Feasibility, criterion and construct convergent validity of the 2-minute walk test and the 10-meter walk test in an oncological context

Objective

To examine the feasibility, the criterion, and the construct convergent validity of the 2-Minute Walk Test (2MWT) and the 10-Meter Walk Test (10MeWT) against the 6-Minute Walk Test (6MWT) to assess walking capacity in people with cancer. The criterion concurrent validity of a self-test version of the 10MeWT (10MeWTself-test) was also evaluated against the 10MeWT.

Methods

Fifty-six people with cancer performed the 2MWT, the 10MeWT at comfortable and fast speeds, the 6MWT, and the 10MeWTself-test. The feasibility of the tests was assessed using safety, adverse events, space requirements, time taken to administer and interpret the tool, equipment or training required, cost, and portability as criteria. Validity was assessed using Pearson correlation coefficients and Bland Altman plots.

Results

The 2MWT, 6MWT, 10MeWT, and 10MeWTself-test were feasible for people with cancer. The 2MWT and the 10MeWT results were moderately to strongly correlated with the 6MWT results (0.61 < r < 0.84, p < 0.001). The 10MeWTself-test results were strongly correlated with the 10MeWT results at comfortable and fast speeds (r = 0.99, p < 0.001).

Conclusions

The 2MWT, 10MeWT, and 10MeWTself-test are simple, rapid, and feasible tests for use in people with cancer. The strong correlation between the 2MWT and 6MWT results indicates that the 2MWT can be used as an alternative walking capacity assessment tool. The 10MeWT results moderately correlated with those of the other two tests, suggesting that it partially measures the same construct of walking capacity in walking-independent outpatients with cancer. The 10MeWTself-test showed promising results but needs further investigations in ecological settings.

Hematologic toxicities of chemotherapy in breast and ovarian cancer patients carrying BRCA1/BRCA2 germline pathogenic variants. A single center experience and review of the literature

BRCA1 and BRCA2 play a central role in DNA repair and their germline pathogenic variants (gBRCA) confer a high risk for developing breast and ovarian cancer. Standard chemotherapy regimens for these cancers include DNA-damaging agents. We hypothesized that gBRCA carriers might be at higher risk of developing chemotherapy-related hematologic toxicity and therapy-related myeloid neoplasms (t-MN). We conducted a retrospective study of women newly diagnosed with invasive breast or ovarian cancer who were screened for gBRCA1/gBRCA2 at Geneva University Hospitals. All patients were treated with (neo-)adjuvant chemotherapy. We evaluated acute hematologic toxicities by analyzing the occurrence of febrile neutropenia and severe neutropenia (grade 4) at day 7-14 of the first cycle of chemotherapy and G-CSF use during the entire chemotherapy regimen. Characteristics of t-MN were collected. We reviewed medical records from 447 patients: 58 gBRCA1 and 40 gBRCA2 carriers and 349 non-carriers. gBRCA1 carriers were at higher risk of developing severe neutropenia (32% vs. 14.5%, p = 0.007; OR = 3.3, 95% CI [1.6-7], p = 0.001) and of requiring G-CSF for secondary prophylaxis (58.3% vs. 38.2%, p = 0.011; OR = 2.5, 95% CI [1.4-4.8], p = 0.004). gBRCA2 carriers did not show increased acute hematologic toxicities. t-MN were observed in 2 patients (1 gBRCA1 and one non-carrier). Our results suggested an increased acute hematologic toxicity upon exposure to chemotherapy for breast and ovarian cancer among gBRCA1 but not gBRCA2 carriers. A deeper characterization of t-MN is warranted with the recent development of PARP inhibitors in frontline therapy in gBRCA breast and ovarian cancer.

[Is ketogenic diet effective against cancer ?]

The ketogenic diet, which consists of reduced carbohydrate intake and increased fat intake, is a recognized treatment option for children with intractable epilepsy. This diet is now receiving renewed interest from physicians and researchers because of its potential therapeutic effect in other diseases, such as neurodegenerative diseases, metabolic syndrome or cancer. Since cancer is one of the major public health challenges, complementary approaches to improve the efficacy of standard anti-cancer therapies are the subject of much research. This article reviews the place of the ketogenic diet as a complementary therapy in cancer, the scientific evidence and possible practical aspects of such an approach.

A multicenter phase II trial of anti-EGFR-immunoliposomes loaded with doxorubicin in patients with advanced triple negative breast cancer

Advanced triple negative breast cancer (TNBC) is an aggressive, but initially chemo-sensitive disease. The prognosis is poor and more than three quarters of patients experience progression 12 months after the initiation of conventional first-line chemotherapy. Approximately two thirds of TNBC express epidermal growth factor receptor 1 (EGFR). We have developed an anti-EGFR targeted nanocontainer drug by inserting anti-EGFR antibody fragments into the membrane of pegylated liposomes (anti-EGFR-ILs-dox). The payload consists of doxorubicin, a standard drug for TNBC. In a first-in-human phase I trial in 26 patients with various advanced solid malignancies, anti-EGFR-ILs-dox has shown little toxicity and encouraging efficacy. In this single-arm phase II trial, we assessed the efficacy of anti-EGFR-ILs-dox as first-line therapy in patients with advanced, EGFR + TNBC. The primary endpoint was progression-free survival at 12 months (PFS12m). Secondary endpoints included overall response rate (ORR), duration of response (DOR), time to progression (TTP), overall survival (OS) and adverse events (AEs). 48 patients received anti-EGFR-ILs-dox 50 mg/m² iv, on day one of a 28 days-cycle until progression. The Kaplan-Meier estimate for PFS12m was 13% (one-sided 90% CI 7%, 95% CI [5%, 25%]), median PFS was 3.5 months (95% CI 1.9, 5.4). The trial has not reached its primary endpoint. There were no new toxicity signals. Based on these results, anti-EGFR-ILs-dox should not be further developed for TNBC. It remains an open question whether anti-EGFR-ILs-dox would offer more opportunities in other EGFR-expressing malignancies, where targeting this receptor has already shown anticancer effects.Trial registration: This trial was registered at clinicaltrials.gov: NCT02833766. Registered 14/07/2016.

Immunotherapy in Urological, Gynecological and Gastrointestinal Cancers - Current Landscape

Immunotherapy is becoming increasingly important in the management of urological, gynecological, and gastrointestinal cancers. Immune checkpoint inhibitor-based combinations have become a standard of care for patients with metastatic renal and liver cancers, as well as for many patients with bladder, cervical, gastric, and esophageal cancers, based on various biomarkers. Some tumor types are less responsive to immunotherapy, such as prostate and colon cancer. In these tumors, however, a subgroup of patients with a microsatellite-instability-high/DNA-mismatch repair deficient molecular phenotype significantly benefits from immunotherapy. Molecular characterization is therefore essential to identify patients who may benefit from these treatments. One of the major challenges is the search for new predictive biomarkers and novel combinations or strategies to further improve patient outcome.

Influence of chemotherapy on postural control and quality of life in women with gynaecological cancer: a protocol of a prospective observational study

INTRODUCTION

Chemotherapy-induced peripheral neuropathy is a frequent side effect of some chemotherapies that can cause postural control disorders and has a serious impact on quality of life (QoL). An enhanced understanding of postural control dysfunction could help build a systematic and accurate assessment as well as specific exercises to limit the impact on QoL. This study aims to assess the influence of chemotherapy on postural control and the QoL for women with gynaecological cancer.

METHODS AND ANALYSIS

This prospective observational study will include 37 participants with cancer treated using neurotoxic chemotherapy. Their postural control in various conditions (rigid and foam surfaces, eyes open and closed, with and without tendon vibration, and dual tasks), limits of stability, QoL and modified Total Neuropathy Score will be assessed. A linear mixed model will compare postural control pre-chemotherapy and post-chemotherapy.

ETHICS AND DISSEMINATION

This study was approved by an ethical review board in Geneva (CCER-2020-01639). The study findings will be disseminated through conference presentations and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04692168.

Differential impact of tamoxifen and aromatase inhibitors on thrombin generation: the prospective HEMOBREAST cohort

Tamoxifen and aromatase inhibitors (AIs) are potent antitumoral agents against breast cancer. Tamoxifen increases the risk of venous thromboembolism (VTE), but the influence of AIs on the risk of VTE remains unclear. To inform clinical decisions, we evaluated associations of tamoxifen or AIs with changes of surrogate hemostatic biomarkers. This prospective cohort included 107 women with localized breast cancer starting tamoxifen (n = 42) or an AI (n = 65). Thrombin generation (CAT) its sensitivity to thrombomodulin (TM) or activated protein C (APC), and specific coagulation parameters, were measured before and 10-16 weeks after initiation of treatmen Compared with baseline, endogenous thrombin potential and thrombin peak increased in tamoxifen users (+86 nM × min; 95% confidence interval [CI], 30-142; and +33 nM; 95% CI, 21-45) but not in AI users (n = 65; +44 nM × min; 95% CI, -4 to 93; and +7 nM; 95% CI, -3 to 17). Normalized TM sensitivity ratios increased with tamoxifen (+0.26; 95% CI, 0.19-0.33y) but not with AI (+0.02; 95% CI, -0.03 to 0.07). Plasma levels of fibrinogen, antithrombin, protein C, and Tissue Factor Pathway Inhibitor decreased, and free protein S increased with tamoxifen but not with AIs. The observed shift toward increased coagulability associated with tamoxifen is in line with its known increased risk of VTE. In contrast, AIs do not appear to impact hemostasis, suggesting a lack of associated VTE risk. The trial was registered at www.clinicaltrials.gov as #NCT03381963.

Ovarian cancer with high-level focal ERBB2 amplification responds to trastuzumab and pertuzumab

Epithelial ovarian cancer (EOC) is usually diagnosed at an advanced stage and significantly contributes to cancer mortality in women. Despite multimodal treatment associating chemotherapy and surgery, most patients ultimately progress and require palliative systemic therapy. In EOC, the efficacy of anti-HER2 agents is minimal even after selecting patients for HER2 expression. ERBB2 gene amplification is observed in 3-10% of patients, depending on the specific method of detection and cutoffs. We report the case of a young woman with a FIGO stage IV high-grade serous ovarian cancer with an amplification of ERBB2. She was treated with the association of trastuzumab - pertuzumab after two lines of standard treatment and presented an excellent long-lasting partial response after 36 months of treatment. The association of trastuzumab and pertuzumab, without chemotherapy, has not been previously tested in this context and could be more efficacious than monotherapy with either agent. In addition, the significant benefit observed in this case could be attributed to the presence of a high-level focal amplification that is relatively rare and probably more specific than an increase in HER2 expression. In conclusion, prospective trials of the trastuzumab and pertuzumab combination should be considered in an appropriately selected EOC patient population.

Gestational trophoblastic disease in Switzerland: retrospective study of the impact of a regional reference centre

AIMS OF THE STUDY

The European Society of Medical Oncology (ESMO) recommends that countries should have reference centres to provide adequate diagnosis and treatment of gestational trophoblastic disease. A trophoblastic disease centre in the French-speaking part of Switzerland was inaugurated in 2009. The objectives of this study were to report the activity of the centre during the last 10 years and analyse gestational trophoblastic disease outcomes.

METHODS

This was a retrospective study with data collected from all cases of gestational trophoblastic disease referred to the centre from 2009 to 2018. All histological specimens as well as data for treatment and follow-up of gestational trophoblastic disease and neoplasia were reviewed. Clinical features, including age, prognostic score and International Federation of Gynecology and Obstetrics (FIGO) stages (in the case of gestational trophoblastic neoplasia), human chorionic gonadotropin (hCG) follow-up, treatment and outcome were reported.

RESULTS

The centre registered 354 patients, and these patients presented 156 cases of partial hydatidiform moles, 163 cases of complete hydatidiform moles and 14 cases of gestational trophoblastic neoplasia. During follow-up, 35 gestational trophoblastic neoplasms were diagnosed after hCG persistence. After pathology review, the overall agreement rates between our centre and a participating provider hospital was 82%. Methotrexate was the first line of single-agent chemotherapy for most patients, with resistance rates of 23%. Multi-agent chemotherapy was used as first-line treatment for five patients. None of the patients followed up by the centre died from gestational trophoblastic disease.

CONCLUSIONS

This study reflects the activity of the Swiss trophoblastic disease centre from the French-speaking part of Switzerland created in 2009, and its role as local and national reference centre, in terms of global health, for women with gestational trophoblastic disease.

Clinical outcome of breast cancer in carriers of BRCA1 and BRCA2 mutations according to molecular subtypes

BRCA1/BRCA2 genes play a central role in DNA repair and their mutations increase sensitivity to DNA-damaging agents. There are conflicting data regarding the prognostic value of BRCA germline mutations in breast cancer (BC) patients. We collected clinical, pathological and genetic data of a cohort 925 BC patients preselected for genetic screening and treated with neoadjuvant or adjuvant chemotherapy, of whom 266 were BRCA carriers. Overall, 171 women carried a BRCA1 mutation, 95 carried a BRCA2 mutation, and 659 were non-carriers. In the entire cohort, there was a prolonged disease-free survival (DFS) for BRCA carriers (hazard ratio (HR) = 0.63; 95% confidence interval (CI), 0.44–0.90 for BRCA1; HR = 0.72; 95%CI, 0.47–1.1 for BRCA2; p = 0.020) and a trend toward prolonged disease-specific survival (DSS; HR = 0.65; 95%CI, 0.40–1.1 for BRCA1; HR = 0.78; 95%CI, 0.44–1.38 for BRCA2; p = 0.19) though not statistically significant. In the TNBC group, BRCA carriers had prolonged DFS (adjusted HR = 0.50; 95%CI, 0.28–0.89 for BRCA1; adjusted HR = 0.37; 95%CI, 0.11–1.25, for BRCA2; p = 0.034) and DSS (adjusted HR = 0.42; 95%CI, 0.21–0.82 for BRCA1; adjusted HR = 0.45; 95%CI, 0.11–1.9 for BRCA2; p = 0.023). In the non-TNBC group, the BRCA1 or BRCA2 mutations did not have any impact on survival. These results suggest that BRCA1/BRCA2 germline mutations are associated with prolonged survival only if women were diagnosed with TNBC.

Durable response to palbociclib and letrozole in ovarian cancer with CDKN2A loss

Alterations of the Retinoblastoma (Rb) pathway are frequent in ovarian cancer, typically resulting from CDKN2A down-regulation, CCNE1 amplification, CCND1/2 amplification, and RB1 loss. However, bi-allelic CDKN2A mutation or homozygous deletion is a very rare event, concerning less than 5% of patients.Initial trials with palbociclib in serous ovarian cancer have shown very modest benefit in unselected patient populations, thus underlining the need for a biomarker predicting response. We report the case of a heavily pre-treated patient with a serous ovarian tumor harboring a homozygous deletion of the CDKN2A gene that derived significant, prolonged clinical benefit from palbociclib, a CDK4/6 oral inhibitor, with letrozole. Treatment with palbociclib and letrozole started on February 2018, with an ongoing response after 12 months.In conclusion, homozygous CDKN2A deletion is rare and could be used to predict response to CDK4/6 inhibitors in association with other genomic features. We encourage further trials in this direction.

A population-based cohort of young women diagnosed with breast cancer in Geneva, Switzerland

PURPOSE

Breast cancer is the most frequently diagnosed cancer among women worldwide. Despite the fact that breast cancer is more frequent after fifty years of age, breast cancer among young women has recently drawn particular attention due to an increase in incidence in several western countries. With the exception of individuals with a high genetic risk, breast cancer occurring in younger women remains poorly understood. This project aims at investigating the patient, tumour and treatment characteristics as well as the long-term health outcomes of these women by evaluating numerous variables that were collected from their pathology and medical files, including the social environment, family history, fertility and pregnancy.

PARTICIPANTS

We constituted a population-based cohort from the Geneva Cancer Registry of 1586 patients with breast cancer who were aged less than 46 years at the time of diagnosis.

FINDINGS TO DATE

Breast cancer was diagnosed before the age of 35 years in 225 women (14.2%), between 35 and 39 years of age in 368 women (23.2%) and between 40 and 45 years of age in 993 women (62.6%). Most of the patients were diagnosed with luminal A or luminal B molecular subtypes (32.8 and 37.5%, respectively), stage I or II tumours (75.2%), and estrogen (74.8%) and progesterone (67.5%) positive receptors. During the study period, 16.7% of these women developed loco-regional recurrences and 25.4% developed distant metastases; the majority (66.3%) did not have a recurrence. Regarding mortality, 474 (29.9%) women died during the study period, 347 (73.2%) from breast cancer.

FUTURE PLANS

The results of this study will help filling the knowledge gap about treatment of young breast cancer patients and having a child after breast cancer, and will provide clinicians and public health professionals' with additional information to improve quality of care and decrease the impact of breast cancer in young women.

[Doctor, is it reasonable for me to pursue a physical activity in my condition?]

The prevalence of cancer is increasing, with an estimated number of new cases of 21.6 million worldwide by 2030. Progress in cancer therapies has turned it into a chronic disease. Physical exercise is essential both for the general population and for oncology patients. Practicing exercise reduces the risk of developing certain cancer types and, in oncologic patients, it can reduce symptoms secondary to the disease and to treatment as well as decrease the risk of relapsing. Encouraging adapted physical exercise to every oncologic patient is therefore essential (or crucial). It is recommended to practice regular physical activity equivalent to 150 minutes of moderate intensity or 75 minutes of high intensity activity per week.

[Hypnotherapy in psycho-oncology : clinical benefits and future prospects]

After a cancer diagnosis, emotional distress is common. We currently have many conventional treatments such as radiotherapy, surgery, chemotherapy, targeted therapies and immunotherapy to fight cancer. However, these treatments are associated with significant adverse effects, which may themselves be the cause of psychic suffering. Hypnosis has been shown to be effective in relieving some of these symptoms, but its practice is still limited in oncology. This is as much related to ignorance about the discipline as to a lack of large randomized prospective studies. This article provides an overview of hypnotherapy and its benefits in the field of psycho-oncology and discusses the prospects for the future.

Molecular apocrine tumours in EORTC 10994/BIG 1-00 phase III study: pathological response after neoadjuvant chemotherapy and clinical outcomes

BACKGROUND

We explored, within the EORTC10994 study, the outcomes for patients with molecular apocrine (MA) breast cancer, and defined immunohistochemistry (IHC) as androgen-receptor (AR) positive, oestrogen (ER) and progesterone (PR) negative. We also assessed the concordance between IHC and gene expression arrays (GEA) in the identification of MA cancers.

METHODS

Centrally assessed biopsies for AR, ER, PR, HER2 and Ki67 by IHC were classified into six subtypes: MA, triple-negative (TN) basal-like, luminal A, luminal B HER2 negative, luminal B HER2 positive and "other". The two main objectives were the pCR rates and survival outcomes in the overall MA subtype (and further divided by HER2 status) and the remaining five subtypes.

RESULTS

IHC subtyping was obtained in 846 eligible patients. Ninety-three (11%) tumours were classified as the MA subtype. Both IHC and GEA data were available for 64 patients. In this subset, IHC concordance was 88.3% in identifying MA tumours compared with GEA. Within the MA subtype, pCR was observed in 33.3% of the patients (95% CI: 29.4-43.9) and the 5-year recurrence-free interval was 59.2% (95% CI: 48.2-68.6). Patients with MA and TN basal-like tumours have lower survival outcomes.

CONCLUSIONS

Irrespective of their HER2 status, the prognosis for MA tumours remains poor and adjuvant trials evaluating anti-androgens should be considered.

BRCA1/BRCA2 germline mutations and chemotherapy-related hematological toxicity in breast cancer patients

PURPOSE

BRCA1 and BRCA2 proteins are central to DNA repair process through homologous recombination. We hypothesize that BRCA1/BRCA2 mutation carriers may exhibit increased hematological toxicity when receiving genotoxic chemotherapy.

METHODS

We included women with primary breast cancers screened for BRCA1/BRCA2 germline mutations and treated with (neo)adjuvant chemotherapy in Geneva (Swiss cohort). The primary endpoint was the incidence of febrile neutropenia following the first chemotherapy cycle (C1). Secondary endpoints were the incidence of grade 3-4 neutropenia, grade 4 neutropenia and hospitalization during C1, G-CSF use and chemotherapy dose reduction during the entire chemotherapy regimen. Long-term toxicities (hematological, cardiac and neuropathy) were assessed in the Swiss cohort and a second cohort of patients from Lyon (French cohort).

RESULTS

Overall, 221 patients were assessed for acute hematological toxicity, including 23 BRCA1 and 22 BRCA2 carriers. Following the C1, febrile neutropenia had an incidence of 35% (p = 0.002), 14% (p = 0.562) and 10% among BRCA1, BRCA2 and non-carriers, respectively. Grade 4 neutropenia was found in 57% of BRCA1 (p < 0.001), 14% of BRCA2 (p = 0.861) and 18% of non-carriers. G-CSF support was necessary in 86% of BRCA1 (p = 0.005), 64% of BRCA2 (p = 0.285) and 51% of non-carriers. For long-term toxicity analysis, 898 patients were included (167 BRCA1-, 91 BRCA2- and 640 non-carriers). There was no difference between the 3 groups.

CONCLUSIONS

BRCA1 germline mutations is associated with greater acute hematological toxicity in breast cancer patients. These observations could have implication for primary prophylaxis with G-CSF.

Abstract P1-18-01: Incidence of hypocalcemia in patients with metastatic breast cancer under treatment with denosumab: A non-inferiority phase III trial assessing prevention of symptomatic skeletal events (SSE) with denosumab administered every 4 weeks versus every 12 weeks: SAKK 96/12 (REDUSE)

Background

Monthly Denosumab (DN) has shown superiority over zoledronic acid (ZA) in delaying skeletal related events. Randomized trials have shown that ZA given every 12 weeks (q12w) is non-inferior to ZA given every 4 weeks (q4w). The primary endpoint of the REDUSE-trial is non-inferiority for SSE for DN q12w versus q4w. Here we present early data for hypocalcemia (HC), a secondary endpoint.

Methods

Patients with bone metastasis from breast cancer (BC) not pretreated with DN or Bisphosphonates were randomized 1:1 to receive DN q4w (Arm A) versus q12w (Arm B) after a 3-month induction phase with q4w therapy for both arms. All patients received vitamin D 400 U (VitD) and calcium (Ca) 500 mg daily. Measurement of albumin-corrected serum-Ca was mandatory before each DN injection (HC defined as &lt;2.0 mmol/l like in CTCAE V4.0). This safety interim analysis was performed after 3.5 years of accrual. Patients who received at least 1 dose of DN were considered evaluable.

Results

351 BC-patients are currently included (177 in Arm A, 174 in Arm B). HC was the most common side effect with a rate of 20% in the first 16 weeks (during the induction phase with DN q4w for both Arms) and 19% afterwards (combined for Arms A and B). After week 16 HC-prevalence differed between the two arms: while HC was present in 25% in Arm A (q4w), the rate was only 12% in Arm B (q12w). Grade 3 HC (i.e. corrected Ca 1.5 - 1.74 mmol/l or hospitalisation indicated) was rare (0.3%), no grade 4 HC occurred. After 1 year of treatment, the rate of HC compared to the induction phase had decreased in Arm B but not in Arm A (A: 25%, B: 12%). Since HC improved in more patients in Arm B than in Arm A whereas it worsened in more patients in Arm A than in Arm B, a remarkable difference for HC resulted between the two arms.

Rates of hypocalcemia and change of severity after week 16* Arm A (N = 177)Arm B (N = 174)Rates of hypocalcemian (%)n (%)Patients with hypocalcemia at any time49 (28%)46 (26%)Patients with hypocalcemia after week 16*44 (25%)21 (12%)   Change in hypocalcemia grade after week 16*for the 49 patients with hypocalcemiafor the 46 patients with hypocalcemiaWorsening25 (51%)8 (17%)Stable10 (20%)9 (20%)Improving14 (29%)29 (63%)   *week 16: i.e. the time where the schedules of DN begin to differ between Arm A and Arm BArm A: DN q4w for weeks 1 - 12 and likewise thereafter / Arm B: DN q4w for weeks 1 - 12 and q12w thereafter

Conclusions

In our trial up to 20% of all BC patients treated with DN experienced HC in the q4w induction phase despite mandatory supplementation of VitD and Ca. This rate is considerably higher than the numbers reported in the registration trials of DN (where it was 5.5% for BC). After the induction phase, HC is markedly reduced in the q12w arm compared to q4w. This suggests that DN given q12w has a more favorable long-term safety profile in terms of HC compared to DN q4w.

Citation Format: Müller A, Templeton AJ, Hayoz S, Hawle H, Hasler-Strub U, Schwitter M, Pestalozzi BC, Pagani O, Bützberger P, Wehrhahn T, Rauch D, Inauen R, Betticher D, Zaman K, Bodmer A, Popescu RA, Rothschild S, Schardt J, Borner M, Fuhrer A, Schär C, Gillessen S, von Moos R, For the Swiss Group for Clinical Cancer Research (SAKK). Incidence of hypocalcemia in patients with metastatic breast cancer under treatment with denosumab: A non-inferiority phase III trial assessing prevention of symptomatic skeletal events (SSE) with denosumab administered every 4 weeks versus every 12 weeks: SAKK 96/12 (REDUSE) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-18-01.

Towards the first targeted therapy for triple-negative breast cancer: Repositioning of clofazimine as a chemotherapy-compatible selective Wnt pathway inhibitor

Wnt signaling is overactivated in triple-negative breast cancer (TNBC) and several other cancers, and its suppression emerges as an effective anticancer treatment. However, no drugs targeting the Wnt pathway exist on the market nor in advanced clinical trials. Here we provide a comprehensive body of preclinical evidence that an anti-leprotic drug clofazimine is effective against TNBC. Clofazimine specifically inhibits canonical Wnt signaling in a panel of TNBC cells in vitro. In several mouse xenograft models of TNBC, clofazimine efficiently suppresses tumor growth, correlating with in vivo inhibition of the Wnt pathway in the tumors. Clofazimine is well compatible with doxorubicin, exerting additive effects on tumor growth suppression, producing no adverse effects. Its excellent and well-characterized pharmacokinetics profile, lack of serious adverse effects at moderate (yet therapeutically effective) doses, its combinability with cytotoxic therapeutics, and the novel mechanistic mode of action make clofazimine a prime candidate for the repositioning clinical trials. Our work may bring forward the anti-Wnt targeted therapy, desperately needed for thousands of patients currently lacking targeted treatments.

[« Doctor, I am fasting during chemotherapy » : illusion or new clinical facts ?]

Fasting concomitantly with oncology treatments (chemotherapy mainly) induces a growing interest among patients following overmediatisation of recent discoveries. The goal of this article is to provide updated information about this approach. According to preclinical studies, fasting may be a way to increase the therapeutic index of major oncology treatments. However, clinical data is based on small exploratory studies only and the results of larger scale studies are not yet available. The approach of fasting during chemotherapy can and should neither be recommended nor implemented in standard care. However, further scientific and clinical investigation may contribute to a better understanding of the metabolic aspects of cancer.

A genetic polymorphism repurposes the G-protein coupled and membrane-associated estrogen receptor GPER to a transcription factor-like molecule promoting paracrine signaling between stroma and breast carcinoma cells

GPER is a membrane-associated estrogen receptor of the family of G-protein coupled receptors. For breast cancer, the contribution of GPER to promoting the proliferation and migration of both carcinoma cells and cancer-associated fibroblasts (CAFs) in response to estrogen and other agonists has extensively been investigated. Intriguingly, GPER was previously found to be localized to the nucleus in one isolate of breast CAFs. Moreover, this nuclear GPER was shown to bind regulatory sequences of cancer-relevant target genes and to induce their expression. We decided to find out what induces the nuclear localization of GPER, how general this phenomenon is, and what its functional significance is. We discovered that interfering with N-linked glycosylation of GPER, either by mutation of the predicted glycosylation sites or pharmacologically with tunicamycin, drives GPER into the nucleus. Surveying a small set of CAFs from breast cancer biopsies, we found that a relatively common single nucleotide polymorphism, which results in the expression of a GPER variant with the amino acid substitution P16L, is associated with the nuclear localization of GPER. GPER with P16L fails to be glycosylated, presumably because of a conformational effect on the nearby glycosylation sites. GPER P16L is defective for membrane-associated signaling, but instead acts like an estrogen-stimulated transcription factor. In CAFs, it induces the secretion of paracrine factors that promote the migration of carcinoma cells. This raises the possibility that the GPER P16L polymorphism could be a risk factor for breast cancer.

High-throughput sequencing of nodal marginal zone lymphomas identifies recurrent BRAF mutations

Nodal marginal zone lymphoma (NMZL) is a rare small B-cell lymphoma lacking disease-defining phenotype and precise diagnostic markers. To better understand the mutational landscape of NMZL, particularly in comparison to other nodal small B-cell lymphomas, we performed whole-exome sequencing, targeted high-throughput sequencing, and array-comparative genomic hybridization on a retrospective series. Our study identified for the first time recurrent, diagnostically useful, and potentially therapeutically relevant BRAF mutations in NMZL. Sets of somatic mutations that could help to discriminate NMZL from other closely related small B-cell lymphomas were uncovered and tested on unclassifiable small B-cell lymphoma cases, in which clinical, morphological, and phenotypical features were equivocal. Application of targeted gene panel sequencing gave at many occasions valuable clues for more specific classification.

Location of Mutation in BRCA2 Gene and Survival in Patients with Ovarian Cancer

Purpose: BRCA2 plays a central role in homologous recombination by loading RAD51 on DNA breaks. The objective of this study is to determine whether the location of mutations in the RAD51-binding domain (RAD51-BD; exon 11) of BRCA2 gene affects the clinical outcome of ovarian cancer patients.Experimental Design: A study cohort of 353 women with ovarian cancer who underwent genetic germline testing for BRCA1 and BRCA2 genes was identified. Progression-free survival (PFS), platinum-free interval (PFI), and overall survival (OS) were analyzed. The Cancer Genome Atlas (TCGA) cohort of ovarian cancer (n = 316) was used as a validation cohort.Results: In the study cohort, 78 patients were carriers of germline mutations of BRCA2 After adjustment for FIGO stage and macroscopic residual disease, BRCA2 carriers with truncating mutations in the RAD51-BD have significantly prolonged 5-year PFS [58%; adjusted HR, 0.36; 95% confidence interval (CI), 0.20-0.64; P = 0.001] and prolonged PFI (29.7 vs. 15.5 months, P = 0.011), compared with noncarriers. BRCA2 carriers with mutations located in other domains of the gene do not have prolonged 5-year PFS (28%, adjusted HR, 0.67; 95% CI, 0.42-1.07; P = 0.094) or PFI (19 vs. 15.5 months, P = 0.146). In the TCGA cohort, only BRCA2 carriers harboring germline or somatic mutations in the RAD51-BD have prolonged 5-year PFS (46%; adjusted HR, 0.30; 95% CI, 0.13-0.68; P = 0.004) and 5-year OS (78%; adjusted HR, 0.09; 95% CI, 0.02-0.38; P = 0.001).Conclusions: Among ovarian cancer patients, BRCA2 carriers with mutations located in the RAD51-BD (exon 11) have prolonged PFS, PFI, and OS. Clin Cancer Res; 24(2); 326-33. ©2017 AACR.

[Doctor, I'm hot! Managing the effects of menopause in patients with breast cancer]

The incidence of breast cancer is rising up, but the mortality rate is decreasing, leading to a growing number of survivors. Most of these women are postmenopausal at diagnosis or will reach menopause following anti-cancer treatments. Most of them have hormone-sensitive tumors and will receive an anti-hormonal treatment. Endocrine therapy is associated with many adverse effects, including a worsening of climacteric symptoms with a negative impact on quality of life and therefore a suboptimal therapeutic adherence. Some supportive therapies can alleviate these adverse effects and should be offered to patients.

Breast cancer in younger women in Switzerland 1996-2009: a longitudinal population-based study

BACKGROUND

Breast cancer (BC) is the most commonly diagnosed cancer and a leading cause of death in younger women.

METHODS

We analysed incidence, mortality and relative survival (RS) in women with BC aged 20-49 years at diagnosis, between 1996 and 2009 in Switzerland. Trends are reported as estimated annual percentage changes (EAPC).

RESULTS

Our findings confirm a slight increase in the incidence of BC in younger Swiss women during the period 1996-2009. The increase was largest in women aged 20-39 years (EAPC 1.8%). Mortality decreased in both age groups with similar EAPCs. Survival was lowest among women 20-39 years (10-year RS 73.4%). We observed no notable differences in stage of disease at diagnosis that might explain these differences.

CONCLUSIONS

The increased incidence and lower survival in younger women diagnosed with BC in Switzerland indicates possible differences in risk factors, tumour biology and treatment characteristics that require additional examination.

Neoadjuvant treatment with docetaxel plus lapatinib, trastuzumab, or both followed by an anthracycline-based chemotherapy in HER2-positive breast cancer: results of the randomised phase II EORTC 10054 study

BACKGROUND

Neoadjuvant trials conducted using a double HER2 blockade with lapatinib and trastuzumab, combined with different paclitaxel-containing chemotherapy regimens, have shown high pathological complete response (pCR) rates, but at the cost of important toxicity. We hypothesised that this toxicity might be due to a specific interaction between paclitaxel and lapatinib. This trial assesses the toxicity and activity of the combination of docetaxel with lapatinib and trastuzumab.

PATIENTS AND METHODS

Patients with stage IIA to IIIC HER2-positive breast cancer received six cycles of chemotherapy (three cycles of docetaxel followed by three cycles of fluorouracil, epirubicin, cyclophosphamide). They were randomised 1 : 1 : 1 to receive during the first three cycles either lapatinib (1000 mg orally daily), trastuzumab (4 mg/kg loading dose followed by 2 mg/kg weekly), or trastuzumab + lapatinib at the same dose. The primary end point was pCR rate defined as ypT0/is. Secondary end points included safety and toxicity. pCR rate defined as ypT0/is ypN0 was assessed as an exploratory analysis. In June 2012, arm A was closed for futility based on the results from other studies.

RESULTS

From October 2010 to January 2013, 128 patients were included in 14 centres. The percentage of the 122 assessable patients with pCR in the breast, and pCR in the breast and nodes, was numerically highest in the lapatinib + trastuzumab group (60% and 56%, respectively), intermediate in the trastuzumab group (52% and 52%), and lowest in the lapatinib group (46% and 36%). Frequency (%) of the most common grade 3-4 toxicities in the lapatinib /trastuzumab/lapatinib + trastuzumab arms were: febrile neutropenia 23/15/10, diarrhoea 9/2/18, infection (other) 9/4/8, and hepatic toxicity 0/2/8.

CONCLUSIONS

This study demonstrates a numerically modest pCR rate increase with double anti-HER2 blockade plus chemotherapy, but suggests that the use of docetaxel rather than paclitaxel may not reduce toxicity.

CLINICALTRIALSGOV

NCT00450892.

Isolated tumor cells in sentinel lymph nodes of invasive breast cancer: cell displacement or metastasis?

The goal of this study was to determine whether the presence of isolated tumoral cells (ITCs) in sentinel lymph nodes (SLNs) after core needle biopsy (CNB) is related to the time interval between CNB and surgery and to histopathologic features of invasive breast cancer. Data from 633 consecutive patients with no micrometastasis or metastasis on both frozen sections and definitive pathologic examination of SLNs were retrieved from a prospective data base. No association was found between ITCs and the time interval between CNB and SLNB. The association was significant with tumor size, the tumor lymphovascular invasion (LVI) and the histologic type of the tumor. This study adds supplementary data to the association between tumoral LVI and ITCs in SLNs, The time interval between CNB procedure and SLNB was not related to affect presence of ITCs, which might not suggest the iatrogenic origin of these cells.

Pathological complete response after neoadjuvant chemotherapy is an independent predictive factor irrespective of simplified breast cancer intrinsic subtypes: a landmark and two-step approach analyses from the EORTC 10994/BIG 1-00 phase III trial

BACKGROUND

Pathological complete response (pCR) following chemotherapy is strongly associated with both breast cancer subtype and long-term survival. Within a phase III neoadjuvant chemotherapy trial, we sought to determine whether the prognostic implications of pCR, TP53 status and treatment arm (taxane versus non-taxane) differed between intrinsic subtypes.

PATIENTS AND METHODS

Patients were randomized to receive either six cycles of anthracycline-based chemotherapy or three cycles of docetaxel then three cycles of eprirubicin/docetaxel (T-ET). pCR was defined as no evidence of residual invasive cancer (or very few scattered tumour cells) in primary tumour and lymph nodes. We used a simplified intrinsic subtypes classification, as suggested by the 2011 St Gallen consensus. Interactions between pCR, TP53 status, treatment arm and intrinsic subtype on event-free survival (EFS), distant metastasis-free survival (DMFS) and overall survival (OS) were studied using a landmark and a two-step approach multivariate analyses.

RESULTS

Sufficient data for pCR analyses were available in 1212 (65%) of 1856 patients randomized. pCR occurred in 222 of 1212 (18%) patients: 37 of 496 (7.5%) luminal A, 22 of 147 (15%) luminal B/HER2 negative, 51 of 230 (22%) luminal B/HER2 positive, 43 of 118 (36%) HER2 positive/non-luminal, 69 of 221(31%) triple negative (TN). The prognostic effect of pCR on EFS did not differ between subtypes and was an independent predictor for better EFS [hazard ratio (HR) = 0.40, P < 0.001 in favour of pCR], DMFS (HR = 0.32, P < 0.001) and OS (HR = 0.32, P < 0.001). Chemotherapy arm was an independent predictor only for EFS (HR = 0.73, P = 0.004 in favour of T-ET). The interaction between TP53, intrinsic subtypes and survival outcomes only approached statistical significance for EFS (P = 0.1).

CONCLUSIONS

pCR is an independent predictor of favourable clinical outcomes in all molecular subtypes in a two-step multivariate analysis.

CLINICALTRIALSGOV

EORTC 10994/BIG 1-00 Trial registration number NCT00017095.

Abstract P6-04-05: Tamoxifen dose escalation based on endoxifen level: a prospective trial with genotyping, phenotyping and pharmacokinetics over 4 months

Background: Retrospective studies assessing the impact of tamoxifen (Tam) metabolism and its active metabolite, endoxifen, on the efficacy of the treatment produced conflicting results. The prospective CYPTAM-BRUT 2 trial is ongoing1. In the present study we assessed if the level of Tam metabolites could be improved by doubling tamoxifen dose in breast cancer patients (pts) with any CYP2D6 genotype, poor (PM), intermediate (IM) and also extensive metabolizer (EM).

Patients and methods: This multicenter, prospective, open-label trial included pts treated with Tam for ≥ 4 months. CYP2D6 activity was determined centrally by genotyping and phenotyping (dextromethorphan test). Liquid chromatography-tandem-mass spectrometry was used to measure Tam, N-desmethyltamoxifen (N-DMT), 4-hydroxytamoxifen (4-HT) and endoxifen twice at baseline (Tam 20 mg qd), then at days 30, 90 and 120 after having increased the dose to 20 mg bid. Endoxifen increase and the differences between genotype/phenotype subgroups were analyzed by ANOVA.

Results: 76 pts were analyzed. Steady-state concentrations for Tam and its metabolites were reached in 30 days after doubling the dose. A range of 1.6 to 1.8 fold increase was observed. Geometric mean plasma concentrations in ng/ml (CV%) were: at baseline and day 30 respectively 134 (48) and 246 (46) for tamoxifen (p &lt; 0.0001); 246 (53) and 413 (48) for N-DMT (p &lt; 0.0001); 2.3 (44) and 3.7 (51) for 4HT (p &lt; 0.0001); 18.7 (89) and 31.1 (92) for endoxifen (p = 0.005).

The level of endoxifen increased 1.4 to 1.7 folds in all genotype subgroups with geometric mean plasma concentrations in ng/ml (CV%): 6.9 (36) to 9.7 (24) in PMs (p = 0.7); 14.2 (69) to 20.7 (76) in IMs (p &lt; 0.0001); and 22.6 (76) to 38.7 (85) in EMs (p &lt; 0.0001). Similar results were obtained while considering phenotype subgroups. Genotypes and phenotypes explained less than 30% of the variability in endoxifen levels.

The occurrence of hot flashes and night sweating were followed prospectively. Endoxifen levels did not predict an increase in HF/NS events' overall occurrence (OR = 1.01, CI95% 0.78–1.31 for HF and 1.01, CI95% 0.79–1.29 for NS). Twelve pts received CYP2D6 inhibitors. Nine pts did not complete the planned 4 months with tamoxifen 20 mg bid. The main reasons were mood disorders, hot flashes, headache and nausea. Self-reported treatment compliance assessed by monthly anonymous questionnaire was ≥ 95%, except 80–95% in 4 pts.

Conclusions: This is the first trial reporting the impact of the increase of tamoxifen dose in all CYP2D6 genotypes, including EMs. Dose escalation of tamoxifen increased significantly the plasma level of endoxifen by similar ratio in all genotype subgroups.

Because of a huge inter-individual variability genotyping and phenotyping are not adequate surrogate markers of endoxifen level. Very low endoxifen levels are observed even in pts classified as EM.

Future trials aiming to improve the plasma level of endoxifen should consider direct measurement of the metabolite in plasma and adjust tamoxifen dose according to the initial level of the metabolite independently of the genotype.

Reference

1. A. Dieudonné, Journal of Clinical Oncology, 2011; vol 29, No 15, suppl (May 20, 2011): TPS 140

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-04-05.

[Breast cancer and obesity, a dangerous relation]

Obesity is associated with different cancers including breast cancer, whose incidence is increased in postmenopausal women. It has an adverse impact on the prognosis of the patients, regardless of their menopausal status. The fact of receiving a systemic adjuvant therapy does not neutralize the prognostic role of obesity. Moderate weight loss after cancer diagnosis could improve the outcome of the patients, while a weight gain during treatment seems without significant effect. Currently available data are still too incomplete to justify systematic programs to lose weight with an oncologic therapeutic aim. However, it is worth to encourage and support our patients to have an optimal diet, physical activity, and to lose weight as promotion of general health.

Prevention of palmoplantar erythrodysesthesia (PPE) with an antiperspirant in breast cancer patients treated with pegylated liposomal doxorubicin (PLD), a placebo-controlled, double blinded, phase lll trial (SAKK 92/08)

9059

Background: PPE, also known as hand-foot syndrome, is a distinctive adverse drug reaction of PLD treatment. PLD has been detected in elevated concentrations in eccrine sweat glands in palms and soles. We postulated that prophylactic administration of an antiperspirant (F511 cream) prior and during treatment with PLD could decrease the incidence of PPE. Methods: Patients (pts) with metastatic breast cancer treated with PLD monotherapy ≥10mg/m2 per week applied an antiperspirant to the left or right hand and foot and a corresponding placebo to the opposite site with double-blinding for the content of the cream applied to either side (intra-patient randomization). The creams were applied once daily during the first week, then three times per week. The primary endpoint was the rate of PPE grade (G) ≥ 2 in the antiperspirant or placebo treated side. Pts were evaluable if they developed PPE G ≥ 2 or had received cumulatively at least 160mg/m2 PLD. Patient-reported extent of symptom burden was a secondary endpoint. Using McNemar’s matched pairs design 53 pts were needed to detect a difference of 20% between the sides with a significance level of 5% and power of 90%. Results: 52 of 90 pts from 11 Swiss centers included were evaluable. Median age was 64.5 years; median duration of PLD treatment was 12 weeks. 30 pts developed PPE G ≥ 2. In 3 pts PPE G ≥ 2 occurred on the placebo side but not on the antiperspirant side (p=0.097; table). PPE G ≥ 2 was borderline significantly more frequent in placebo foot than antiperspirant foot (p=0.048). Patient-reported extent of symptom burden showed a trend in favor of the antiperspirant side for skin problems (peeling, blistering, bleeding) in the group of pts with PPE G ≥ 2 (p=0.051). Conclusions: In this double-blind trial with intra-patient randomization we observed a trend towards less PPE G ≥ 2 with application of the antiperspirant cream F511 in pts treated with PLD as determined by the treating physician and reported by the pts. [Table: see text]

[PARP inhibitors: new therapeutic agents in breast and ovarian cancer]

PARP inhibitors are novel drugs under development in oncology, particularly against breast and ovarian cancer. They act on the DNA repair mechanisms in synergy with the loss of BRCA function of the tumor cells, thereby inducing a genetic instability that leads to cell death. The clinical benefit of PARP inhibitors has been demonstrated for breast and ovarian cancer in BRCA germline mutation carriers. Their use in sporadic triple negative breast cancers, that share similarities with BRCA1 mutated tumors, is currently investigated with encouraging preliminary results.

Abstract PD05-09: Prospective Assessment of CYP2D6 by Genotyping, Phenotyping and Measurement of Tamoxifen, 4-Hydroxy-Tamoxifen and Endoxifen in Breast Cancer Patients Treated with Tamoxifen

Background: CYP2D6 is genetically highly polymorphic and several studies support that patients classified as poor-or intermediate-metabolizers achieve less or no benefit from tamoxifen treatment probably because they have lower levels of endoxifen. Genotyping is currently the major method used in studies and in clinical practice. However the ability of genotyping to predict plasma levels of endoxifen is uncertain for an individual patient. We assessed prospectively CYP2D6 activity by genotyping, phenotyping and the measurement of tamoxifen and its metabolites. Methods: Patients were genotyped for CYP2D6 (*1, *3, *4, *5, *6 and *XN) polymorphism. The CYP2D6 phenotype was determined by the dextromethorphan test. Plasma was collected at 2 time points after at least 4 months of treatment with tamoxifen 20 mg daily: tamoxifen, 4-hydroxytamoxifen, N-demethyltamoxifen and endoxifen were measured with high performance liquid chromatography coupled to triple stage tandem mass spectrometry. Linear regression analyses were performed on log transformed concentrations of tamoxifen, its metabolites, and the ratios 4- hydroxytamoxifen/tamoxifen, endoxifen/N-demethyltamoxifen versus the different genotype groups (UM, EM, IM, PM) and the dextromethorphan/dextrorphan ratio.

Results: The data of 26 patients are currently available. Geometric mean plasma concentrations (coefficient of variation %) of tamoxifen, N-desmethyltamoxifen, 4-OH-tamoxifen and endoxifen were 377 nmol/L (39%), 482 nmol/L (36%), 5.9 nmol/L (52%) and 60.7 nmol/L (94%), respectively. Genetic variation in CYP2D6 was significantly correlated with endoxifen, 4-hydroxytamoxifen and the ratios of 4-hydroxytamoxifen/tamoxifen and endoxifen/N-demethyltamoxifen: determination coefficients (R-squared) of 44% (P=0.0002), 30% (P=0.0038), 57% (P= &lt;0.0001) and 47% (P=0.0001), respectively. Phenotypes defined by the dextromethorphan/dextrorphan ratio were significantly correlated with endoxifen and the ratios of 4-hydroxytamoxifen/tamoxifen and endoxifen/N-demethyltamoxifen: determination coefficients of 47% (P=0.0002), 39% (P=0.0012) and 59% (P= &lt;0.0001), respectively. Conclusions: Our data confirm a significant correlation between CYP2D6 activity defined by genotyping or by phenotyping and plasma levels of endoxifen. However, the important interindividual variability in the concentrations of the metabolites of tamoxifen remains largely unexplained, suggesting that CYP2D6 genotyping and phenotyping are not sufficient to predict plasma levels of the active metabolites of tamoxifen. These preliminary results are consistent with a potential superiority of monitoring the active metabolites themselves rather than genetic or phenotypic surrogates. The study is ongoing and more data will be presented.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD05-09.

[Impact of breast MRI and PET-CT in breast cancer staging]

The preoperative staging of breast carcinoma determines the type of surgery. Mammography and echography are considered standard. Even though, breast MRI shows better performance for evaluation of the size of the tumor and for detection of additional foci of the tumor. Breast MRI appears to lead to more extensive surgery or increased numbers of mastectomy. But it remains unclear whether breast MRI contributes to reduce positive surgical margins, local recurrences and whether it increases survival. Because of the low predictive positive value, every MRI finding should be confirmed by core needle biopsy. PET-CT has the best sensibility for the detection of distant metastasis but should only be used in very high risk patients.