The Importance of Planned Dose of Chemotherapy on Time: Do We Need to Change Our Clinical Practice?

A real-world multicentre evaluation of atezolizumab plus platinum-etoposide chemotherapy as first-line treatment in patients with extensive-stage small cell lung cancer in Italy

INTRODUCTION

The aim of this study was to analyze real-life data from a cohort of adult patients receiving atezolizumab in combination with carboplatin and etoposide for first-line treatment of ES-SCLC, in order to assess relative dose intensity (RDI), time-to-treatment discontinuation (TTD), time-to-treatment failure (TTF), progression-free survival (PFS), overall survival (OS) of treatments as well as the correlation between these outcomes.

METHODS

An observational retrospective study was conducted. All patients treated with atezolizumab combined with carboplatin and etoposide for first-line treatment of ES-SCLC were included. Median TTD, TTF, PFS and OS were calculated in our cohort of patient by the Kaplan Meier method.

RESULTS

The curves obtained with the Kaplan Meier method of TTF and TTD are substantially similar, indicating a good concordance of the information extracted by the two different data sources. This tendency was confirmed also when the TTD versus PFS curves were compared. The median OS registered was 11.8 months. Patients with no liver metastases showed a longer median time of OS than patients with liver metastases. The mean value of RDI for the entire cohort was 87.4%.

CONCLUSIONS

Our study showed that TTD, calculated from the administration data is a useful proxy of TTF as registered in the clinical chart. TTD is a real-world outcome that can be used to demonstrate the efficacy of drugs used for administered therapies. It can be used as an end point for RWE studies, where the evaluation is less structured and standardized.

Supportive Care: The "Keystone" of Modern Oncology Practice

The Multinational Association of Supportive Care in Cancer (MASCC) defines supportive care as "the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer journey from diagnosis through treatment to post-treatment care. Supportive care aims to improve the quality of rehabilitation, secondary cancer prevention, survivorship, and end-of-life care". This article will provide an overview of modern supportive care in cancer, discussing its definition, its relationship with palliative care, models of care, "core" service elements (multi-professional/multidisciplinary involvement), the evidence that supportive care improves morbidity, quality of life, and mortality in various groups of patients with cancer, and the health economic benefits of supportive care. The article will also discuss the current and future challenges to providing optimal supportive care to all oncology patients.

Online scheduling using a fixed template: the case of outpatient chemotherapy drug administration

In this paper, we use a fixed template of slots for the online scheduling of appointments. The template is a link between planning the service capacity at a tactical level and online scheduling at an operational level. We develop a detailed heuristic for the case of drug administration appointments in outpatient chemotherapy. However, the approach can be applied to online scheduling in other application areas as well. The desired scheduling principles are incorporated into the cost coefficients of the objective function of a binary integer program for booking appointments in the template, as requests arrive. The day and time of appointments are decided simultaneously, rather than sequentially, where optimal solutions may be eliminated from the search. The service that we consider in this paper is an example to show the versatility of a fixed template online scheduling model. It requires two types of resource, one of which is exclusively assigned for the whole appointment duration, and the other is shared among multiple appointments after setting up the service. There is high heterogeneity among appointments on a day of this service. The appointments may range from fifteen minutes to more than eight hours. A fixed template gives a pattern for the scheduling of possibly required steps before the service. Instead of maximizing the fill-rate of the template, the objective of our heuristic is to have high performance in multiple indicators pertaining to various stakeholders (patients, nurses, and the clinic). By simulation, we illustrate the performance of the fixed template model for the key indicators.

How translational modeling in oncology needs to get the mechanism just right

Translational model‐based approaches have played a role in increasing success in the development of novel anticancer treatments. However, despite this, significant translational uncertainty remains from animal models to patients. Optimization of dose and scheduling (regimen) of drugs to maximize the therapeutic utility (maximize efficacy while avoiding limiting toxicities) is still predominately driven by clinical investigations. Here, we argue that utilizing pragmatic mechanism‐based translational modeling of nonclinical data can further inform this optimization. Consequently, a prototype model is demonstrated that addresses the required fundamental mechanisms.

Targeting pan-essential genes in cancer: Challenges and opportunities

Despite remarkable successes in the clinic, cancer targeted therapy development remains challenging and the failure rate is disappointingly high. This problem is partly due to the misapplication of the targeted therapy paradigm to therapeutics targeting pan-essential genes, which can result in therapeutics whereby efficacy is attenuated by dose-limiting toxicity. Here we summarize the key features of successful chemotherapy and targeted therapy agents, and use case studies to outline recurrent challenges to drug development efforts targeting pan-essential genes. Finally, we suggest strategies to avoid previous pitfalls for ongoing and future development of pan-essential therapeutics.

Plasma Cytokeratin 18 and fecal Alpha-1 Antitrypsin concentrations in dogs with osteosarcoma receiving carboplatin chemotherapy

Gastrointestinal (GI) toxicosis is a common side effect of cytotoxic chemotherapy treatment in humans and dogs. Measurement of cytokeratin 18 (CK18), an intracellular structural protein released during epithelial apoptosis, and Alpha1‐Antitrypsin (A1AT) in faeces provides a mechanism for evaluating damage to the intestinal mucosa secondary to cytotoxic chemotherapy. Our goal was to evaluate the clinical utility of plasma CK18 and faecal A1‐AT levels as non‐invasive biomarkers of cytotoxic chemotherapy induced GI toxicity. We conducted a prospective cohort study in dogs (N = 10) with osteosarcoma undergoing amputation followed by carboplatin chemotherapy. We hypothesized that plasma CK18 and faecal A1‐AT levels would increase following carboplatin administration due to drug‐induced GI epithelial damage/apoptosis, and that plasma CK18 and faecal A1‐AT levels would correlate with severity of GI toxicity. Mean baseline plasma CK18 concentration was variable amongst patients; however, CK18 concentration prior to carboplatin chemotherapy treatment was not significantly different from CK18 levels after treatment. There was significant intra and inter‐patient variability in mean faecal A1‐AT levels at baseline. Mean A1‐AT concentration did not change significantly from day 0 to day 21. Gastrointestinal toxicity was minimal; therefore, we were unable to determine the association of plasma CK18 and faecal A1‐AT concentrations with development of GI toxicosis. In this study population, plasma CK18 and faecal A1‐AT concentration were not clinically useful biomarkers for the detection of GI toxicosis secondary to carboplatin administration. Further prospective evaluation of CK18 and A1‐AT as biomarkers of drug‐induced GI toxicity is warranted in a larger cohort of dogs receiving cytotoxic chemotherapy.

AVMA clinical trial registration number: AAHSD004827.

Machine learning model to predict oncologic outcomes for drugs in randomized clinical trials

Predicting oncologic outcome is challenging due to the diversity of cancer histologies and the complex network of underlying biological factors. In this study, we determine whether machine learning (ML) can extract meaningful associations between oncologic outcome and clinical trial, drug-related biomarker and molecular profile information. We analyzed therapeutic clinical trials corresponding to 1102 oncologic outcomes from 104 758 cancer patients with advanced colorectal adenocarcinoma, pancreatic adenocarcinoma, melanoma and nonsmall-cell lung cancer. For each intervention arm, a dataset with the following attributes was curated: line of treatment, the number of cytotoxic chemotherapies, small-molecule inhibitors, or monoclonal antibody agents, drug class, molecular alteration status of the clinical arm's population, cancer type, probability of drug sensitivity (PDS) (integrating the status of genomic, transcriptomic and proteomic biomarkers in the population of interest) and outcome. A total of 467 progression-free survival (PFS) and 369 overall survival (OS) data points were used as training sets to build our ML (random forest) model. Cross-validation sets were used for PFS and OS, obtaining correlation coefficients (r) of 0.82 and 0.70, respectively (outcome vs model's parameters). A total of 156 PFS and 110 OS data points were used as test sets. The Spearman correlation (r_s ) between predicted and actual outcomes was statistically significant (PFS: r_s = 0.879, OS: r_s = 0.878, P < .0001). The better outcome arm was predicted in 81% (PFS: N = 59/73, z = 5.24, P < .0001) and 71% (OS: N = 37/52, z = 2.91, P = .004) of randomized trials. The success of our algorithm to predict clinical outcome may be exploitable as a model to optimize clinical trial design with pharmaceutical agents.

Docetaxel dose-intensity effect on overall survival in patients with metastatic castrate-sensitive prostate cancer

BACKGROUND

Several studies assessed the association of docetaxel dose intensity (DI) and efficacy in metastatic castrate-resistant prostate cancer (mCRPC) patients with contradicting conclusions. In this retrospective analysis, we will assess whether the docetaxel DI used in patients with metastatic castrate-sensitive prostate cancer (mCSPC) is associated with overall survival (OS).

METHODS

All patients with mCSPC treated at The Ottawa Hospital Cancer Centre that received docetaxel chemotherapy between June 2014 and September 2017 were identified. The association between relative dose intensity (RDI) and OS was assessed using univariate and multivariable Cox model adjusting for age, Gleason score, burden of disease, visceral involvement, de novo metastases and baseline prostate-specific antigen (PSA).

RESULTS

Eighty-one patients were included in the analysis. Only 35 patients (43%) were able to complete the planned treatment with a RDI of at least 90%. On a univariate analysis, higher RDI and number of cycles of docetaxel received were associated with longer OS. For every 10% decrease in RDI, the risk of death increased by 23% (HR 1.23, 95% CI 1.09-1.4, P = 0.001). For every increment of one cycle (and up to six), the risk of death decreased by 27% (HR 0.73, 95% CI 0.61-0.88, P = 0.001). On multivariate analysis, reduced RDI was the only predictor significantly associated with OS (HR 1.18, 95% CI 1.02-1.36, P = 0.026).

CONCLUSIONS

Our study suggests that in mCSPC, reduced docetaxel RDI is associated with shorter survival. Unnecessary dose reductions, treatment delays and early discontinuation should be avoided. Granulocyte colony-stimulating factor may be considered to maintain standard DI.

Tumor Drug Distribution after Local Drug Delivery by Hyperthermia, In Vivo

Tumor drug distribution and concentration are important factors for effective tumor treatment. A promising method to enhance the distribution and the concentration of the drug in the tumor is to encapsulate the drug in a temperature sensitive liposome. The aim of this study was to investigate the tumor drug distribution after treatment with various injected doses of different liposomal formulations of doxorubicin, ThermoDox (temperature sensitive liposomes) and DOXIL (non-temperature sensitive liposomes), and free doxorubicin at macroscopic and microscopic levels. Only ThermoDox treatment was combined with hyperthermia. Experiments were performed in mice bearing a human fibrosarcoma. At low and intermediate doses, the largest growth delay was obtained with ThermoDox, and at the largest dose, the largest growth delay was obtained with DOXIL. On histology, tumor areas with increased doxorubicin concentration correlated with decreased cell proliferation, and substantial variations in doxorubicin heterogeneity were observed. ThermoDox treatment resulted in higher tissue drug levels than DOXIL and free doxorubicin for the same dose. A relation with the distance to the vasculature was shown, but vessel perfusion was not always sufficient to determine doxorubicin delivery. Our results indicate that tumor drug distribution is an important factor for effective tumor treatment and that its dependence on delivery formulation merits further systemic investigation.

Glyco-functionalised quantum dots and their progress in cancer diagnosis and treatment

Despite all major breakthroughs in recent years of research, we are still unsuccessful to effectively diagnose and treat cancer that has express and metastasizes. Thus, the development of a novel approach for cancer detection and treatment is crucial. Recent progress in Glyconanotechnology has allowed the use of glycans and lectins as bio-functional molecules for many biological and biomedical applications. With the known advantages of quantum dots (QDs) and versatility of carbohydrates and lectins, Glyco-functionalised QD is a new prospect in constructing biomedical imaging platform for cancer behaviour study as well as treatment. In this review, we aim to describe the current utilisation of Glyco-functionalised QDs as well as their future prospective to interpret and confront cancer.

Merit-based Claim Adjudication for Cancer Treatment Toxicities - Policy Trends that Lower Downstream Costs

BACKGROUND

-Due largely to the lack of effective therapeutic options, between 1973-2013, chemoradiation toxic mucositis (CRTM) has remained an uncapped expenditure for 40 years, with incremental costs of $17,000-$40,000 per patient per episode. Costs in patient morbidity and mortality have continued as well. A recent therapeutic option associated with complete prevention and/or rapid sustained elimination (high potency polymerized cross-linked sucralfate, HPPCLS) delivers value by eliminating downstream costs CRTM experienced in the first 12 months. While many insurers carry the therapy as a specialty pharmacy support drug, few are familiar with the associated health economic benefits and the statutory requirements driving its coverage.

PURPOSE

-To present the rationale behind early policy trends that frame CRTM as an emergent/urgent medical condition mandated coverage as an essential health benefit. Rather than problematic for costs, this coverage trend appears to be value-based.

METHODS

-Discuss early adverse claim experience of HPPCLS. Present the costs, tenets and statutes driving policy trend toward obligatory coverage of CRTM. Review the ethical (fiduciary) and statutory requirements for CRTM coverage.

RESULTS

-CRTM coverage is ethically responsible since it is a direct consequence of authorized cancer treatment. The symptom/signs complex of CRTM meets the 'prudent layperson' statutory definition of emergency medical condition. All previously uncapped downstream costs of CRTM can be reduced to the cost of therapy, saving $15-$30K per patient per CRTM episode.

CONCLUSIONS

-Policy trend of CRTM coverage as an emergent/urgent medical condition is a value-based approach of toxicity management, conserving resources, cutting costs and eliminating patient morbidity and mortality.

Clinical audit to assess delays in chemotherapy administration at daycare oncology center at a tertiary care hospital in Karachi, Pakistan

Aim

There were delays reported by patients in chemotherapy administration in daycare oncology. Therefore, we decided to audit all processes which are involved in chemotherapy administration. The objective was to improve our service by decreasing the time between admission and initiation of chemotherapy and identify the reasons for delays.

Materials and Methods

The audit was conducted in three parts. In Review I, audit tool was developed and information documented of 109 patients receiving chemotherapy at daycare center from April 14 to May 13, 2015. Five processes were assessed out of which delay in initial assessment by the nurse was the only factor identified leading to delay in chemotherapy. Review II was done from March 1 to 31, 2016 of 208 patients after increasing the number of nurses and Review III from June 7 to August 25, 2016 of 287 patients by dividing the initial assessment process at two different areas to decrease delay in initial assessment.

Results

Seventy-two percent of patients had their initial assessment done within 15 min of arrival in daycare in the first audit. In the second part of audit this percentage decreased to 55%, and finally, in the third part of the audit, percentage was improved and increased to 75% after separating initial assessment process into two areas (P < 0.001, Kruskal-Wallis test).

Conclusion

After separating initial assessment process into two different areas, delays in chemotherapy administration were reduced.

Marginal structural models with dose-delay joint-exposure for assessing variations to chemotherapy intensity

Marginal structural models are causal models designed to adjust for time-dependent confounders in observational studies with dynamically adjusted treatments. They are robust tools to assess causality in complex longitudinal data. In this paper, a marginal structural model is proposed with an innovative dose-delay joint-exposure model for Inverse-Probability-of-Treatment Weighted estimation of the causal effect of alterations to the therapy intensity. The model is motivated by a precise clinical question concerning the possibility of reducing dosages in a regimen. It is applied to data from a randomised trial of chemotherapy in osteosarcoma, an aggressive primary bone-tumour. Chemotherapy data are complex because their longitudinal nature encompasses many clinical details like composition and organisation of multi-drug regimens, or dynamical therapy adjustments. This manuscript focuses on the clinical dynamical process of adjusting the therapy according to the patient’s toxicity history, and the causal effect on the outcome of interest of such therapy modifications. Depending on patients’ toxicity levels, variations to therapy intensity may be achieved by physicians through the allocation of either a reduction or a delay of the next planned dose. Thus, a negative feedback is present between exposure to cytotoxic agents and toxicity levels, which acts as time-dependent confounders. The construction of the model is illustrated highlighting the high complexity and entanglement of chemotherapy data. Built to address dosage reductions, the model also shows that delays in therapy administration should be avoided. The last aspect makes sense from the cytological point of view, but it is seldom addressed in the literature.

Does intensified chemotherapy increase survival outcomes of osteosarcoma patients? A meta-analysis

Study Design

Meta-analysis.

Background

Although some new insights have been offered for clinical and scientific relevance, minor progress has been made in osteosarcoma treatment after a dramatic survival improvement in the late 1980s with the addition of chemotherapy to surgery. Intensified chemotherapy strategies have been suggested to increase the survival rate of patients with osteosarcoma. We performed this study to access whether intensified chemotherapy strategiesincreased survival outcomes of osteosarcoma patients compared with conventional chemotherapy strategies.

Methods

MEDLINE/PubMed, EMBASE, BIOSIS Previews, and Cochrane Library were searched from database set up to October2016. Randomized controlled trials (RCTs) and comparative clinical trials (CCTs) on intensified versus conventional chemotherapy strategies for osteosarcoma patients met the inclusion criteria, and the methodological quality standard were retrieved and reviewed. Data on participant characteristics, interventions, follow-up period, and outcomes were extracted from the included studies and analyzed by Review Manager 5.3.

Results

12 studies (8 RCTs and 4CCT) involving 4112 patients were selected. There were no significant differences between intensified and conventional chemotherapy strategies group in 3-year event-free survival (OR, 1.01; 95% CI, [0.74–1.37]; P = 0.97), 5-year event-free survival (OR, 1.00; 95% CI, [0.86–1.17]; P = 0.97), and 5-year overall survival (OR, 1.04; 95% CI, [0.87–1.26]; P = 0.64), and good histologic response to preoperative chemotherapy (OR, 1.12; 95% CI, [0.78–1.60]; P = 0.55). Pooled analysis of local recurrence rate showed that local recurrence rate was significantly decreased in the intensified group compared with that in the conventional group (OR, 0.60; 95% CI, [0.42–0.85]; P = 0.004).

Conclusions

Intensified chemotherapy might not be a preferred treatment for all of the osteosarcoma patients.

Practice insights on patient care-management overview for chemoradiation toxic mucositis-guidelines, guideline-supported therapies and high potency polymerized cross-linked sucralfate (ProThelial)

AIM

To offer a practice insight for the management of chemoradiation toxic mucositis.

METHOD

Review chemoradiation toxic mucositis, its pathobiology and breadth of symptom presentation. Review mucositis guidelines and guideline-supported anti-mucositis therapies. Offer guidance on guidelines and an abbreviated review of high potency cross-linked sucralfate for management of chemoradiation toxic mucositis.

RESULT

There are six major mucositis guidelines but only one that is current and regularly updated. Guidelines from the Multinational Association Supportive Cancer Care suggest 14 interventions gleaned from controlled trials, 12 of which are off-label uses of therapies that offer statistically significant but incrementally beneficial outcomes. Several evidence-based limitations of guidelines are discussed. Data on high potency polymerized cross-linked sucralfate confirming complete prevention and rapid (2-3 days) elimination, sustained throughout cancer treatment is verified as high quality evidence in accordance to standards adopted by Agency for Healthcare Research and Quality. A 96-97% reduction in mucositis duration qualifies as a positive Glasziou treatment effect, which is discussed as an additional measure of evidence-based medicine.

CONCLUSION

Statistically significant but fractional treatment effects of guideline-supported interventions are not likely to substantially alter the course of mucositis when it occurs nor completely prevent its onset. Complete prevention and rapid sustained elimination should be the goal, therefore high potency polymerized cross-linked sucralfate may be useful. Where guidelines fail, institution-based protocols led by oncology pharmacists could succeed. In an effort to eliminate toxic mucositis, enhance compliance to chemoradiation regimens, and improve survival, such protocols for practice may verify pharmacoeconomic benefits, if any, in using high potency polymerized cross-linked sucralfate to manage toxic mucositis.

US oncology-wide incidence, duration, costs and deaths from chemoradiation mucositis and antimucositis therapy benefits

Approximate oncology-wide incidence, duration, costs and deaths associated with mucositis and identify health economic benefits of antimucositis therapies. Review the literature relevant to the clinical experience of mucositis by pathophysiology, incidence, duration, costs and deaths. Use US insurance actuarial and epidemiology on cancer to generalize an oncology-wide impact of toxic mucositis. Toxic mucositis causes oropharyngoesophageal ulcerations, chemo-induced nausea, vomiting and diarrhea. Acutely, it lasts 102 days/six cycles of chemotherapy, 60 days in human stem-cell transplantation patients and 70-84 days in head and neck cancer patients at annual costs of US$13.23 billion/522,166 treated patients (US$20,892/erosive-type mucositis patient, US$25,337/physiologic mucositis patient) and 46,699 deaths. Using antimucositis therapies prior to 2013 provided fractional benefits at high costs. By completely preventing and rapidly reversing mucositis, high-potency polymerized cross-linked sucralfate promises superior health economic benefits.

Clinico-pathological Study of Limb Salvage Surgery for Osteosarcoma: Experience in a Rural Cancer Center

Although recent multimodality therapeutic protocols have led to improved survival in osteosarcoma (OS), the outcome still remains dismal. Ongoing international multicentric trials on OS aim to randomize patients for optimum management, based on histological response to NACT. The pathologic response to neoadjuvant chemotherapy (NACT) is the most important factor predicting prognosis. In this study of 23 cases of limb salvage surgery post neoadjuvant chemotherapy, mean age was 18.3 years, with male predominance. 65.5 % cases were conventional OS. Histologic assessment of chemotherapeutic effect done by Huvos grading revealed good response (Huvos lll and lV) in 15 (65.2 %) and poor response (Huvos l and ll) in eight (34.8 %). A scoring based on MRI with a scale of 1-6 was compared with histologic response. Five (62.5 %) of poor responders showed score of >3 and 73.3 % of good responders showed ≤3. Dose intensity of NACT was calculated and correlated with the histological response. 53.3 % of good responders showed ARDI > 0.9. Five (21.7 %) developed local recurrence and 10(43.4 %) had pulmonary metastasis. Adoption of more aggressive treatment modalities may ensure better histologic response and longer event free survival.

Bringing a genomic perspective to the safety of drug treatment in oncology

This article describes the clinical relevance of toxicity of therapies administered to patients with cancer, putting the patient, rather than disease, at the center of the evaluation of safety of anti-cancer therapy. Hence, the implications of adverse events are described from the patient perspective, focusing on the impact of patient safety on quality of life and efficacy of treatment. Issues revolving around other types of safety, such as financial toxicity, are also discussed. The role played by genetics in the assessment of a patient’s risk of adverse events is also discussed, both in relation to the potential of genomic research and in the context of current tools of fruition in clinical care.

Porous Pt Nanoparticles with High Near-Infrared Photothermal Conversion Efficiencies for Photothermal Therapy

Plasmonic nanostructures are of potential in acting as a type of optical agents for cancer photothermal therapy. To effectively function as photothermal therapy agents, plasmonic nanostructures are strongly desired to have good biocompatibility and high photothermal conversion efficiencies. In this study, poly(diallyldimethylammonium chloride)-coated porous Pt nanoparticles are synthesized for photothermal therapy. The Pt nanoparticles possess broadband near-infrared light absorption in the range from 650 to 1200 nm, therefore allowing for selecting different laser wavelengths for photothermal therapy. The as-prepared Pt nanoparticles exhibit remarkable photothermal conversion efficiencies under 809 and 980 nm laser irradiation. In vitro studies indicate that the Pt nanoparticles display good biocompatibility and high cellular uptake efficiencies through an endocytosis pathway. Photothermal heating using 808 nm laser irradiation (>7.0 W cm^-2 , 3 min) leads to notable cytotoxic effect, and more than 70% of cells are photothermally ablated after 3 min irradiation at 8.4 W cm^-2 . Furthermore, simultaneous application of photothermal therapy synergistically enhances the cytotoxicity of an anti-cancer drug doxorubicin. Therefore, the porous Pt nanoparticles have great potential as an attractive photothermal agent for cancer therapy.

Randomized study of the clinical effects of ω-3 fatty acid-containing enteral nutrition support during neoadjuvant chemotherapy on chemotherapy-related toxicity in patients with esophageal cancer

OBJECTIVES

Omega-3 (ω-3) fatty acids have potential positive effects during chemotherapy, such as body weight maintenance and muscle mass preservation. However, little is known about the effect this supplement might have on reducing chemotherapy-induced toxicities. The aim of this study was to determine the usefulness of ω-3 fatty acid supplementation in the reduction of chemotherapy-related toxicities.

METHODS

Sixty-one patients undergoing neoadjuvant chemotherapy for esophageal cancer randomly received ω-3-rich enteral nutrition (EN; n = 31) or ω-3-poor EN support (n = 30) for 15 d during chemotherapy. The daily dosage of ω-3 fatty acids was 900 mg in the ω-3-rich group and 250 mg in the ω-3-poor group. The primary endpoint was the frequency of grade 3/4 neutropenia, and secondary endpoints included other chemotherapy-related adverse events, body weight, and inflammatory markers.

RESULTS

The total and dietary intake calories during chemotherapy were equal in both groups. There was no significant difference in the body weight change after chemotherapy between the two groups. There was no significant difference in the incidence of grade 3/4 leukopenia and neutropenia (P > 0.05). However, stomatitis was significantly less frequent in the ω-3-rich group, than in the ω-3-poor group (P = 0.018). Grade 3/4 diarrhea occurred relatively less frequently in the ω-3-rich group than in the ω-3-poor group; however, this difference was not significant (16.1% versus 36.7%, respectively, P = 0.068). Increases in the aspartate aminotransferase and alanine aminotransferase levels were seen significantly less frequently in the ω-3-rich group than in the ω-3-poor group (P = 0.012 and P = 0.015, respectively).

CONCLUSIONS

ω-3-rich EN support decreased the frequency of chemotherapy-induced mucosal toxicities, such as stomatitis and diarrhea, and exhibited a hepatoprotective effect during chemotherapy, compared with the ω-3-poor EN support.

Preclinical Characterization of G1T28: A Novel CDK4/6 Inhibitor for Reduction of Chemotherapy-Induced Myelosuppression

Chemotherapy-induced myelosuppression continues to represent the major dose-limiting toxicity of cytotoxic chemotherapy, which can be manifested as neutropenia, lymphopenia, anemia, and thrombocytopenia. As such, myelosuppression is the source of many of the adverse side effects of cancer treatment including infection, sepsis, bleeding, and fatigue, thus resulting in the need for hospitalizations, hematopoietic growth factor support, and transfusions (red blood cells and/or platelets). Moreover, clinical concerns raised by myelosuppression commonly lead to chemotherapy dose reductions, therefore limiting therapeutic dose intensity, and reducing the antitumor effectiveness of the treatment. Currently, the only course of treatment for myelosuppression is growth factor support which is suboptimal. These treatments are lineage specific, do not protect the bone marrow from the chemotherapy-inducing cytotoxic effects, and the safety and toxicity of each agent is extremely specific. Here, we describe the preclinical development of G1T28, a novel potent and selective CDK4/6 inhibitor that transiently and reversibly regulates the proliferation of murine and canine bone marrow hematopoietic stem and progenitor cells and provides multilineage protection from the hematologic toxicity of chemotherapy. Furthermore, G1T28 does not decrease the efficacy of cytotoxic chemotherapy on RB1-deficient tumors. G1T28 is currently in clinical development for the reduction of chemotherapy-induced myelosuppression in first- and second-line treatment of small-cell lung cancer. Mol Cancer Ther; 15(5); 783-93. ©2016 AACR.

ErbB small molecule tyrosine kinase inhibitor (TKI) induced diarrhoea: Chloride secretion as a mechanistic hypothesis

Diarrhoea is a common, debilitating and potentially life threatening toxicity of many cancer therapies. While the mechanisms of diarrhoea induced by traditional chemotherapy have been the focus of much research, the mechanism(s) of diarrhoea induced by small molecule ErbB TKI, have received relatively little attention. Given the increasing use of small molecule ErbB TKIs, identifying this mechanism is key to optimal cancer care. This paper critically reviews the literature and forms a hypothesis that diarrhoea induced by small molecule ErbB TKIs is driven by intestinal chloride secretion based on the negative regulation of chloride secretion by ErbB receptors being disrupted by tyrosine kinase inhibition.

The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people

Background:

Although comorbidities are identified in routine oncology practice, intervention plans for the coexisting needs of older people receiving chemotherapy are rarely made. This study evaluates the impact of geriatrician-delivered comprehensive geriatric assessment (CGA) interventions on chemotherapy toxicity and tolerance for older people with cancer.

Methods:

Comparative study of two cohorts of older patients (aged 70+ years) undergoing chemotherapy in a London Hospital. The observational control group (N=70, October 2010–July 2012) received standard oncology care. The intervention group (N=65, September 2011–February 2013) underwent risk stratification using a patient-completed screening questionnaire and high-risk patients received CGA. Impact of CGA interventions on chemotherapy tolerance outcomes and grade 3+ toxicity rate were evaluated. Outcomes were adjusted for age, comorbidity, metastatic disease and initial dose reductions.

Results:

Intervention participants undergoing CGA received mean of 6.2±2.6 (range 0–15) CGA intervention plans each. They were more likely to complete cancer treatment as planned (odds ratio (OR) 4.14 (95% CI: 1.50–11.42), P=0.006) and fewer required treatment modifications (OR 0.34 (95% CI: 0.16–0.73), P=0.006). Overall grade 3+ toxicity rate was 43.8% in the intervention group and 52.9% in the control (P=0.292).

Conclusions:

Geriatrician-led CGA interventions were associated with improved chemotherapy tolerance. Standard oncology care should shift towards modifying coexisting conditions to optimise chemotherapy outcomes for older people.

Lipegfilgrastim for the prophylaxis and treatment of chemotherapy-induced neutropenia

Chemotherapy is frequently associated with hematologic toxicity. Neutropenia with or without fever is a relevant cause of morbidity, mortality and costs, compromising treatment administration and clinical outcomes. The development of granulocyte colony-stimulating factors has had a positive impact on the clinician's approach to neutropenia. Such agents, currently used for primary and secondary prophylaxis of chemotherapy-induced neutropenia and febrile neutropenia (FN), are effective in limiting hematologic toxicities and consequently allow the administration of intensive dose-dense regimens. Several biosimilar products of filgrastim have been developed over the years, showing effects similar to the originator drug. Until now, pegfilgrastim has been the only available long-acting factor, requiring just a single administration per chemotherapy cycle. The recent approval of the novel granulocyte colony-stimulating factors, lipegfilgrastim, offers interesting therapeutic alternatives. In fact, similar to pegfilgrastim, it has been demonstrated to reduce the duration of neutropenia and the occurrence of FN during chemotherapy safely.

Improving the relative dose intensity of systemic chemotherapy in a community-based outpatient cancer center

PURPOSE

This three-phase study was performed to improve the mean relative dose intensity (RDI) of chemotherapy administered to patients in a community-based outpatient cancer center.

METHODS

Medical records were reviewed for patients who began receiving systemic chemotherapy for lymphoma or cancer of the breast, lung, endometrium, ovary, or colon. During phase 1, records were reviewed and the mean RDI was determined through collection of demographic, diagnostic, chemotherapy, and laboratory data. Phase 2 involved implementation of quality improvement initiatives to improve the RDI: development of a febrile neutropenia risk assessment tool, revision of our dose cancellation policy, and interdisciplinary education. Finally, after implementation of these initiatives, the mean RDI was prospectively determined in phase 3, similar to phase 1.

RESULTS

The mean RDI was determined to be 83% during phase 1 compared with 91% during phase 3 (P=.0087). For adjuvant chemotherapy, the mean RDI was 85% and 95% for phases 1 and 3, respectively (P=.0035). Likewise, for metastatic disease, the mean RDI was 76% and 82% for phases 1 and 3, respectively (P=.3935). The proportion of regimens that met or exceeded the recommended minimum goal RDI of 85% was 54% for phase 1 and 80% for phase 3. Granulocyte colony-stimulating factor use increased from 69% preintervention to 81% postintervention.

CONCLUSION

The mean overall RDI improved above the threshold goal of 85%, with the RDI for adjuvant chemotherapy reaching 95%, after implementation of three quality-improvement initiatives. With continued education and following policies already in place, further improvements in RDI could be demonstrated.

Impact of chemotherapy-induced peripheral neuropathy on treatment delivery in nonmetastatic breast cancer

PURPOSE

To determine the incidence of dose-limiting (DL) chemotherapy-induced peripheral neuropathy (CIPN) events in clinical practice.

PATIENTS AND METHODS

This retrospective cohort study included 488 women who received docetaxel or paclitaxel. The primary outcome was a DL event (dose delay, dose reduction, or treatment discontinuation) attributed to CIPN (DL CIPN). The paired t test was used to test the difference in received cumulative dose and planned cumulative dose by dose reduction and treatment discontinuation status.

RESULTS

A total of 150 unique DL events occurred in 120 women (24.6%). More than one third (37.3%; n=56) of the events were attributed to CIPN. The 56 DL CIPN events occurred in 50 women (10.2%). DL CIPN incidence differed significantly by agent (docetaxel, 2.4%; n=five of 209; paclitaxel, 16.1%; n=45 of 279; P<.001). DL CIPN occurred in 24.5% and 14.4% of women who received paclitaxel 80 mg/m2 weekly for 12 cycles and 175 mg/m2 biweekly for four cycles, respectively (adjusted odds ratio, 2.11; 95% CI, 0.97 to 4.60; P=.06). The cumulative dose actually received was significantly lower than the planned cumulative dose among women who had a dose reduction or treatment termination attributed to CIPN (9.4% less; P<.001 and 28.4% less; P<.001, respectively).

CONCLUSION

Oncologists limited the dosing of chemotherapy because of CIPN in a significant proportion of paclitaxel recipients, most frequently in those who received a weekly regimen. Patients who had their dose reduced or discontinued received significantly less cumulative chemotherapy than planned. The implications of these DL CIPN events on treatment outcomes must be investigated.

Can knowledge of germline markers of toxicity optimize dosing and efficacy of cancer therapy?

The systemic treatment of cancer with traditional cytotoxic chemotherapeutic agents and more targeted agents is often complicated by the onset of adverse drug reactions. Pharmacogenetic prediction of adverse drug reactions might have consequences for dosing and efficacy. This review discusses relevant examples where the germline variant-toxicity relationship has been validated as an initial step in developing clinically useful pharmacogenetic markers and provides examples where germline variants have influenced dosing strategies and/or survival or other outcomes of efficacy. This review will also provide insight into the reasons why more pharmacogenetic markers have not been routinely integrated into clinical practice.

Appropriate chemotherapy dosing for obese adult patients with cancer: American Society of Clinical Oncology clinical practice guideline

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.

Quantum dots hold promise for early cancer imaging and detection

Despite all major breakthroughs in recent years of research concerning the complex events that lead to cancer expression and metastasis, we are not yet able to effectively treat cancer that has spread to vital organs. The various clinical phases originating from cancer diagnosis through treatment and prognosis require a comprehensive understanding of these events, to utilise pre-symptomatic, minimally invasive and targeted cancer management techniques. Current imaging modalities such as ultrasound, computed tomography, magnetic resonance imaging and gamma scintigraphy facilitate the pre-operative study of tumours, but they have been rendered unable to visualise cancer in early stages, due to their intrinsic limitations. The semiconductor nanocrystal quantum dots (QDs) have excellent photo-physical properties, and the QDs-based probes have achieved encouraging developments in cellular (in vitro) and in vivo molecular imaging. However, the same unique physical and chemical properties which renowned QDs attractive may be associated with their potentially catastrophic effects on living cells and tissues. There are critical issues that need to be further examined to properly assess the risks associated with the manufacturing and use of QDs in cancer management. In this review, we aim to describe the current utilisation of QDs as well as their future prospective to decipher and confront cancer.

Incidence of reduced chemotherapy relative dose intensity among women with early stage breast cancer in US clinical practice

Chemotherapy is widely used to treat early stage breast cancer (ESBC). Reductions and delays in dose administered--e.g., due to advanced age or febrile neutropenia (FN)--are generally believed to increase risk of disease progression and reduce survival. Little is known about incidence of reduced chemotherapy dose intensity among women with ESBC in the current era of US clinical practice. This study employed a retrospective cohort design and electronic medical records from > 65 community oncology/hematology clinics in > 35 states (2004-2010). The study population comprised adult women who received myelosuppressive chemotherapy for ESBC (stages I-IIIA). For each such woman, each unique cycle of chemotherapy within their first observed course was identified. Incidence of chemotherapy dose delays (≥ 7 days for any drug in ≥ 1 cycles), chemotherapy dose reductions (≥ 15% for any drug in ≥ 1 cycles), and low chemotherapy relative dose intensity (RDI <85% over the course) relative to published reference standards were descriptively analyzed for the seven most-frequently planned regimens in the study database. A total of 2,228 women (70% of the subjects who received chemotherapy for ESBC and met other selection criteria) initiated 1 of the 7 most-frequently planned regimens. Mean age of subjects was 54 years and 69% received primary prophylaxis against FN with a colony-stimulating factor. Incidence of dose delays, dose reductions, and low RDI was 31, 24, and 26%, respectively; low RDI typically was due to premature treatment discontinuation. For patients (n = 626) receiving the most common regimen (dose-dense AC-T: doxorubicin/cyclophosphamide, Q2 × 4 cycles, paclitaxel or docetaxel, Q2 × 4 cycles), incidence of dose delays, dose reductions, and low RDI was 42, 29, and 32%, respectively. In the current era of US clinical practice, chemotherapy dose delays and dose reductions are common among women with ESBC receiving frequently used myelosuppressive dose-dense, as well as conventional, chemotherapy regimens.

Attitudes regarding the use of hematopoietic colony-stimulating factors and maintenance of relative dose intensity among gynecologic oncologists

OBJECTIVE

To assess the attitudes regarding the use of colony-stimulating factor (CSF) and the maintenance of relative dose intensity (RDI) by gynecologic oncologists during the administration of chemotherapy to patients with epithelial ovarian cancer.

METHODS

A nationwide survey of 608 gynecologic oncologists was performed using a 19-point questionnaire. The questionnaire assessed the following domains: (1) demographic information, (2) patterns of CSF use during first-line and relapse chemotherapies for patients with epithelial ovarian cancer, and (3) use of CSFs to maintain RDI.

RESULTS

The response rate to the survey was 42% (n = 255). Eighty-six percent (220/255) of the respondents routinely administer chemotherapy. In the first-line setting, 67% of physicians who routinely administer chemotherapy preferred to use CSFs for secondary prophylaxis after a neutropenic complication, whereas only 2% would use CSFs for primary prophylaxis. In the recurrent disease setting, physicians were more likely to administer a regimen with minimal myelosuppression (74% reported "likely" or "very likely"), to dose delay or modify if neutropenic complications occur (78%), or to administer CSFs for secondary prophylaxis (85%) than to dose attenuate upon initiation of chemotherapy (49%) or to administer CSFs for primary prophylaxis (46%). Most physicians would administer CSFs to maintain RDI in both the first-line (75%) and palliative settings (62%), and 49% would strive to maintain a dose intensity of more than 85%.

CONCLUSIONS

Most gynecologic oncologists use CSFs as secondary prophylaxis for neutropenic complications rather than as primary prophylaxis. Most gynecologic oncologists monitor RDI and use CSFs to maintain RDI in their patients with ovarian carcinoma.

Dose intensity comparison between weekly and 3-weekly Cisplatin delivered concurrently with radical radiotherapy for head and neck cancer: a retrospective comparison from New Cross Hospital, Wolverhampton, UK

AIMS

In this retrospective comparison, we describe the differences in dose intensity, delays and toxicity between weekly Cisplatin and 3-weekly Cisplatin given concurrently to patients with locally advanced squamous head and neck cancer (SCCHN) at New Cross Hospital, Wolverhampton.

MATERIALS AND METHODS

Fifty-one patients received radical Cisplatin based chemoradiotherapy for stage 4a SCCHN of the head and neck between September 2000 and December 2004. Twenty-seven patients were treated with 3-weekly inpatient Cisplatin for 3 cycles (20 patients-80 mg/m(2); 7 patients-100 mg/m(2)) concomitantly with radiotherapy (66-70 Gy/33-35 fractions). Twenty-four patients received a similar radiotherapy schedule but received weekly Cisplatin 33-40 mg/m(2).

RESULTS

More patients received a higher cumulative dose of at least 240 mg/m(2) if given weekly Cisplatin 40 mg/m(2) or 3-weekly Cisplatin 80 mg/m(2) compared with those receiving Cisplatin 3-weekly 100 mg/m(2) (p=0.04). Maximum cumulative dose achievable in the latter group was only 200 mg/m(2) and none achieved the full 3 cycles. Mean Cisplatin dose in the weekly Cisplatin 40 mg/m(2) regime (mean 202 mg/m(2)) and 3-weekly arm of 80 mg/m(2) (mean 203 mg/m(2)) was higher than that reached if given 3-weekly Cisplatin 100 mg/m(2) (mean 180 mg/m(2)) although statistically insignificant (p=0.39) due to the small number of patients. More delays (29% vs. 41%) and omission of chemotherapy (5.6% vs. 17.4%) occurred in the 3-weekly compared with the weekly regime. Toxicity, radiotherapy overall treatment time and delays were similar between the two groups.

CONCLUSION

Delivery of 100 mg/m(2) Cisplatin 3-weekly with radiotherapy was less tolerated than 40 mg/m(2) weekly and resulted in less patients achieving cumulative dose beyond 200 mg/m(2), potentially lowering chemotherapy dose intensity.

Variables Involved in Measuring Cancer Response to Treatment

In this article, the discussions about concepts involved in anticancer therapy, including cell death pathways and the variables that guide clinical management, such as intents and types of anticancer therapy regimens and modalities, are a prelude to the review of FDG PET/CT imaging parameters used in the evaluation of response to therapy. The review also includes brief discussions about differences between evaluation of cytostatic and cytotoxic therapy regimens and induction and neoadjuvant therapy regimens.

FDG-PET Evaluation of Response to Treatment

This article discusses evaluating response after and during therapy in various settings and for the types of cancers for which ample evidence demonstrates that PET imaging with flourodeoxyglucose provides a valuable surrogate for response to therapy. It also briefly discusses pitfalls in obtaining an optimal assessment of response and issues that need further attention for this modality to become established as an independent predictor of response to anticancer therapy.

Role of heat treatment in childhood cancers: distinct resistance profiles of solid tumor cell lines towards combined thermochemotherapy

BACKGROUND

Since information on the efficacy of hyperthermia in combination with chemotherapy on pediatric tumors is limited, we performed a systematic analysis on the synergistic effects of a combined application of heat and chemotherapy on 20 tumor cell lines derived from patients with neuroblastomas, Ewing tumors, germ cell tumors (GCT), and osteosarcomas.

METHODS

Cisplatin (cDDP), a cross-linking agent, and etoposide (VP-16), a topoisomerase II inhibitor, were examined either alone or in combination with heat (42 degrees C, 43 degrees C) by using the XTT-assay 1.

RESULTS

Our data demonstrate that heat stress at 43 degrees C for 1 hr, but not at 42 degrees C, leads to a notable cytotoxic effect on the different tumor cells. The comparison of mean survival fractions reveals values between 62% for neuroblastoma cells and 76% for Ewing tumor cells. Analyzing the sensitivity to chemotherapy alone, our results show that cDDP (5 microg/ml) reduces cell growth to 47% in Ewing tumor cells, to 61% in neuroblastoma cells, to 75% in GCT cells, and to 76% in osteosarcoma cells. Treatment with VP-16 (10 microg/ml) decreases cell survival to mean values between 58% (neuroblastomas) and 77% (osteosarcomas). Simultaneous application of heat and chemotherapy enhances synergistically cDDP cytotoxicity in all tumor types tested, whereas the efficacy of VP-16 is only slightly influenced by additional application of hyperthermia. The cytotoxicity of cDDP (5 microg/ml) can be increased by a factor of between 1.5 and 2.5 at 42 degrees C and from 2.6 to 14.0 at 43 degrees C. Furthermore, the results show that the sensitivity to heat (43 degrees C) as well as the sensitivity to chemotherapy and combined thermochemotherapy varies considerably between cell lines of the same tumor group.

CONCLUSIONS

Simultaneous application of hyperthermia synergistically enhances the cytotoxicity of the alkylating agent cDDP, but not of the topoisomerase II inhibitor VP-16, in a defined spectrum of cell lines from different pediatric tumor entities.

The consequences of diarrhea occurring during chemotherapy for colorectal cancer: a retrospective study

PURPOSE

Diarrhea is one of the dose-limiting toxicities associated with chemotherapy agents in treatment regimens for colorectal cancer. The objectives of this study were to analyze the impact of all grades of diarrhea on clinical decisions for patients receiving treatment for colorectal cancer by characterizing the diarrhea that occurred, quantifying changes in chemotherapy treatment, identifying methods to treat diarrhea, and determining the economic impact. Patients and Methods. We retrospectively reviewed the treatment of 100 consecutive patients with colorectal cancer who experienced diarrhea during the course of chemotherapy. The diarrhea was documented in the progress notes and graded according to National Cancer Institute Common Toxicity Criteria. Changes in chemotherapy treatment and resource utilization associated with diarrhea were recorded.

RESULTS

The 100 patients received 673 chemotherapy cycles, of which 45% +/- 2% were associated with diarrhea. Approximately 52% of patients experienced diarrhea of grades 3 or 4, and 56 patients underwent 66 modifications in their chemotherapy treatment, such as dose reductions (22), delays in therapy (8), discontinuations of therapy (15), or multiple changes (11). Thirty-seven patients consumed resources beyond oral antidiarrheals to control diarrhea: 14 patients received emergency outpatient treatment, 23 patients were hospitalized, 21 patients received intravenous fluids, and one death due to dehydration was reported. Discussion and Conclusion. Diarrhea was a significant consequence of colorectal chemotherapy, with the majority of patients experiencing grades 3 or 4 diarrhea and 56% of all patients also modifying their chemotherapy treatment. Even mild diarrhea of grades 1 and 2 was associated with changes in treatment in 11% of patients; thus, diarrhea of all grades should be recognized and treated appropriately to maintain full-dose chemotherapy.