALGB investigators and the patients participating in CALGB research as critical and committed partners will be reviewed here.
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Affiliation(s)
- Mark R. Green
- Medical University of South Carolina, Charleston, South Carolina
- Network for Medical Communication and Research Analytics, Atlanta, Georgia
| | - Stephen L. George
- CALGB Statistical Center, Duke University Medical Center, Durham, North Carolina
| | - Richard L. Schilsky
- Cancer and Leukemia Group B, Central Office of the Chairman and University of Chicago, Chicago, Illinois
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Clinical feasibility of (neo)adjuvant taxane-based chemotherapy in older patients: analysis of >4,500 patients from four German randomized breast cancer trials. Breast Cancer Res 2008; 10:R77. [PMID: 18796139 PMCID: PMC2614510 DOI: 10.1186/bcr2144] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 09/16/2008] [Indexed: 12/27/2022] Open
Abstract
Introduction Despite the fact that people older than 65 years of age have the highest incidence of developing breast cancer, these patients are excluded from clinical trials in most cases. Furthermore, most physicians tend towards therapy regimens without the use of dose-dense, highly active taxane-based treatments because of a lack of data regarding toxicities of these compounds in older patients. Methods Pooled side-effect data were analyzed from four prospective, randomized clinical trials in which patients of different age groups (< 60 years, between 60 and 64 years, and > 64 years) with primary breast cancer received taxane-based chemotherapy. Results Dose delays, dose reductions, hospitalization, and therapy discontinuation increased with age. Hematologic toxicities and some nonhematologic toxicities were generally more common in older patients. Leucopenia increased from 55.3% in patients aged < 60 years to 65.5% in patients aged > 64 years (P < 0.001), and neutropenia increased from 46.9% to 57.4% (P < 0.001). There was no difference, however, in clinically more relevant febrile neutropenia between the different age groups. Thrombopenia shows a similar age-dependent increase, whereas there is no difference between the age groups concerning anemia. Hot flushes and elevated liver enzymes decreased with increasing age. Conclusions The present pooled analysis of a substantial cohort of older primary breast cancer patients demonstrates that taxane-containing (neo)adjuvant chemotherapy is feasible in older patients and that toxicity can be reduced by sequential therapy regimens.
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Biganzoli L, Licitra S, Moretti E, Pestrin M, Zafarana E, Di Leo A. Taxanes in the elderly: can we gain as much and be less toxic? Crit Rev Oncol Hematol 2008; 70:262-71. [PMID: 18762431 DOI: 10.1016/j.critrevonc.2008.07.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 07/10/2008] [Accepted: 07/18/2008] [Indexed: 10/21/2022] Open
Abstract
Taxanes are very effective agents in several types of cancer. However, their activity is counterbalanced by side effects that could represent a limitation of their use in older cancer patients. This review aims at evaluating whether or not there are data supporting a tailored use of standard taxanes i.e. docetaxel and paclitaxel in elderly patients with the aim to increase their therapeutic index. In addition, recent data on the role of nanoparticle albumine-bound paclitaxel in breast cancer are discussed in this paper.
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Affiliation(s)
- Laura Biganzoli
- Sandro Pitigliani Medical Oncology Unit, Department of Oncology, Hospital of Prato, Tuscany Cancer Institute, Piazza dell'Ospedale 2, 59100 Prato, Italy.
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