Prescriptions of analgesics during chronic cancer disease trajectories: A complete national cohort study

PURPOSE

Pain management principles vary considerably between chronic noncancer, acute and cancer pain. Cancer patients responding to oncological treatment may live with low tumor burden for years. Opioid treatment should reflect that the ratio between benefits and risks in these patients is different from patients with a rapidly progressive disease. Our study investigated the prescription patterns of analgesics in patients who died 6 to 9 years after cancer diagnosis.

PATIENTS AND METHODS

A pharmaco-epidemiological study based on the Norwegian Prescription Database and Cancer Registry of Norway. The 1-year periodic prevalence of receiving different analgesics and of persistent opioid use were analyzed. Persistent opioid use was defined as >365 Defined Daily Doses or >9000 mg Oral Morphine Equivalents during 365 days with prescriptions in all quarters of the 365 days period. Data were reported for the first 7 years for patients who lived 8-9 years after cancer diagnosis (N = 1502), while for patients who lived 6-7 years (N = 3817) data was reported for the first 5 years after diagnosis.

RESULTS

Compared to age- and gender adjusted general population, the 1-year periodic prevalence of opioid prescription was doubled the first year after diagnosis and remained raised with approximately 50%. The prevalence of persistent opioid use was threefold of the general population. Approximately 55% of patients with persistent opioid use 4 years after a cancer diagnosis were co-medicated with high doses of benzodiazepines and/or benzodiazepine-related hypnotics.

CONCLUSION

The findings of increased opioid use raise concerns regarding whether the benefits outweigh risks and side effects in this population.

Restart of androgen deprivation therapy after goserelin induced pituitary apoplexy in a patient with disseminated prostate cancer a case report and five-years follow-up

Pituitary apoplexy is a clinical syndrome caused by hemorrhage or infarction of a pituitary adenoma. There have been a few reports in the literature of rapid onset of pituitary apoplexy after goserelin injection. To the best of our knowledge, there is no publication in the literature reporting re-introducing goserelin therapy for patients with prostate cancer after the onset of pituitary apoplexy. In this case report, we present the onset and clinico-radiological course of pituitary apoplexy induced by the initiation of goserelin and during continuation of goserelin with up to five-years follow-up.

The NEOLETEXE trial: a neoadjuvant cross-over study exploring the lack of cross resistance between aromatase inhibitors

The aromatase inhibitor letrozole (Femar®/Femara®) and the aromatase inactivator exemestane (Aromasin®) differ in their biochemical effect on the aromatase enzyme. Letrozole is a competitive aromatase inhibitor while exemestane binds irreversibly to the aromatase enzyme. This pharmacological difference is of clinical interest since a lack of cross-resistance has been documented. It has been demonstrated in several clinical trials that exemestane may cause a disease regression following resistance to nonsteroidal aromatase inhibitors. The exact mechanism(s) behind this phenomenon is yet unknown. Here, we present the NEOLETEXE trial with the aim of exploring the individual mechanisms involved behind the observed lack of cross resistance.

Clinical trial registration: The trial has been approved by the Regional Ethics Committee of South-East Norway (project number 2015/84).

Abstract OT1-01-01: The NEO-LET-EXE-trial: An intra-patient cross-over trial to explore the "lack of cross-resistance" between steroidal and non-steroidal aromatase inhibitors

Background. The aromatase inhibitor letrozole and the aromatase inactivator exemestane currently belong to the most widely used antihormonal drugs for breast cancer worldwide. Both compounds are strongly suppressing estradiol levels in postmenopausal patients with breast cancer. However, in the metastatic setting, these drugs may be used after another, causing new responses in selected patients following switching to the alternative drug after progressing on the first choice. This well-known “lack of cross resistance” has been recognized for some time and is documented by several trials. However, the precise explanation for this clinical observation is still unknown. The solution may potentially lead us to a novel strategy to treat hormone-sensitive breast cancer.

Trial design. NEO-LET-EXE is a neoadjuvant, randomized, open-label, intra-patient cross-over trial .

Eligibility criteria. Postmenopausal patients suffering from estrogen receptor (ER) positive (>50%), HER-2 negative, locally advanced breast cancer, suitable for neoadjuvant/presurgical antihormonal therapy, may be enrolled. Age: 18+ (no upper limit).

Specific aims. To explain the phenomenon of a lack of cross-resistance between steroidal and non-steroidal aromatase inhibitors in vivo. Sequential tumor biopsies and blood samples, obtained at baseline and following 2 months of therapy with each drug given in sequence, will be used to perform a comprehensive exploration of the consequences of each drug therapy. The influence on plasma and tissue steroids (estrogens, androgens, etc.) will be compared. In addition, whole genome sequencing, whole exome sequencing, epigenetics, proteomics and plasma analysis (cytokines, tumor DNA fragments, etc.) will be performed.

Statistical methods. Data will be analyzed using mixed effects models.

Present accrural and target accrural. 49 out of planned 100 patients have been enrolled so far. The last patient is expected to enter the trial in Q4 2019.

Citation Format: Bahrami N, Sauer T, Loeng M, Gravdehaug B, Engebretsen SS, Aljabri B, Bemanian V, Lindstrøm JC, Lüders T, Kristensen VN, Geisler J. The NEO-LET-EXE-trial: An intra-patient cross-over trial to explore the "lack of cross-resistance" between steroidal and non-steroidal aromatase inhibitors [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 OT1-01-01.

Abstract P3-06-11: Time-course DNA and RNA profiling of tumors from intra-patient cross-over trial of sequential use of aromatase inhibitors

Background. The NEO-LET-EXE trial examines the neoadjuvant use of sequential administration of the aromatase inhibitor letrozole (Femar / Femara) and the aromatase inactivator exemestane (Aromasin). Although both drugs nearly completely inhibit aromatase, resistance to both is developed with time. However, when used sequentially, in some patients after switching to the alternative drug and progressing on the first choice, new responses may appear. The mechanism behind this clinical observation is currently not known. The solution may lead to a novel strategy to re-sensitize tumors to hormonal treatment. Prior studies have examined genomics at the four month time point, but not at both two months and four months.

Material. Postmenopausal patients with estrogen receptor (ER) positive (>50%), HER-2 negative locally advanced breast cancer may be enrolled. Age: 18+ (no upper limit). Present accrural and target accrural: 49 out of planned 100 patients have been enrolled so far. The last patient is expected to enter the trial in Q4 2019.

Study design. In the neoadjuvant, randomized, open-label, intra-patient cross-over trial NEO-LET-EXE biopsies are taken before treatment, after two months on one aromatase inhibitor and swap to the other aromatase inhibitor, and at surgery at four months.

Results. In order to explain the phenomenon of a lack of cross-resistance between steroidal and non-steroidal aromatase inhibitors we profiled biopsies at three time points per patient by whole exome and whole transcriptome sequencing from FFPE from 25 patients. A total of 56 DNA whole exomes and 41 RNA seq transcriptomes were generated from FFPE samples available. When grouping both arms together, mutational burden decreased at two months, while clonality of mutations increased, providing evidence of selection. At four months, mutational burden increased from the two month timepoint. In particular, PIK3CA somatic variants present at the first time point were not detected at two months. However, these were detected again at significant variant allele fractions at four months after switch of treatment. The majority of gene expression changes happen in the initial two months, with fewer changes between two and four months. Instead, significant changes in alternative splicing at two months and four months were observed, for example for FGFR1, which does not experience a large fold change in expression between these two points. Our preliminary results show significant DNA and RNA changes in the first two months of aromatase inhibition leading to fewer, more clonal variants. Comparison of the four month to two month time point shows fewer RNA changes than the prior two months and an increase in the number of somatic variants compared to the two month timepoint.

Citation Format: Vaske CJ, Parulkar R, Bahrami N, Sauer T, Loeng M, Gravdehaug B, Aljabri B, Bemanian V, Lindstrøm J, Lüders T, Kristensen V, Geisler J. Time-course DNA and RNA profiling of tumors from intra-patient cross-over trial of sequential use of aromatase inhibitors [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 P3-06-11.

Early vascular complications after endovascular repair of aortoiliac aneurysms

The purpose of this study was to estimate the frequency of and review the treatment options for intraoperative endograft access-related vascular complications and early postoperative vascular complications of endovascular repair for aortoiliac aneuryms (EVAR). Between February 1998 and April 2000, 53 patients (46 males, 7 females) with aneurysms of the abdominal aorta (AAA) and iliac arteries were treated with endovascular grafts (48 AAA, and 5 iliac aneurysms). All procedures were performed using open exposure of the femoral arteries. One patient with an AAA was converted to open repair (primary technical success, 98.1%). We recorded the need for adjunctive vascular procedures or intervention to the access arteries (iliofemoral) or the endograft because of thrombosis or distal embolization. Events were classified as either intraoperative, early postoperative (< 30 postoperative days), or late postoperative. Their etiology and treatment were recorded. The results were compared to those from other series reported in the literature and to published registry data. From our results we concluded that the need for adjunctive vascular procedures to the iliofemoral arteries at the time of EVAR is significant. These procedures are necessary to either repair damage to the access arteries from the delivery system or provide a conduit for graft delivery in cases where the access arteries are inadequate. Early postoperative vascular complications are due to technical factors resulting in residual graft limb stenoses. Both intraoperative and early postoperative vascular complications after EVAR are more common in female patients. These complications can be effectively treated with a variety of open surgical and transfemoral endovascular techniques.

Incidence of major venous and renal anomalies relevant to aortoiliac surgery as demonstrated by computed tomography

Preoperative knowledge of the presence of major venous anomalies facilitates the safe performance of aortic surgery. The purpose of the study was to estimate the incidence, as detected by abdominal and pelvic computed tomography (CT), of major venous and renal anomalies related to the abdominal aorta in an adult population. A total of 1822 intravenous contrast-enhanced abdominal and pelvic CT scans done in 1822 patients at two university teaching hospitals were randomly selected and prospectively reviewed (between June 1999 and March 2000) to identify major venous and renal anomalies associated with the abdominal aorta and iliac arteries. An interpreting staff radiologist then indicated on adata sheet whether any of the following anomalies were present or absent: (1) retroaortic left renal vein, (2) circumaortic left renal vein, (3) left-sided inferior vena cava (IVC) without situs inversus, (4) left-sided IVC with situs inversus, (5) duplicate IVC, (6) preaortic confluence of the iliac veins, or (7) horseshoe kidney. The CT scans reviewed had been performed for a wide variety of indications. Thirty-four scans were excluded from the study because either the anomalies we were looking for could not be assessed for technical reasons or the patient had a previous left nephrectomy and therefore assessment of the left renal vein was impossible. From this analysis we found that in an adult population, the prevalence of major venous and renal anomalies related to the abdominal aortaand iliac arteries and detected by CT scan was 5.65%. Prior to aortic surgery, preoperative knowledge of the presence of such anomalies helps with operative planning and may reduce the risk of major venous hemorrhage associated with these anomalies.