1
|
Hoog CJPO', Mehra N, Maliepaard M, Bol K, Gelderblom H, Sonke GS, de Langen AJ, van de Donk NWCJ, Janssen JJWM, Minnema MC, van Erp NP, Boerrigter E. Dose selection of novel anticancer drugs: exposing the gap between selected and required doses. Lancet Oncol 2024; 25:e340-e351. [PMID: 39089312 DOI: 10.1016/s1470-2045(24)00134-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 08/03/2024]
Abstract
Historically, dose selection of anticancer drugs has mainly been based on establishing the maximum tolerated dose in phase 1 clinical trials with a traditional 3 plus 3 design. In the era of targeted therapies and immune-modulating agents, this approach does not necessarily lead to selection of the most favourable dose. This strategy can introduce potentially avoidable toxicity or inconvenience for patients. Multiple changes in drug development could lead to more rational dose selection, such as use of better predictive preclinical models, adaptive and randomised trial design, evaluation of multiple dose levels in late-phase development, assessment of target activity and saturation, and early biomarker use for efficacy and safety evaluation. In this Review, we evaluate the rationale and validation of dose selection in each phase of drug development for anticancer drugs approved by the European Medicines Agency and US Food and Drug Administration from Jan 1, 2020, to June 30, 2023, and give recommendations for dose optimisation to improve safety and patient convenience. In our evaluation, we classified 20 (65%) of the 31 recently registered anticancer agents as potential candidates for dose optimisation, which could be achieved either by reducing the dose (n=10 [32%]) or adjusting the dosage regimen (n=10 [32%]). Dose selection seemed to be adequately justified for nine (29%) of the drugs, whereas the reviewed data were inconclusive for formulating a recommendation on dose optimisation for two (6%) of the drugs.
Collapse
Affiliation(s)
| | - Niven Mehra
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marc Maliepaard
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, Netherlands; Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, Netherlands
| | - Kalijn Bol
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Adrianus J de Langen
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam University Medical Center, location Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Emmy Boerrigter
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
2
|
Ulaner GA, Silverstein M, Nangia C, Tetef M, Vandermolen L, Coleman C, Khan S, MacDonald H, Patel T, Techasith T, Mauguen A. ER-Targeted PET for Initial Staging and Suspected Recurrence in ER-Positive Breast Cancer. JAMA Netw Open 2024; 7:e2423435. [PMID: 39058489 PMCID: PMC11282447 DOI: 10.1001/jamanetworkopen.2024.23435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 07/28/2024] Open
Abstract
Importance There are insufficient data comparing 16α-18F-fluoro-17β-estradiol (FES) positron emission tomography (PET) computed tomography (CT) with standard-of-care imaging (SOC) for staging locally advanced breast cancer (LABC) or evaluating suspected recurrence. Objective To determine the detection rate of FES PET/CT and SOC for distant metastases in patients with estrogen receptor (ER)-positive LABC and recurrences in patients with ER-positive BC and suspected recurrence. Design, Setting, and Participants This diagnostic study was conducted as a single-center phase 2 trial, from January 2021 to September 2023. The study design provided 80% power to find a 20% detection rate difference. Participants included patients with ER-positive LABC (cohort 1) or suspected recurrence (cohort 2). Data were analyzed from September 2023 to February 2024. Exposure Participants underwent both SOC imaging and experimental FES PET/CT. When there were suspicious lesions on imaging, 1 was biopsied for histopathological reference standard to confirm presence (true positive) or absence (false positive) of malignant neoplasm. Main Outcomes and Measures The outcome of interest was the detection rate of FES PET CT vs SOC for distant metastases and recurrences. Results A total of 124 patients were accrued, with 62 in cohort 1 (median [IQR] age, 52 [32-84] years) and 62 in cohort 2 (median [IQR] age, 66 [30-93] years). In cohort 1, of 14 true-positive findings, SOC imaging detected 12 and FES detected 11 (P > .99). In cohort 2, of 23 true-positive findings, SOC detected 16 and FES detected 18 (P = .77). In 30 patients with lobular histology, of 11 true-positive findings, SOC detected 5 and FES detected 9 (P = .29). There were 6 false-positive findings on SOC and 1 false-positive finding on FES PET/CT (P = .13). Conclusions and Relevance In this diagnostic study with pathological findings as the reference standard, no difference was found between FES PET/CT and current SOC imaging for detecting distant metastases in patients with ER-positive LABC or recurrences in patients with ER-positive tumors and suspected recurrence. FES PET/CT could be considered for both clinical indications, which are not part of current Appropriate Use Criteria for FES PET. The findings regarding FES PET/CT in patients with lobular tumors, and for lower false positives than current SOC imaging, warrant further investigation.
Collapse
Affiliation(s)
- Gary A. Ulaner
- Molecular Imaging and Therapy, Hoag Family Cancer Institute, Irvine, California
- Radiology and Translational Genomics, University of Southern California, Los Angeles
| | - Mel Silverstein
- Surgery, Hoag Family Cancer Institute, Newport Beach, California
| | - Chaitali Nangia
- Medicine, Hoag Family Cancer Institute, Newport Beach, California
| | - Merry Tetef
- Department of Medicine, University of California, Los Angeles
| | - Louis Vandermolen
- Department of Medicine, University of Southern California, Los Angeles
| | - Colleen Coleman
- Surgery, Hoag Family Cancer Institute, Newport Beach, California
| | - Sadia Khan
- Surgery, Hoag Family Cancer Institute, Newport Beach, California
| | | | - Trushar Patel
- Radiology, Hoag Family Cancer Institute, Newport Beach, California
| | - Tust Techasith
- Radiology, Hoag Family Cancer Institute, Newport Beach, California
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
3
|
Loeser A, Kim JS, Peppercorn J, Burkard ME, Niemierko A, Juric D, Kalinsky K, Rugo H, Glenn L, Hodgdon C, Maues J, Johnson S, Padron N, Parekh K, Lustberg M, Bardia A. The Right Dose: Results of a Patient Advocate-Led Survey of Individuals With Metastatic Breast Cancer Regarding Treatment-Related Side Effects and Views About Dosage Assessment to Optimize Quality of Life. JCO Oncol Pract 2024; 20:972-983. [PMID: 38518184 DOI: 10.1200/op.23.00539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/29/2023] [Accepted: 02/07/2024] [Indexed: 03/24/2024] Open
Abstract
PURPOSE Although patients with metastatic breast cancer (MBC) have been living longer with the advent of more effective treatments such as targeted therapy and immunotherapy, the disease remains incurable, and most patients will undergo therapy indefinitely. When beginning therapy, patients are typically prescribed dose often based upon the maximum tolerated dose identified in phase I clinical trials. However, patients' perspectives about tolerability and willingness to discuss individualized dosing of drugs upon initiation of a new regimen and throughout the course of treatment have not been comprehensively evaluated. METHODS Patient advocates and medical oncologists from the Patient-Centered Dosing Initiative (PCDI) developed a survey to ascertain the prevalence and severity of MBC patients' treatment-related side effects, the level of patient-physician communication, mitigation strategies, perception about the relative efficacy of higher versus lower doses, and willingness to discuss alternative dosing. The PCDI distributed the anonymous confidential online survey in August 2020 to individuals with self-reported MBC. RESULTS One thousand and two hundred twenty-one patients with MBC completed the survey. 86.1% (n = 1,051) reported experiencing at least one significant treatment-related side effect, and of these, 20.3% (n = 213) visited the emergency room/hospital and 43.2% (n = 454) missed at least one treatment. Nearly all patients with side effects (97.6%, n = 1,026) informed their doctor and 81.7% (n = 838) received assistance. Of the 556 patients given a dose reduction for side-effect mitigation, 82.6% (n = 459) reported relief. Notably, majority of patients (53.3%, n = 651) do not believe that higher dose is always more effective than lower dose, and 92.3% (n = 1,127) would be willing to discuss flexible dosing options with their physicians based upon personal characteristics to optimize quality of life. CONCLUSION Given that the majority of patients with MBC experienced at least one substantial treatment-related side effect and most patients given a dose reduction reported improvement, innovative dosage-related strategies are warranted to sustain and improve patients' well-being. Patient-physician discussions in which the patient's unique attributes and circumstances are assessed upon initiation of new treatment and throughout the course of therapy may facilitate the identification of the most favorable dose for each patient, and the majority of patients would be receptive to this approach.
Collapse
Affiliation(s)
- Anne Loeser
- Patient-Centered Dosing Initiative, New York, NY
- Yale School of Medicine, New Haven, CT
| | | | | | | | | | | | | | - Hope Rugo
- University of California, San Francisco, San Francisco, CA
| | - Lesley Glenn
- Patient-Centered Dosing Initiative, New York, NY
| | | | - Julia Maues
- Patient-Centered Dosing Initiative, New York, NY
| | | | | | | | | | - Aditya Bardia
- UCLA Health Jonsson Comprehensive Cancer Center, Los Angeles, CA
| |
Collapse
|
4
|
Levine MN, Kemppainen J, Rosenberg M, Pettengell C, Bogach J, Whelan T, Saha A, Ranisau J, Petch J. Breast cancer learning health system: Patient information from a data and analytics platform characterizes care provided. Learn Health Syst 2024; 8:e10409. [PMID: 39036532 PMCID: PMC11257056 DOI: 10.1002/lrh2.10409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 07/23/2024] Open
Abstract
Purpose In a learning health system (LHS), data gathered from clinical practice informs care and scientific investigation. To demonstrate how a novel data and analytics platform can enable an LHS at a regional cancer center by characterizing the care provided to breast cancer patients. Methods Socioeconomic information, tumor characteristics, treatments and outcomes were extracted from the platform and combined to characterize the patient population and their clinical course. Oncologists were asked to identify examples where clinical practice guidelines (CPGs) or policy changes had varying impacts on practice. These constructs were evaluated by extracting the corresponding data. Results Breast cancer patients (5768) seen at the Juravinski Cancer Centre between January 2014 and June 2022 were included. The average age was 62.5 years. The commonest histology was invasive ductal carcinoma (74.6%); 77% were estrogen receptor-positive and 15.5% were HER2 Neu positive. Breast-conserving surgery (BCS) occurred in 56%. For the 4294 patients who received systemic therapy, the initial indications were adjuvant (3096), neoadjuvant (828) and palliative (370). Metastases occurred in 531 patients and 495 patients died. Lowest-income patients had a higher mortality rate. For the adoption of CPGs, the uptake for adjuvant bisphosphonate was very low, 8% as predicted, compared to 64% for pertuzumab, a HER2 targeted agent and 40.2% for CD4/6 inhibitors in metastases. During COVID-19, the provincial cancer agency issued a policy to shorten the duration of radiation after BCS. There was a significant reduction in the average number of fractions to the breast by five fractions. Conclusion Our platform characterized care and the clinical course of breast cancer patients. Practice changes in response to regulatory developments and policy changes were measured. Establishing a data platform is important for an LHS. The next step is for the data to feedback and change practice, that is, close the loop.
Collapse
Affiliation(s)
- Mark N. Levine
- Department of OncologyMcMaster UniversityHamiltonOntarioCanada
- Escarpment Cancer Research InstituteHamiltonOntarioCanada
| | - Joel Kemppainen
- Centre for Data Science and Digital HealthHamilton Health SciencesHamiltonOntarioCanada
| | - Morgan Rosenberg
- Centre for Data Science and Digital HealthHamilton Health SciencesHamiltonOntarioCanada
| | | | - Jessica Bogach
- Department of SurgeryMcMaster UniversityHamiltonOntarioCanada
| | - Tim Whelan
- Department of OncologyMcMaster UniversityHamiltonOntarioCanada
- Escarpment Cancer Research InstituteHamiltonOntarioCanada
| | - Ashirbani Saha
- Department of OncologyMcMaster UniversityHamiltonOntarioCanada
- Escarpment Cancer Research InstituteHamiltonOntarioCanada
| | - Jonathan Ranisau
- Centre for Data Science and Digital HealthHamilton Health SciencesHamiltonOntarioCanada
| | - Jeremy Petch
- Centre for Data Science and Digital HealthHamilton Health SciencesHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Population Health Research Institute, Hamilton Health SciencesHamiltonOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoHamiltonOntarioCanada
| |
Collapse
|
5
|
Zettler ME. Dose Optimization of Targeted Therapies for Oncologic Indications. Cancers (Basel) 2024; 16:2180. [PMID: 38927886 PMCID: PMC11202153 DOI: 10.3390/cancers16122180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Therapeutic advances in oncology in the 21st century have contributed to significant declines in cancer mortality. Notably, targeted therapies comprised the largest proportion of oncology drugs approved by the United States (US) Food and Drug Administration (FDA) over the past 25 years and have become the standard of care for the treatment of many cancers. However, despite the metamorphosis of the therapeutic landscape, some aspects of cancer drug development have remained essentially unchanged. In particular, the dose-finding methodology originally developed for cytotoxic chemotherapy drugs continues to be implemented, even though this approach no longer represents the most appropriate strategy for modern cancer therapies. In recognition of the need to reconsider assumptions, adapt the dose selection process for newer drugs, and design alternative strategies, the FDA has undertaken several initiatives in recent years to address these concerns. These actions include the launch of Project Optimus in 2021 and the issuance of draft guidance for industry on dose optimization of oncology drugs in 2023. Amid this evolving regulatory environment, the present manuscript reviews case studies for six different targeted cancer therapies, highlighting how dose-finding challenges have been managed to date by oncologists, sponsors, and regulators.
Collapse
|
6
|
Strohbehn GW, Stadler WM, Boonstra PS, Ratain MJ. Optimizing the doses of cancer drugs after usual dose finding. Clin Trials 2024; 21:340-349. [PMID: 38148731 DOI: 10.1177/17407745231213882] [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] [Indexed: 12/28/2023]
Abstract
Since the middle of the 20th century, oncology's dose-finding paradigm has been oriented toward identifying a drug's maximum tolerated dose, which is then carried forward into phase 2 and 3 trials and clinical practice. For most modern precision medicines, however, maximum tolerated dose is far greater than the minimum dose needed to achieve maximal benefit, leading to unnecessary side effects. Regulatory change may decrease maximum tolerated dose's predominance by enforcing dose optimization of new drugs. Dozens of already approved cancer drugs require re-evaluation, however, introducing a new methodologic and ethical challenge in cancer clinical trials. In this article, we assess the history and current landscape of cancer drug dose finding. We provide a set of strategic priorities for postapproval dose optimization trials of the future. We discuss ethical considerations for postapproval dose optimization trial design and review three major design strategies for these unique trials that would both adhere to ethical standards and benefit patients and funders. We close with a discussion of financial and reporting considerations in the realm of dose optimization. Taken together, we provide a comprehensive, bird's eye view of the postapproval dose optimization trial landscape and offer our thoughts on the next steps required of methodologies and regulatory and funding regimes.
Collapse
Affiliation(s)
- Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Division of Medical Oncology, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Walter M Stadler
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Philip S Boonstra
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, USA
| |
Collapse
|
7
|
Thall PF, Garrett-Mayer E, Wages NA, Halabi S, Cheung YK. Current issues in dose-finding designs: A response to the US Food and Drug Adminstration's Oncology Center of Excellence Project Optimus. Clin Trials 2024; 21:267-272. [PMID: 38570906 PMCID: PMC11132935 DOI: 10.1177/17407745241234652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
With the advent of targeted agents and immunological therapies, the medical research community has become increasingly aware that conventional methods for determining the best dose or schedule of a new agent are inadequate. It has been well established that conventional phase I designs cannot reliably identify safe and effective doses. This problem applies, generally, for cytotoxic agents, radiation therapy, targeted agents, and immunotherapies. To address this, the US Food and Drug Administration's Oncology Center of Excellence initiated Project Optimus, with the goal "to reform the dose optimization and dose selection paradigm in oncology drug development." As a response to Project Optimus, the articles in this special issue of Clinical Trials review recent advances in methods for choosing the dose or schedule of a new agent with an overall objective of informing clinical trialists of these innovative designs. This introductory article briefly reviews problems with conventional methods, the regulatory changes that encourage better dose optimization designs, and provides brief summaries of the articles that follow in this special issue.
Collapse
Affiliation(s)
- Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Nolan A Wages
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Halabi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Ying Kuen Cheung
- Department of Biostatistics, Columbia University, New York, NY, USA
| |
Collapse
|
8
|
Jagannath S, Delimpasi S, Grosicki S, Van Domelen DR, Bentur OS, Špička I, Dimopoulos MA. Association of Selinexor Dose Reductions With Clinical Outcomes in the BOSTON Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:917-923.e3. [PMID: 37743180 DOI: 10.1016/j.clml.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Dose modifications in response to adverse events (AEs) can maintain tumor response and improve therapy tolerability. We conducted a post-hoc analysis of the efficacy and safety of reduced selinexor doses in the BOSTON trial (NCT03110562). PATIENTS AND METHODS Efficacy, safety, and quality of life (QoL) in 195 patients with relapsed/refractory multiple myeloma randomized to once-weekly (QW) selinexor (100 mg), QW subcutaneous bortezomib (1.3 mg/m2), and twice-weekly dexamethasone (20 mg) were compared between patients with dose reductions and those without. RESULTS In total, 126 patients (65%) had selinexor dose reductions (median dose 71.4 mg/wk). In patients with dose reductions versus those without median progression-free survival was 16.6 months (95% CI 12.9-not evaluable [NE]) versus 9.2 months [95% CI 6.8-15.5]), overall response rate was 81.7% (95% CI 73.9-88.1%) versus 66.7% (95% CI 54.3-77.6%), ≥very good partial response was (51.6% [95% CI 42.5-60.6%] vs. 31.9% [95% CI 21.2-44.2]), median duration of response was not reached (95% CI 13.8-NE) versus 12.0 months (95% CI 8.3-NE), and time to next treatment was 22.6 months (95% CI 14.6-NE) versus 10.5 months (95% CI 6.3-18.2). Mean best change from baseline on the EORTC QLQ-C30 Global Health Status/QoL scale was 10.0 ± 20.5 versus 4.0 ± 20.9. Duration-adjusted AE rates that were lower after selinexor dose reduction included thrombocytopenia (62.5% before vs. 47.6% after), nausea (31.6% vs. 7.3%), fatigue (28.1% vs. 9.9%), decreased appetite (21.5% vs. 6.4%), anemia (17.9% vs. 10.3%), and diarrhea (12.9% vs. 5.2%). CONCLUSION Appropriate dose reductions in response to AEs of the 100 mg selinexor starting dose in the BOSTON study were associated with improved efficacy, reduced AE rates and improved QoL.
Collapse
Affiliation(s)
- Sundar Jagannath
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | | | | | | | | | - Ivan Špička
- Charles University and General Hospital, Prague, Czech Republic
| | | |
Collapse
|
9
|
Ozluk AA, Outlaw D, Akce M, Fowler ME, Hess DL, Giri S, Williams GR. Management of Older Adults With Colorectal Cancer: The Role of Geriatric Assessment. Clin Colorectal Cancer 2023; 22:390-401. [PMID: 37949790 PMCID: PMC11065137 DOI: 10.1016/j.clcc.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/17/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
Older adults share a growing burden of cancer morbidity and mortality. This is present across the spectrum of oncologic diagnoses and is particularly true with colorectal cancer (CRC), where older adults continue to share the burden of diagnoses. However, optimal cancer treatment decision making in older adults remains a significant challenge, as the majority of previous clinical trials shaping the current treatment landscape have focused on younger patients, often with more robust performance status and fewer medical comorbid conditions. The heterogeneous aging process of older adults with CRC necessitates a personalized treatment approach, as approximately three-quarters of older adults with CRC also have a concominant geriatric syndrome and more than half of older adults with CRC are pre-frail or frail. Treatment decisions shoud be multifaceted, including consultation with the patient and their familes regarding their wishes, with consideration of the patient's quality of life, functional status, medical comorbid conditions, social support, and treatment toxicity risk. Geriatric assessment is a systematic and validated approach to assess an older adults's potential strengths and vulnerabilities, which can in turn be used to assist with comprehensive cancer care planning and support. In this review, we will summarize current treatment approaches for older adults with CRC, with a particular focus on the incorporation of the geriatric assessment.
Collapse
Affiliation(s)
- Ahmet Anil Ozluk
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Darryl Outlaw
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mehmet Akce
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mackenzie E Fowler
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Daniel L Hess
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Smith Giri
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Grant R Williams
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
10
|
Dayes IS, Metser U, Hodgson N, Parpia S, Eisen AF, George R, Blanchette P, Cil TD, Arnaout A, Chan A, Levine MN. Impact of 18F-Labeled Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Versus Conventional Staging in Patients With Locally Advanced Breast Cancer. J Clin Oncol 2023; 41:3909-3916. [PMID: 37235845 DOI: 10.1200/jco.23.00249] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/08/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE Patients with locally advanced breast cancer (LABC) typically undergo staging tests at presentation. If staging does not detect metastases, treatment consists of curative intent combined modality therapy (neoadjuvant chemotherapy, surgery, and regional radiation). Positron emission tomography-computed tomography (PET-CT) may detect more asymptomatic distant metastases, but the evidence is based on uncontrolled studies. METHODS For inclusion, patients had histological evidence of invasive ductal carcinoma of the breast and TNM stage III or IIb (T3N0, but not T2N1). Consenting patients from six regional cancer centers in Ontario were randomly assigned to 18F-labeled fluorodeoxyglucose PET-CT or conventional staging (bone scan, CT of the chest/abdomen and pelvis). The primary end point was upstaging to stage IV. A key secondary outcome was receiving curative intent combined modality therapy (ClinicalTrials.gov identifier: NCT02751710). RESULTS Between December 2016 and April 2022, 184 patients were randomly assigned to whole-body PET-CT and 185 patients to conventional staging. Forty-three (23%) PET-CT patients were upstaged to stage IV compared with 21 (11%) conventional staged patients (absolute difference, 12.3% [95% CI, 3.9 to 19.9]; P = .002). Consequently, treatment was changed in 35 (81.3%) of 43 upstaged PET-CT patients and 20 (95.2%) of the 21 upstaged conventional patients. Subsequently, 149 (81%) patients in the PET-CT group received combined modality treatment versus 165 (89.2%) patients in the conventional staging group (absolute difference, 8.2% [95% CI, 0.1 to 15.4]; P = .03). CONCLUSION In patients with LABC, PET-CT detected more distant metastases than conventional staging, and fewer PET-CT patients received combined modality therapy. Our randomized trial demonstrates the utility of the PET-CT staging strategy.
Collapse
Affiliation(s)
- Ian S Dayes
- Department of Oncology, McMaster University, Hamilton, ON, Canada
- Juravinski Cancer Centre-Hamilton Health Sciences, Hamilton, ON, Canada
- Ontario Clinical Oncology Group, Hamilton, ON, Canada
- Escarpment Cancer Research Institute, Hamilton, ON, Canada
| | - Ur Metser
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- University Health Network Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nicole Hodgson
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
- Ontario Clinical Oncology Group, Hamilton, ON, Canada
- Escarpment Cancer Research Institute, Hamilton, ON, Canada
| | - Andrea F Eisen
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, ON, Canada
- Ontario Health, Toronto, ON, Canada
| | - Ralph George
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- St Michael's Hospital, Toronto, ON, Canada
| | - Phillip Blanchette
- Department of Oncology, Western University, London, ON, Canada
- London Health Sciences Regional Cancer Program, London, ON, Canada
| | - Tulin D Cil
- University Health Network Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Angel Arnaout
- Department of Surgery, Ottawa University, Ottawa, ON, Canada
- Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Adrien Chan
- Northern Ontario School of Medicine, Thunder Bay ON, Canada
- Thunder Bay Regional Health Sciences Cancer Centre, Thunder Bay, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
- Juravinski Cancer Centre-Hamilton Health Sciences, Hamilton, ON, Canada
- Ontario Clinical Oncology Group, Hamilton, ON, Canada
- Escarpment Cancer Research Institute, Hamilton, ON, Canada
| |
Collapse
|
11
|
Harvey RD. The earlier the better? Or better late than never? Dose optimization in oncology. J Natl Cancer Inst 2023; 115:485-487. [PMID: 36919765 PMCID: PMC10165476 DOI: 10.1093/jnci/djad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/08/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Affiliation(s)
- R Donald Harvey
- Departments of Hematology and Medical Oncology and Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA, USA
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
| |
Collapse
|