Outcome without any adjuvant systemic treatment in stage I ER+/HER2- breast cancer patients included in the MINDACT trial

BACKGROUND

Adjuvant systemic treatments (AST) reduce mortality, but have associated short- and long-term toxicities. Careful selection of patients likely to benefit from AST is needed. We evaluated outcome of low-risk breast cancer patients of the EORTC 10041/BIG 3-04 MINDACT trial who received no AST.

PATIENTS AND METHODS

Patients with estrogen receptor-positive, HER2-negative, lymph node-negative tumors ≤2 cm who received no AST were matched 1 : 1 to patients with similar tumor characteristics treated with adjuvant endocrine therapy (ET), using propensity score matching and exact matching on age, genomic risk (70-gene signature) and grade. In a post hoc analysis, distant metastasis-free interval (DMFI) and overall survival (OS) were assessed by Kaplan-Meier analysis and hazard ratios (HR) by Cox regression. Cumulative incidences of locoregional recurrence (LRR) and contralateral breast cancer (CBC) were assessed with competing risk analyses.

RESULTS

At 8 years, DMFI rates were 94.8% [95% confidence interval (CI) 92.7% to 96.9%] in 509 patients receiving no AST, and 97.3% (95% CI 95.8% to 98.8%) in 509 matched patients who received only ET [absolute difference: 2.5%, HR 0.56 (95% CI 0.30-1.03)]. No statistically significant difference was seen in 8-year OS rates, 95.4% (95% CI 93.5% to 97.4%) in patients receiving no AST and 95.6% (95% CI 93.8% to 97.5%) in patients receiving only ET [absolute difference: 0.2%, HR 0.86 (95% CI 0.53-1.41)]. Cumulative incidence rates of LRR and CBC were 4.7% (95% CI 3.0% to 7.0%) and 4.6% (95% CI 2.9% to 6.9%) in patients receiving no AST versus 1.4% (95% CI 0.6% to 2.9%) and 1.5% (95% CI 0.6% to 3.1%) in patients receiving only ET.

CONCLUSIONS

In patients with stage I low-risk breast cancer, the effect of ET on DMFI was limited, but overall significantly fewer breast cancer events were observed in patients who received ET, after the relatively short follow-up of 8 years. These benefits and side-effects of ET should be discussed with all patients, even those at a very low risk of distant metastasis.

Impact of Second Opinions in Breast Cancer Diagnostics and Treatment: A Retrospective Analysis

BACKGROUND

Breast cancer care is becoming increasingly complex, and patients with breast cancer are increasingly aware of the different treatment options, resulting in requests for second opinions (SOs). The current study investigates the impact of breast cancer SOs on final diagnosis and treatment in the Netherlands Cancer Institute (NCI) using a newly designed Breast Cancer Second Opinion (BCSO) classification system.

METHODS

Patients who visited the NCI for an SO between October 2015 and September 2016 were included. Demographics, diagnostics, and treatment proposals were compared between first and SO. Discrepancy was categorized using our BCSO classification system, categorizing SOs into (1) noncomparable, (2) identical, and (3) minor or (4) major discrepancy.

RESULTS

The majority of SOs (n = 591) were patient initiated (90.7%). A total of 121 patients underwent treatment prior to their SO, leaving 470 patients for assessment of discrepancies according to our BCSO classification system. More than 45% of these SOs resulted in at least one discrepancy, with comparable rates for physician- and patient-initiated SOs (42.5% vs. 45.6%, p = 0.708). Significantly more discrepancies were observed in patients with additional imaging (51.3% vs. 37.2%, p = 0.002) and biopsies (53.7% vs. 40.3%, p = 0.005). Almost 60% of all discrepancies were categorized as major (neoadjuvant systemic treatment instead of primary surgery, breast-conserving surgery instead of mastectomy, and proposing postmastectomy immediate breast reconstruction).

CONCLUSIONS

Our findings show substantial differences in diagnostic and treatment options in breast cancer patients visiting the Netherlands Cancer Institute for an SO, thereby emphasizing more consensus for the indications of these treatment modalities.

Radiological complete remission in HER2-positive metastatic breast cancer patients: what to do with trastuzumab?

PURPOSE

Patients with HER2-positive metastatic breast cancer (MBC) treated with trastuzumab may experience durable tumor response for many years. It is unknown if patients with durable radiological complete remission (rCR) can discontinue trastuzumab. We analyzed clinical characteristics associated with rCR and overall survival (OS) in a historic cohort of patients with HER2-positive MBC and studied the effect of stopping trastuzumab in case of rCR.

METHODS

We included patients with HER2-positive MBC treated with first or second-line trastuzumab-based therapy in eight Dutch hospitals between 2000 and 2014. Data were collected from medical records. We used multivariable regression models to identify independent prognostic factors for rCR and OS. Time-to-progression after achieving rCR for patients who continued and stopped trastuzumab, and breast cancer-specific survival were also evaluated.

RESULTS

We identified 717 patients with a median age of 53 years at MBC diagnosis. The median follow-up was 109 months (IQR 72-148). The strongest factor associated with OS was achievement of rCR, adjusted hazard ratio 0.27 (95% CI 0.18-0.40). RCR was observed in 72 patients (10%). The ten-year OS estimate for patients who achieved rCR was 52 versus 7% for patients who did not achieve rCR. Thirty patients with rCR discontinued trastuzumab, of whom 20 (67%) are alive in ongoing remission after 78 months of median follow-up since rCR. Of forty patients (58%) who continued trastuzumab since rCR, 13 (33%) are in ongoing remission after 68 months of median follow-up. Median time-to-progression in the latter group was 14 months.

CONCLUSIONS

Achieving rCR is the strongest predictor for improved survival in patients with HER2-positive MBC. Trastuzumab may be discontinued in selected patients with ongoing rCR. Further research is required to identify patients who have achieved rCR and in whom trastuzumab may safely be discontinued.

Abstract P6-17-19: What to do with trastuzumab therapy after achieving radiological complete remission (rCR) in HER2+ metastatic breast cancer (MBC)?

Intro MBC is generally considered incurable, but patients with HER2+ disease treated with trastuzumab do relatively well and some have an exceptional durable response and survive over 10 years. We analyzed the clinical-pathological characteristics associated with long-term survival in patients with HER2+ MBC treated with trastuzumab. In addition, we studied the effect of stopping trastuzumab in case of rCR.

Methods We included all patients with HER2+ MBC treated with first- or second-line trastuzumab-based palliative therapy between January 2000 and December 2014 in 8 Dutch hospitals (Netherlands Cancer Institute, Erasmus Medical Center, Albert Schweitzer Hospital, Reinier de Graaf Hospital, Amphia Hospital, St. Antonius Hospital, Ikazia Hospital, Haga Hospital). Patients were identified through the Netherlands Cancer Registry and linkage with the institutes' tumor registries. Data was collected from medical records using case record forms. Primary endpoint was overall survival (OS), defined as first-date of MBC until death due to any cause. Kaplan-Meier survival estimates were calculated and multivariable Cox-regression models used to identify prognostic factors for improved survival. Time to progression (TTP) after achieving rCR for patients who continued and stopped trastuzumab and breast cancer specific survival were secondary outcomes.

Results We included 744 patients (median age 53, range 24-87). Median follow-up (FU) was 109 months (range 0-178). Clinical factors associated with improved survival in multivariable analyses were single-organ metastases, ER-positivity, no skin or liver metastases, no prior trastuzumab, local therapy of metastatic disease and achievement of rCR. In line with our first single center analyses1, achievement of rCR was the strongest predictor of improved survival (multivariable HR 0.30, 95%CI 0.20-0.46). RCR was observed in 71 patients (10%), of whom 60 had been treated with trastuzumab and chemotherapy, 9 with trastuzumab and hormonal therapy, and 2 with hormonal therapy. In patients with rCR the estimated 10-year OS was 53% versus 7% in patients who did not achieve rCR (p<0.001).

Thirty patients stopped trastuzumab after achieving rCR. Median time between onset of rCR and last gift of trastuzumab in these patients was 6 months (0-132). Twenty-one patients (70%) remain in complete remission after a median FU of 75 months (range 54-90) since onset of rCR. Nine patients experienced disease progression after a median time of 14 months (range 9-62) since last gift of trastuzumab. Of these, 8 patients died due to MBC and one again achieved an ongoing rCR. Out of 39 patients who continued trastuzumab after achieving rCR, 12 are in ongoing remission after a median FU of 71 months (range 51-91). In this group median TTP was 14 months (range 5-23).

Conclusion Achieving rCR is strongly associated with long-term survival in patients with HER2+ MBC. Seventy percent of patients who stopped trastuzumab after achieving rCR remained in remission, suggesting this can be an attractive approach in selected patients. External validation of these findings is required, however, as well as additional analyses to characterize the patients -and their tumors- who achieved rCR.

1 Steenbruggen, CancerRes 2017

Citation Format: Steenbruggen TG, Bouwer NI, Smorenburg CH, Rier HN, Jager A, Beelen KJ, ten Tije AJ, de Jong PC, Drooger JC, Holterhues C, Horlings HM, Sanders J, Levin M-D, Sonke GS. What to do with trastuzumab therapy after achieving radiological complete remission (rCR) in HER2+ metastatic breast cancer (MBC)? [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 P6-17-19.

Treatment decision-making in elderly women with ovarian cancer: an age-based comparison

Objective

To investigate treatment choices and outcomes in women with ovarian cancer, comparing elderly (≥75 years) and younger patients (<75 years).

Methods

A single-center retrospective analysis of patients diagnosed with ovarian cancer between 2010 and 2015. The initial treatment plan and course of treatment were extracted from medical files.

Results

Of 128 included patients, 34% were aged ≥75 years. The initial treatment plan consisted of the combination of cytoreductive surgery and platinum-based doublet chemotherapy (ie, standard treatment) in only 10% of the elderly patients with an indication for this treatment. 5% of these patients completed this treatment without adaptations (compared with 85% and 48%, respectively, in younger patients). 38% of the elderly patients with an indication for cytoreductive surgery and chemotherapy received best supportive care only. Patient preference was an important reason to withhold standard treatment. Surgery- and chemotherapy-related complications and hospital admissions did not differ between groups. Median survival was lower in the elderly (p=0.002) and in patients receiving best supportive care (p<0.001).

Conclusions

Elderly patients were less frequently treated in accordance with the treatment guideline. To select those older patients who may benefit from (adapted) treatment is challenging. Future studies should evaluate determinants associated with treatment completion to improve outcomes in this vulnerable population.

Current decisions on neoadjuvant chemotherapy for early breast cancer: Experts' experiences in the Netherlands

PURPOSE

To evaluate the opinion of surgical and medical oncologists on neoadjuvant chemotherapy (NAC) for early breast cancer.

METHODS

Surgical and medical oncologists (N = 292) participating in breast cancer care in the Netherlands were invited for a 20-question survey on the influence of patient, disease, and management related factors on their decisions towards NAC.

RESULTS

A total of 138 surgical and medical oncologists from 64 out of 89 different Dutch hospitals completed the survey. NAC was recommended for locally advanced breast cancer (94%) and for downstaging to enable breast conserving surgery (BCS) (75%). Despite willingness to downstage, 64% of clinicians routinely recommended NAC when systemic therapy was indicated preoperatively. Reported reasons to refrain from NAC are comorbidities (68%), age >70 years (52%), and WHO-performance status ≥2 (93%). Opinions on NAC and surgical management were inconclusive; while 75% recommends NAC to enable BCS, some stated that BCS after NAC increases the risk of a non-radical resection (21%), surgical complications (9%) and recurrence of disease (5%).

CONCLUSION

This article emphasizes the need for more consensus among specialists on the indications for NAC in early BC patients. Unambiguous and evidence-based treatment information could improve doctor-patient communication, supporting the patient in chemotherapy timing decision-making.

Randomized phase 2 study of gemcitabine and cisplatin with or without vitamin supplementation in patients with advanced esophagogastric cancer

Purpose

Preclinical research and prior clinical observations demonstrated reduced toxicity and suggested enhanced efficacy of cisplatin due to folic acid and vitamin B12 suppletion. In this randomized phase 2 trial, we evaluated the addition of folic acid and vitamin B12 to first-line palliative cisplatin and gemcitabine in patients with advanced esophagogastric cancer (AEGC).

Methods

Patients with AEGC were randomized to gemcitabine 1250 mg/m² (i.v. days 1, 8) and cisplatin 80 mg/m² (i.v. day 1) q 3 weeks with or without folic acid (450 µg/day p.o.) and vitamin B12 (1000 µg i.m. q 9 weeks). The primary endpoint was response rate (RR). Secondary endpoints included overall survival (OS), time to progression (TTP), toxicity, and exploratory biomarker analyses. Cisplatin sensitivity and intracellular platinum levels were determined in adenocarcinoma cell lines cultured under high and low folate conditions in vitro.

Results

Adenocarcinoma cells cultured in medium with high folate levels were more sensitive to cisplatin and this was associated with increased intracellular platinum levels. In the randomized phase 2 clinical trial, which ran from October 2004 to September 2013, treatment was initiated in 78 of 82 randomized pts, 39 in each study arm. The RR was similar; 42.1% for supplemented patients vs. 32.4% for unsupplemented patients; p = 0.4. Median OS and TTP were 10.0 and 5.9 months for supplemented vs. 7.7 and 5.4 months for unsupplemented patients (OS, p = 0.9; TTP, p = 0.9). Plasma homocysteine was lower in the supplemented group [n = 20, 6.9 ± 1.6 (mean ± standard error of mean, SEM) µM; vs. 12.5 ± 4.0 µM; p < 0.001]. There was no significant difference in the C_max of gemcitabine and cisplatin in the two treatment groups.

Conclusion

Folic acid and vitamin B12 supplementation do not improve the RR, PFS, or OS of cisplatin and gemcitabine in patients with AEGC.

Abstract P3-08-09: Impact of gene-expression profiling in patients with early breast cancer when applied outside the guideline directed indication area

Purpose

In Dutch guidelines gene expression profiles (GEP) are indicated in estrogen receptor positive early breast cancer patients in whom benefit of chemotherapy (CT) is controversial based on traditional prognostic factors alone. Aim of the current study is to assess the use and impact of GEP on administration of adjuvant CT in breast cancer patients who have according to national guidelines a clear indication to either use or withhold adjuvant chemotherapy (clinical high or low risk).

Methods

Clinical low- and high risk patients, according to Dutch breast cancer guidelines, diagnosed between 2011-2014 were selected from the Netherlands Cancer Registry (NCR). Influence of GEP use and GEP test result on CT administration was assessed with logistic regression.

Results

Overall, 26,425 patients were identified; 4.8% of patients with clinical low- risk (444/ 9,354), 7.5% of the patients with a clinical high-risk (1,281/ 17,071) received a GEP. GEP use was associated with a significantly increased odds of CT administration in clinical low-risk patients (OR=2.12 95%CI: 1.44-3.11). In clinical high-risk patients GEP use was associated with a decreased frequency of CT administration (OR=0.55, 95%CI: 0.48-0.63). Adherence to the GEP result was higher in clinical high-risk patients with a discordant GEP result as compared to clinical low-risk patients with a discordant GEP result: 71.7% vs. 52.2%, respectively.

Conclusion

GEP is frequently used outside the indicated area and significantly influenced the administration of adjuvant CT, although adherence to the test-result was limited.

Citation Format: Schreuder K, Kuijer A, Rutgers EJTh, Smorenburg CH, Van Dalen T, Siesling S. Impact of gene-expression profiling in patients with early breast cancer when applied outside the guideline directed indication area [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-09.

Patients' experiences with decisions on timing of chemotherapy for breast cancer

INTRODUCTION

Despite potential advantages, application of chemotherapy in the neo-adjuvant (NAC) instead of adjuvant (AC) setting for breast cancer (BC) patients varies among hospitals. The aim of this study was to gain insight in patients' experiences with decisions on the timing of chemotherapy for stage II and III BC.

MATERIALS AND METHODS

A 35-item online questionnaire was distributed among female patients (age>18) treated with either NAC or AC for clinical stage II/III invasive BC in 2013-2014 in the Netherlands. Outcome measures were the experienced exchange of information on the possible choice between both options and patients' involvement in the final decision on chemotherapy timing. Chemotherapy treatment experience was measured with the Cancer Therapy Satisfaction Questionnaire (CTSQ).

RESULTS

Of 805 invited patients, 49% responded (179 NAC, 215 AC). NAC-treated patients were younger and more often treated in teaching/academic hospitals and high-volume hospitals. Information on the possibility of NAC was given to a minority of AC-treated patients (AC, stage II:14%, stage III: 31%). Information on pros and cons of both NAC and AC was rated sufficient in about three fourth of respondents. Respondents not always felt having a choice in the timing of chemotherapy (stage II: 54% NAC vs 36% AC; stage III: 26% NAC, 54% AC).

CONCLUSION

The need to make a treatment decision on NAC was found to be made explicit in only a small number of adjuvant treated patients, in particular in BC stage II. Less than half of the respondents felt they had a real choice.

Impact of gene-expression profiling in patients with early breast cancer when applied outside the guideline directed indication area

PURPOSE

In Dutch guidelines, gene expression profiles (GEP) are indicated in estrogen receptor positive early breast cancer patients in whom benefit of chemotherapy (CT) is uncertain based on traditional prognostic factors alone. Aim of the present study is to assess the use and impact of GEP on administration of adjuvant CT in breast cancer patients who have according to national guidelines a clear indication to either use or withhold adjuvant chemotherapy (clinical high or low risk).

METHODS

Clinical low- and high-risk patients, according to Dutch breast cancer guidelines, diagnosed between 2011 and 2014 were selected from the Netherlands Cancer Registry. Influence of GEP use and GEP test result on CT administration was assessed with logistic regression.

RESULTS

Overall, 26,425 patients were identified; 4.8% of patients with clinical low risk (444/9354), 7.5% of the patients with a clinical high risk (1281/17,071) received a GEP. GEP use was associated with significantly increased odds of CT administration in clinical low-risk patients (OR = 2.12 95% CI: 1.44-3.11). In clinical high-risk patients, GEP use was associated with a decreased frequency of CT administration (OR = 0.55, 95% CI: 0.48-0.63). Adherence to the GEP result was higher in clinical high-risk patients with a discordant GEP result as compared to clinical low-risk patients with a discordant GEP result: 71.7% vs. 52.2%, respectively.

CONCLUSION

GEP is frequently used outside the indicated area and significantly influenced the administration of adjuvant CT, although adherence to the test result was limited.

Abstract P3-13-12: The concept of breast contour preserving surgery as parameter in breast cancer surgery

Background

Breast cancer treatment is a multimodality effort to optimize outcome as well as to achieve the optimal cosmetic result. Various treatment strategies can be used for the latter goal: upfront breast conserving surgery (BCS), BCS after neoadjuvant therapy (NAC), and ablative surgery combined with immediate breast reconstruction. The rate of BCS is frequently used as a quality and trend indicator. The aim of the present study was to analyse the combined efforts expressed as the rate of breast contour preserving procedures (BCPP) and compare it to the rate of BCS.

Material and methods

All invasive M0 female breast cancer patients diagnosed and operated in one of the 89 hospitals in the Netherlands between January 2011 – December 2015 were selected from the national NABON Breast Cancer Audit. BCPP (defined as 'primary BCS', 'BCS after NAC', or 'ablative surgery combined with an immediate reconstruction') was calculated for the years of diagnosis, age groups (&lt;30, 30-39, 40-49, 50-59, 60-69 and ≥ 70 years) and the individual hospitals.

Results

A total of 61,309 patients were identified. The rate of upfront BCS remained stable during the study period (52%), while the BCPP rate increased over the years (63% to 71%) due to an equal increase in the proportions of patients receiving NAC with BCS and undergoing ablative surgery with immediate breast reconstruction. While upfront BCS (with and without NAC) rates increased with age (30% in patients aged &lt;30 years to 67% in patients aged 60-69), the rate of BCPP was more or less stable in these age groups, as the rate of ablative surgery with immediate reconstruction showed an inverse relationship with age, decreasing from 44% in patients &lt;30 years to 1% in patients ≥70 years of age.

The rate of BCS varied between hospitals in the Netherlands: 37% to 77%. Although BCPP is more often performed compared to BCS, the variation between hospitals remained (47% to 88%).

Table. Percentage of patients treated with Breast Conserving Surgery (BCS), BCS after neo-adjuvant therapy and immediate breast reconstruction with ablative surgery resulting in total percentages of Breast Contour Preserving Procedures (BCPP). BCSBCSAblative surgeryBCPP  Neo-adjuvant +IBR + Year of Diagnosis    201153%4%6%63%201253%4%7%64%201352%6%8%67%201452%8%9%69%201552%9%11%71%Age Group    &lt;3017%13%44%73%30-3927%14%26%67%40-4938%12%17%68%50-5956%7%11%75%60-6963%5%5%72%≥ 7049%2%1%52%Hospitals    Mean52%6%8%67%Min34%0%0%47%Max66%26%28%88%BCS: Breast Conserving Surgery; IBR: Immediate Breast Reconstruction; BCPP: Breast Contour Preserving Procedures

Conclusions

While the rate of BCS remained stable over recent years, the rate of BCPP has increased significantly. Including immediate reconstruction into the BCPP rate annihilates observed age-dependent differences of the BCS-rates, while institutional differences remained. All in all, combining different treatment strategies into one parameter (BCPP) provides a more appropriate measure of maintaining the breast contour than BCS alone.

Citation Format: van Bommel A, Spronk P, Vrancken Peeters M-J, Mureau M, Siesling S, Smorenburg C, van Dalen T. The concept of breast contour preserving surgery as parameter in breast cancer surgery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-12.

Abstract P1-03-04: Concordance of local immunohistochemistry with TargetPrint microarray based assessment of ER, PR and Her2 and BluePrint molecular subtyping in the Symphony Triple A study

PURPOSE: A decade ago intrinsic biological breast cancer subtypes have been identified which have proven to be of clinical importance in terms of outcome and response to systemic treatment. The aim of the current study is to assess concordance between breast cancer subtypes determined by local immunohistochemistry (IHC) assessment of estrogen receptor (ER), progesterone receptor (PR) and Her2-receptor status and microarray based molecular subtyping in a subset of ER+ early stage breast cancer patients.

PATIENTS AND METHODS: In this prospective observational multicenter study information on local pathology assessment and BluePrint/TargetPrint results were obtained in ER+ Dutch early stage breast cancer patients in whom a 70-gene profile (MammaPrint) was used as they were enrolled in clinical trial based on the existence of controversy regarding the additional value of adjuvant CT. Local IHC assessment of ER, PR and Her2 status were compared with microarray based assessment (TargetPrint/BluePrint) of these characteristics. Reclassification of ER and PR overexpression was assessed by a McNemars test and by Spearman correlation. Furthermore, concordance between the clinical subtypes based on local pathology (Luminal-type: ER+/PR+/Her2-; Her2-type: Her2+ disease) and molecular subtyping was assessed.

RESULTS: Between January 2013 And December 2015 660 patients, treated in 31 hospitals, were enrolled. In 564 (85%) BluePrint and/or TargetPrint was performed in addition to the 70-GS. The majority of patients had ER+/Her2- disease and TargetPrint reclassified 1% (n = 7) of patients as ER-negative (r = 0,250, p &lt;0,001). TargetPrint reclassified 7% (n = 40) and 2% (n = 11) of patients for PR and Her2 status respectively (table 1, r = 0,580, p &lt;0,001 for PR

Table 1. Concordance between immunohistochemistry and TargetPrint. TargetPrint result (ER, PR and Her2 resp.)  ImmunohistochemistryPositiveNegativeOverall discordance (%)p-value*Estrogenreceptor status    Positive557 (99%)6 (1%)  Negativen.a.n.a.1%n.a.Progesterone receptor status    Positive474 (96%)18 (4%)  Negative22 (31%)49 (69%)7%0,636Her2 receptor status    Positive3 (30%)7 (70%)  Negative4 (3%)546 (97%)2%0,549Equivocal0 (0%)3 (1%)  * P-value represents results of the McNemar test.). Based on IHC 545 (98%) patients were regarded as luminal-type and the remaining 2% as Her2-type. BluePrint reclassified 2% of the clinical luminal-type patients: 4 (1%) patients were reclassified as basal-type and 3 (0%) patients as Her2-type. Of the clinical Her2-type patients 80% (n=8) was reclassified by BluePrint as molecular luminal-type.

Table 2. Concordance between clinical subtyping and molecular subtyping according to BluePrint.  BluePrint resultClinical SubtypeNo. ptsLuminalBasalHer2Luminal545539 (99%)4 (1%)3 (0%)Her2108 (80%)02 (20%)Note. Overall discordance 3%.

Conclusion: In the current study we observe a high concordance between microarray-based assessment of ER, PR and Her2 and local pathology in Dutch ER+ early stage breast cancer patients. In the small subset of ER+ patients who are considered candidates for 70 GS use and who have HER2+ tumors by IHC molecular typing of HER2 status is of additional value.

Citation Format: Kuijer A, Straver M, Elias S, Smorenburg C, Wesseling J, Linn S, Rutgers E, Siesling S, van Dalen T. Concordance of local immunohistochemistry with TargetPrint microarray based assessment of ER, PR and Her2 and BluePrint molecular subtyping in the Symphony Triple A study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-03-04.

Abstract P4-21-30: Long-term survival in HER2-positive metastatic breast cancer: The first blow is half the battle

Introduction: Metastatic breast cancer (MBC) is considered an incurable disease. However, long-term survival is increasingly observed in HER2-positive disease since the introduction of trastuzumab. We explored factors associated with long-term survival in a retrospective series at our Institute.

Methods: All patients with histologically proven HER2-positive (3+ score by IHC or HER2 amplification) MBC treated starting first-line trastuzumab-based palliative therapy between January 2003 to January 2013 were included. Patients were identified from the Institute's tumor registry and data were collected from patient records. The primary endpoint was overall survival. Kaplan-Meier survival estimates were calculated and multivariable survival analyses were performed to identify independent prognostic factors. Radiologic complete response (CR) was a secondary endpoint.

Results: We identified 113 patients with a median age at diagnosis of MBC of 52 years (range 27-82). Median follow-up for MBC was 39 months (range 2-148 months). Thirty-eight percent presented with synchronous metastases; 62% had recurrent disease of whom 42% had received prior trastuzumab as part of (neo-)adjuvant treatment. First-line palliative treatment consisted of trastuzumab plus vinorelbine (56%), a taxane (28%), capecitabine (10%), other chemotherapy (3%), or endocrine therapy (2%), and resulted in a CR in 27 patients (24%). In addition, one patient achieved CR to third-line therapy. Most patients with CR had received trastuzumab with a taxane (57%) followed by vinorelbine (32%). Fourteen out of 28 patients with CR are still alive without evidence of disease at a median follow-up of 91 months (range 23-148 months), of whom 8 still receive trastuzumab. Fourteen patients had disease relapse (8 on maintenance trastuzumab, 6 after discontinuation). Overall, 35 patients (31%) survived more than 5 years. Factors associated with long-term survival in univariable analyses were oligo-metastatic disease (1-3 distant metastases), synchronous metastases, no skin or brain metastases, no prior (neo-)adjuvant trastuzumab, first-line palliative treatment with trastuzumab and taxanes, and achieving a radiologic CR on treatment (see table 1). Achieving CR and the absence of skin metastases remained significant factors in multivariable analyses.

Conclusion: Thirty-one percent of patients with metastatic HER2-positive MBC survive over 5 years. Long-term response is particularly seen in patients who achieve a complete radiologic response on first-line treatment. This finding supports a strategy to administer the most effective agents as first line treatment, as is often but not always applied in clinical practice.

Table 1. Prognostic factors associated with overall survival  Univariable  Multivariable  HR95% CIpHR95% CIpSynchronous metastases      No-  -  Yes0.44(0.27-0.70)&lt;0.0010.80(0.46-1.40)0.43Oligo-metastatic disease      No-  -  Yes0.37(0.22-0.62)&lt;0.010.66(0.36-1.17)0.14Skin metastases      No-  -  Yes5.40(2.91-10.01)&lt;0.014.10(2.08-8.14)&lt;0.01Brain metastases      No-  -  Yes2.25(1.03-4.93)0.041.46(0.55-3.98)0.45(Neo-)adjuvant trastuzumab      No-  -  Yes1.87(1.16-2.99)0.011.66(0.93-2.96)0.09Trastuzumab + taxane      No-  -  Yes0.54(0.32-0.89)0.020.69(0.40-1.20)0.19Complete radiologic response      No-  -  Yes0.13(0.06-0.29)&lt;0.010.22(0.09-0.53)0.001

Citation Format: Steenbruggen TG, van Ramshorst MS, Stouthard JML, Rodenhuis S, Linn SC, Sonke GS, Smorenburg CH. Long-term survival in HER2-positive metastatic breast cancer: The first blow is half the battle [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-30.

Results of scalp cooling during anthracycline containing chemotherapy depend on scalp skin temperature

OBJECTIVES

The success of scalp cooling in preventing or reducing chemotherapy induced alopecia (CIA) is highly variable between patients undergoing similar chemotherapy regimens. A decrease of the scalp skin temperature seems to be an important factor, but data on the optimum temperature reached by scalp cooling to prevent CIA are lacking. This study investigated the relation between scalp skin temperature and its efficacy to prevent CIA.

MATERIALS AND METHODS

In this explorative study, scalp skin temperature was measured during scalp cooling in 62 breast cancer patients undergoing up to six cycles of anthracycline containing chemotherapy. Scalp skin temperature was measured by using two thermocouples at both temporal sides of the head. The primary end-point was the need for a wig or other head covering.

RESULTS

Maximal cooling was reached after 45 min and was continued for 90 min after chemotherapy infusion. The scalp skin temperature after 45 min cooling varied from 10 °C to 31 °C, resulting in a mean scalp skin temperature of 19 °C (SEM: 0,4). Intrapersonal scalp skin temperatures during cooling were consistent for each chemotherapy cycle (ANOVA: P = 0,855). Thirteen out of 62 patients (21%) did not require a wig or other head covering. They appeared to have a significantly lower mean scalp skin temperature (18 °C; SEM: 0,7) compared to patients with alopecia (20 °C; SEM: 0,5) (P = 0,01).

CONCLUSION

The efficacy of scalp cooling during chemotherapy is temperature dependent. A precise cut-off point could not be detected, but the best results seem to be obtained when the scalp temperature decreases below 18 °C. TRIALREGISTER.

NL NTR NUMBER

3082.

Changes over time in the impact of gene-expression profiles on the administration of adjuvant chemotherapy in estrogen receptor positive early stage breast cancer patients: A nationwide study

Ten years ago gene-expression profiles were introduced to aid adjuvant chemotherapy decision making in breast cancer. Since then subsequent national guidelines gradually expanded the indication area for adjuvant chemotherapy. In this nation-wide study the evolution of the proportion of patients with estrogen-receptor positive (ER+) tumors receiving adjuvant chemotherapy in relation to gene-expression profile use in patient groups that became newly eligible for chemotherapy according to national guideline changes over time is assessed. Data on all surgically treated early breast cancer patients diagnosed between 2004-2006 and 2012-2014 were obtained from the Netherlands Cancer Registry. ER+/Her2- patients with tumor-characteristics making them eligible for gene-expression testing in both cohorts and a discordant chemotherapy recommendation over time (2004 guideline not recommending and 2012 guideline recommending chemotherapy) were identified. We identified 3,864 patients eligible for gene-expression profile use during both periods. Gene-expression profiles were deployed in 5% and 35% of the patients in the respective periods. In both periods the majority of patients was assigned to a low genomic risk-profile (67% and 69%, respectively) and high adherence rates to the test result were observed (86% and 91%, respectively). Without deploying a gene-expression profile 8% and 52% (p <0.001) of the respective cohorts received chemotherapy while 21% and 28% of these patients received chemotherapy when a gene-expression profile was used (p 0.191). In conclusion, in ER+/Her2- early stage breast cancer patients gene-expression profile use was associated with a consistent proportion of patients receiving chemotherapy despite an adjusted guideline-based recommendation to administer chemotherapy.

Abstract P4-02-01: Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands

Background

The value of magnetic resonance imaging (MRI) for patients with breast cancer remains under debate. Breast MRI may contribute to the planning of local therapy, but also bears the risk of overtreatment. We analyzed the use of MRI and its impact on surgical treatment and risk of detecting contralateral breast cancer in the Netherlands.

Patients and methods

All patients who underwent primary surgery for stage I-III invasive breast cancer in the years 2011-2013 were identified through the Netherlands Cancer Registry. The following data were documented: year of diagnosis, hospital type and volume, age at diagnosis, clinical T and N stage, histological type and grade, presence of multifocality in resection specimen, hormone receptor status, HER2 status and use of MRI. We analyzed whether MRI use was related to type of surgery (primary or secondary mastectomy or breast conserving surgery), surgical margin involvement, and diagnosis of synchronous contralateral breast cancer.

Results

MRI was performed in 10,819 (29,8%) out of 36,333 patients newly diagnosed with invasive breast cancer and treated with primary surgery in the years 2011-2013 in the Netherlands. Use of MRI did not clearly increase in this period.

In the multivariate analysis, patients younger than 50 years of age compared to patients aged 70 years or older (OR 6.34, 95% CI 5.86-6.87), patients with lobular breast cancer compared to those with ductal carcinoma (OR 3.46; 95% CI 3.23-3.70) and patients with multifocal tumors compared to those without multifocality (OR 2.30, 95% CI 2.15-2.45) were more likely to undergo MRI. Hospital volume (&lt;150 versus &gt;150) was only marginally related to MRI use (OR 0.93; 95% CI 0.87-0.99).

Patients with invasive breast cancer undergoing MRI were more likely to undergo primary mastectomy than those without MRI (OR 1.21; 95% CI 1.15-1.28), but the subgroup with invasive lobular cancer undergoing MRI were less likely to undergo primary mastectomy (OR 0.85; 95% CI 0.75-0.98). A significantly lower risk of positive surgical margins was seen in patients with lobular breast cancer and breast conserving surgery who had undergone MRI as compared to those without MRI (OR 0.58, 95% CI 0.44-0.78) and, consequently, also a lower risk of secondary mastectomy (OR 0.60, 95% CI 0.41-0.87). Risk of positive surgical margins was not reduced by MRI use in patients with invasive ductal carcinoma (OR 0.91; 95% CI 0.77-1.07). Patients who underwent MRI were almost four times more frequently diagnosed with contralateral breast cancer, compared to those in whom MRI was not performed (OR 3.60, 95% CI 3.06-4.24).

Conclusion

Breast MRI was significantly more often used in younger patients, patients with lobular and/or multifocal breast cancer. Interestingly, MRI use was associated with less primary and secundary mastectomies in lobular invasive breast cancer, in contrast to an increased number of primary mastectomies in patients with invasive ductal cancer. MRI was further associated with an almost fourfold higher incidence of contralateral breast cancer.

Citation Format: Tjan-Heijnen VC, Lobbes MB, Vriens IJ, van Bommel AC, Nieuwenhuijzen GA, Smidt ML, Boersma LJ, van Dalen T, Smorenburg CH, Siesling S, Voogd AC. Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-01.

A randomized phase III study comparing pegylated liposomal doxorubicin with capecitabine as first-line chemotherapy in elderly patients with metastatic breast cancer: results of the OMEGA study of the Dutch Breast Cancer Research Group BOOG

BACKGROUND

Prospective data on chemotherapy for elderly patients with metastatic breast cancer (MBC) remain scarce. We compared the efficacy and safety of first-line chemotherapy with pegylated liposomal doxorubicin (PLD) versus capecitabine in MBC patients aged ≥65 years in a multicentre, phase III trial.

PATIENTS AND METHODS

Patients were randomized to six cycles of PLD (45 mg/m(2) every 4 weeks) or eight cycles of capecitabine (1000 mg/m(2) twice daily, day 1-14 every 3 weeks).

RESULTS

The study enrolled 78 of the planned 154 patients and was closed prematurely due to slow accrual and supply problems of PLD. Many included patients were aged ≥75 years (54%) and vulnerable (≥1 geriatric condition: 71%). The median dose intensity was 85% for PLD and 84% for capecitabine, respectively. In both arms, the majority of patients completed at least 12 weeks of treatment (PLD 73%; capecitabine 74%). After a median follow-up of 39 months, 77 patients had progressed and 62 patients had died of MBC. Median progression-free survival was 5.6 versus 7.7 months (P = 0.11) for PLD and capecitabine, respectively. Median overall survival was 13.8 months for PLD and 16.8 months for capecitabine (P = 0.59). Both treatments were feasible, grade 3 toxicities consisting of fatigue (both arms: 13%), hand-foot syndrome (PLD: 10%; capecitabine: 16%), stomatitis (PLD: 10%; capecitabine: 3%), exanthema (PLD: 5%) and diarrhoea (PLD: 3%; capecitabine: 5%). Only 1 of 10 patients aged ≥80 years completed chemotherapy, while 3 and 6 patients discontinued treatment due to toxicity or progressive disease, respectively.

CONCLUSION

Both PLD and capecitabine demonstrated comparable efficacy and acceptable tolerance as first-line single-agent chemotherapy in elderly patients with MBC, even in vulnerable patients or patients aged ≥75 years. However, patients aged ≥80 years were unlikely to complete chemotherapy successfully.

CLINICAL TRIAL NUMBERS

EudraCT 2006-002046-10; ISRCTN 11114726; CKTO 2006-09; BOOG 2006-02.

Abstract OT3-1-03: DIRECT: A phase II/III randomized trial with dietary restriction as an adjunct to neoadjuvant chemotherapy for HER2-negative breast cancer

Background:

Preclinical evidence shows that short-term fasting protects normal cells, while cancer cells are sensitized to chemotherapy. Furthermore, a specifically designed very low calorie, low amino acid substitution diet (“Fasting Mimicking Diet”, FMD) has similar effects on chemotherapy as short-term fasting. This trial evaluates the impact of FMD on tolerance to and efficacy of neoadjuvant chemotherapy in women with HER2-negative early breast cancer.

Trial design:

DIRECT is a Dutch, randomized, open-label multicenter phase II/III trial. Women receiving neoadjuvant TAC courses (docetaxel/adriamycin/cyclophosphamide; day 1, q 3 weeks with G-CSF support at day 2) will be randomized with or without FMD for 3 days prior to and the day of chemotherapy and 3 days prior to surgery.

Eligibility criteria:

Eligible women are WHO 0-2, age ≥18 years, HER2-negative, stage II or III breast cancer and adequate bone marrow, liver and renal function, BMI &gt; 19kg/m2 and absence of diabetes mellitus.

Study endpoints:

The primary endpoints are grade III/IV toxicity (phase II) and the pathologic complete response rate (pCR) (phase III). Secondary endpoints are grade I/II toxicity, metabolic and inflammatory response to chemotherapy, DNA damage, apoptosis, immunology and nutrient sensing pathways in the tumor, biomarkers as single nucleotide polymorphisms, Ki67 and tumor stroma/ratio, patient's quality of life and (disease free) survival. Optional side studies include chemotherapy-induced DNA damage and nutrient sensing pathways in leukocytes and proteomics.

Statistical Methods:

Using a 5% significance level based on the two-sided Fisher's exact test with a power of 80%, 128 patients (64/arm) will be enrolled to show a 50% decrease of grade III/IV adverse events in the experimental arm (phase II) and 250 patients (125/arm) are needed to show an improvement of the pCR rate from 18% to 36% (phase III).

Target accrual:

Recruitment will start in September 2013. The expected end of accrual of 250 patients from multiple centers in the Netherlands will be the last quarter of 2015.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-1-03.

Baseline comprehensive geriatric assessment is associated with toxicity and survival in elderly metastatic breast cancer patients receiving single-agent chemotherapy: results from the OMEGA study of the Dutch breast cancer trialists' group

AIM

To evaluate the association between baseline comprehensive geriatric assessment (CGA) or the Groningen Frailty Indicator (GFI) and toxicity in elderly metastatic breast cancer (MBC) patients treated with first-line palliative chemotherapy.

PATIENTS AND METHODS

MBC patients (≥65 years) were randomized between pegylated liposomal doxorubicine or capecitabine. CGA included instrumental activities of daily living (IADL), cognition using the mini-mental state examination (MMSE), mood using the geriatric depression scale (GDS), comorbidity using the Charlson index, polypharmacy and nutritional status using the body mass index. Frailty on CGA was defined as one or more of the following: IADL ≤ 13, MMSE ≤ 23, GDS ≥ 5, BMI ≤ 20, ≥5 medications or Charlson ≥2. The cut-off for frailty on the GFI was ≥4.

RESULTS

Of the randomized 78 patients (median age 75.5 years, range 65.8-86.8 years), 73 were evaluable for CGA; 52 (71%) had one or more geriatric conditions. Grade 3-4 chemotherapy-related toxicity was experienced by 19% of patients without geriatric conditions compared to 56% of patients with two geriatric conditions and 80% of those with three or more (p = 0.002). Polypharmacy was the only individual factor significantly associated with toxicity (p = 0.001). GFI had a sensitivity of 69% and a specificity of 76% for frailty on CGA, and was not significantly associated with survival or toxicity.

CONCLUSION

In this study of elderly patients with MBC, the number of geriatric conditions correlated with grade 3-4 chemotherapy-related toxicity. Therefore, in elderly patients for whom chemotherapy is being considered, a CGA could be a useful addition to the decision-making process.

Unresectable pancreatic tumour? The issue is tissue

The majority of tumours in the pancreas are adenocarcinomas for which therapeutic options are limited and which are associated with an unsatisfactory prognosis. However, alternative diagnoses may result in other therapeutic approaches with often a more favourable outcome. Hence, it is crucial to obtain a histological diagnosis before a definitive therapeutic plan can be devised. In this manuscript, a small series of pancreatic tumours other than adenocarcinoma are described.

Abstract P1-12-05: First-line chemotherapy with pegylated liposomal doxorubicin versus capecitabine in elderly patients with metastatic breast cancer: results of the phase III OMEGA study of the Dutch Breast Cancer Trialists' Group (BOOG)

Background The efficacy and feasibility of chemotherapy in elderly metastatic breast cancer (MBC) patients (pts) have been studied in various phase II studies. However, results of prospective randomized studies in elderly MBC pts are scarce.

Methods In this phase III multicenter study, MBC pts ≥ 65 years eligible for first-line chemotherapy were randomized between pegylated liposomal doxorubicin (PEGdoxo) (45mg/m2, IV, q 4 wks) or capecitabine (Cape) (1000 mg/m2 PO bid, days 1–14, q 3 wks). Other eligibility criteria were ECOG performance status (PS) ≤ 2 (3 allowed if due to pain or pre existing comorbidity), adequate bone marrow and organ functions. Stratification factors were PS (0–1 vs 2–3), HER2 status, visceral/non-visceral disease, adjuvant hormonal therapy (HTx), and HTx for MBC. Baseline geriatric assessment (GA) included functional status, instrumental activities of daily living, cognition, mood, comorbidity, polypharmacy and nutritional status. Chemotherapy was continued for 24 wks in the absence of progressive disease (PD) or unacceptable toxicity. Primary endpoint was progression-free survival (PFS), secondary endpoints were response rate, overall survival (OS), toxicity (CTC criteria) and compliance.

Results Between April 2007 and August 2011, 78 pts were randomized to PEGdoxo (n = 40) or Cape (n = 38). The study was prematurely closed due to slow accrual and supply problems with PEGdoxo. Mean age was 74 years (range 65–86; 75+ 54%; 80+ 13%). Pt characteristics were balanced between the two arms: PS 0–1 77%, ER+ 68%, HER2+ 5%, visceral/non-visceral disease 76%/24%, adjuvant HTx 46%, HTx for MBC 56%, ≥ 3 metastatic sites 50%. Only 22 out of 75 pts with a baseline GA had no geriatric condition (29%), while 32 pts (43%) and 21 pts (28%) had one or ≥ 2 geriatric conditions, respectively. Chemotherapy was given for 6 months in 38%, with a mean dose intensity of 84% in both arms. Reasons for early treatment discontinuation were: PD (31%), toxicity (28%), pt withdrawal (3%). After a median follow up of 32 months, 74 pts had PD and 56 pts had died. The median PFS was 5.7 and 7.7 months with PEGdoxo and Cape (HR 0.68, 95% CI: 0.42–1.11, p = 0.12) and the median OS was 13.8 and 16.8 months, respectively (HR 0.84, 95% CI: 0.49–1.42, p = 0.51). Response was evaluable in 64 pts, with a partial response (PR) in 7 (21%) and 6 pts (19%), and stable disease in 21 (64%) and 17 pts (55%) for PEGdoxo and Cape, respectively. Toxicity was acceptable, mainly being grade 1–2, with for PEGdoxo/Cape grade 1 alopecia in 14/4 pts (grade 2 in 1 PEGdoxo pt), grade 3 fatigue in 5/5 pts, grade 3 HFS in 4/6 pts and grade 3 mucositis in 4/1 pts, respectively. Pts with ≥ 1 geriatric condition more frequently experienced grade 3–4 toxicity, after correcting for type of chemotherapy, age and PS (HR 2.24, 95% CI: 1.21–4.16). Pts aged 75+ had a twofold higher risk of dying, irrespective of treatment arm (HR 2.31, 95% CI: 1.31–4.07).

Conclusions First-line chemotherapy with either PEGdoxo or Cape was feasible in elderly MBC pts, with adequate dose intensity and acceptable toxicity, even in non-fit pts or pts aged 75+. Baseline GA correlated with toxicity.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-12-05.

PD04-02: Recovery of Ovarian Function in Breast Cancer Patients with Chemotherapy-Induced Amenorrhea Receiving Anastrozole in the Dutch DATA Study

Background: In early stage hormone receptor positive breast cancer, aromatase inhibitors (AIs) are established as adjuvant therapy for postmenopausal women. In daily practice AIs are also offered to patients with chemotherapy-induced amenorrhea (CIA). The impact of AIs on estrogen (E2) levels in these patients has not extensively been studied, although this could be very relevant for the efficacy and safety of the adjuvant hormonal treatment. The Dutch phase III DATA study is assessing the impact on disease-free survival of 3 vs. 6 years of anastrozole after 2–3 years of tamoxifen (N=1900 patients in total), and has included both postmenopausal patients and patients with CIA. The current analysis reports on the hormonal data in the CIA group.

Patients and methods: We identified patients from the DATA study &lt; 55 years of age at randomization who had received adjuvant chemotherapy and developed CIA, and excluded patients with ovariectomy or use of LHRH agonist. Patients were considered as having CIA if they were in amenorrhea since 3 months before start of chemotherapy up to 6 months after start of chemotherapy, and did not resume menses during tamoxifen therapy. Patients were eligible if postmenopausal E2 levels were confirmed within the last three months before randomization. Plasma FSH and E2 levels were serially determined at 6-month intervals.

Results: A total of 285 patients with CIA were identified in the DATA study. Median age was 50.8 years (range 35.9 - 54.9). Results on E2 and FSH levels are presented in the Table. During treatment with anastrazole, FSH levels tended to increase over time and E2 levels didn't decline. Of note, FSH increased in nearly all patients with significantly elevated (premenopausal) E2 levels, in contrast to the pattern seen in spontaneous recovery of ovarian function. During follow-up, 4 patients had vaginal bleeding, 2 of them having postmenopausal E2 levels. In 8 (2.8%) patients E2 levels became ≥ 200 pmol/l (considered premenopausal) after 12–30 months use of AI. Using a more strict cutoff value of E2 (≥ 100 pmol/l), 62 (21.8%) patients had elevated levels of E2 during AI treatment. With 70 pmol/l as cutoff value, 117 (41.0%) patients had at some point during treatment an increased E2 level. Updated and detailed analyses will be presented at the meeting.

Ewing's sarcoma and primitive neuroectodermal tumour in adults: single-centre experience in The Netherlands

BACKGROUND

Ewing's sarcoma and peripheral primitive neuroectodermal tumours (PNET) are rare tumours and closely related. They occur most often in children and adolescents. Few studies have been published on treatment outcome in adult patients.

METHODS

We performed a retrospective analysis of patients aged >16 years who were primarily treated at our university hospital for Ewing's sarcoma or PNET. In general, treatment consisted of long-term multiagent chemotherapy, interrupted by individualised local treatment consisting of surgery and/or radiotherapy. We reviewed clinical features and outcomes to present our experience with Ewing's sarcoma and PNET in adults.

RESULTS

From 1979 to 2002, 27 patients with Ewing's sarcoma (20) or PNET (7) were treated. There were 22 men and 5 women, with a median age of 25 years (range 17-49). Ten patients presented with metastases predominantly in lungs (4) or bones (6). Combination therapy consisted of chemotherapy (27), surgery (16) and radiotherapy (16). After a median follow-up of ten years, 14 patients have died (toxicity = 2, progressive disease = 12) and 13 patients are alive and free of disease. Five-year overall survival was 58%. All four patients with bone metastases died, while all five patients presenting with lung metastases are disease-free.

CONCLUSION

The five-year overall survival of 58% in this small series on adult patients is in line with paediatric study outcomes. Patients with lung metastases may even be cured by multimodality therapy. We therefore strongly advocate referral of patients with this rare disease to a specialised oncology centre.

Phase II study of tailored chemotherapy for advanced colorectal cancer with either 5-fluouracil and leucovorin or oxaliplatin and irinotecan based on the expression of thymidylate synthase and dihydropyrimidine dehydrogenase

BACKGROUND

Thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) are essential enzymes for 5-fluorouracil (5-FU) metabolism. In patients with advanced colorectal cancer (ACRC), retrospective studies have shown that low expression levels of TS and DPD correlated with response to 5-FU. We performed a prospective study in which the choice of first-line chemotherapy with either 5-FU or a non-5-FU containing regimen was based on TS and DPD expression.

PATIENTS AND METHODS

Fresh-frozen samples of metastases were obtained from 58 previously untreated patients with ACRC. mRNA expression of TS and DPD was quantified using an RT-PCR assay. Patients with low tumor expression of both TS and DPD received weekly bolus 5-FU/leucovorin (LV) 500 mg/m2 (group A); patients with high TS and/or DPD received 3-weekly oxaliplatin 85 mg/m2 and irinotecan 200 mg/m2 (group B). After progression, cross-over to the alternative regimen was attempted.

RESULTS

Of 53 eligible patients, 31 had tumors with both low TS and low DPD, and were treated in group A. A response was observed in 11 patients [35%; 95% confidence interval (CI) 19% to 54%]. Cross-over to second-line oxaliplatin/irinotecan resulted in a partial response in two out of 16 patients (13%; 95% CI 1% to 38%). In group B, four out of 22 patients responded (18%; 95% CI 5% to 40%), while no responses were observed in 12 patients after cross-over to 5-FU/LV (0%; 95% CI 0% to 28%).

CONCLUSIONS

Prospective selection of 5-FU/LV chemotherapy based on low TS and DPD expression in patients with ACRC did not confirm the high response rates reported in retrospective studies. The procedure of obtaining metastatic tissue and quantitation of enzymes appeared feasible but cumbersome. Before assessing the clinical utility of a predictive marker in a randomized trial, future studies should focus on prospective validation of the assay in a large and well defined population.

Prospective clinical trials using a pharmacogenetic/pharmacogenomic approach

The antitumor activity of most anticancer agents is limited by a number of different factors, such as their cellular targets and activating enzymes, while constitutive genetic polymorphisms may limit drug bioavailability and influence either antitumor efficacy or toxic side effects. An example of a drug for which clear predictive parameters have been identified is 5-fluorouracil (5FU): its antitumor activity is limited by either a high activity of the target enzyme thymidylate synthase (TS) and/or a high activity of its degrading enzyme, dihydropyrimidine dehydrogenase (DPD). Retrospective studies showed a clear correlation between a high expression of TS and a poor response, which was stronger when DPD was included in the evaluation (high DPD, poor response). Therefore we initiated a clinical prospective study in which we treated previously untreated patients with advanced colorectal cancer with tailored chemotherapy: at a low TS-mRNA and low DPD-mRNA patients were stratified to receive a standard weekly 5FU-leucovorin regimen. At a high TS and/or DPD, patients were stratified to receive a combination of oxaliplatin and irinotecan. Up to now this proof-of-principle study demonstrated that selection of patients is possible and can clearly improve the clinical outcome. The next step is to develop algorithms to select patients for combination chemotherapy with 5FU-leucovorin and new compounds, such as oxaliplatin or irinotecan, or novel targeted agents such as bevacizumab or cetuximab. For these combination schedules the optimal combination of predictive factors has to be explored.

FOLFOX3 in heavily pretreated patients with metastatic colorectal cancer

BACKGROUND

The combination of oxaliplatin, 5-fluorouracil (5FU) and leucovorin (LV) has shown to be active and safe as first- or second-line chemotherapy for metastatic colorectal cancer (MCC).

PATIENTS AND METHODS

The outcome of patients with MCC who had progressive disease after at least two lines of palliative chemotherapy and who were subsequently treated with oxaliplatin, 5FU and LV was reviewed. Patients received FOLFOX3 consisting of oxaliplatin (85 mg/m2) on day 1, LV (500 mg/m2) as a two-hour infusion on days 1 and 2, and 5FU (3000 mg/m2) as a 46-hour infusion starting on day 1 in a cycle of two weeks.

RESULTS

A total of 28 patients were treated with a median number of 9.5 cycles (range 1-24) at a mean dose intensity of 73%. Six patients discontinued treatment due to toxicity, of whom three had sensory neuropathy grade 2. Six patients experienced grade 3 toxicity: nausea (1), vomiting (1), diarrhoea (1), leucopenia (2) and thrombocytopenia (1); grade 4 toxicity was not observed. Twenty-five patients were evaluable for response, of whom four achieved a partial response (response rate 14%, based on intention to treat). The median progression-free survival was 5.8 months and the median overall survival was 8.5 months.

CONCLUSION

For heavily pretreated patients with MCC, the FOLFOX3 regimen is a fairly safe and effective treatment.

Weekly paclitaxel as first-line chemotherapy for elderly patients with metastatic breast cancer. A multicentre phase II trial

Paclitaxel is a cytotoxic agent with proven antitumour activity in metastatic breast cancer. Weekly administration of paclitaxel has demonstrated sustained efficacy together with a more favourable toxicity profile (e.g. less myelotoxicity) than the 3-weekly administration. This study evaluates the activity and toxicity of weekly paclitaxel (Taxol(R)) as first-line chemotherapy in elderly patients (>70 years of age) with hormone-refractory metastatic breast cancer. Patients with metastatic breast cancer received 80 mg/m(2) paclitaxel administered weekly on days 1, 8 and 15 of a 28-day cycle. Additional cycles were given until disease progression, or unacceptable toxicity. A dose increase to 90 mg/m(2) was allowed in the absence of toxicity. 26 Patients received a total of 101 cycles (median 4, range 1-11). 22 patients completed at least two cycles (six administrations). In 23 patients who were evaluable for response, there were 10 partial responses (38%), 9 patients with stable disease (35%), while 4 patients had disease progression (15%). The median duration of response was 194 days (>6 months). Overall treatment was relatively well tolerated, but 8 patients (32%) had to prematurely discontinue treatment because of fatigue. Neuropathy >grade 1 was noted only after five or more cycles in 4 patients. Weekly paclitaxel at this dose and schedule is an effective treatment regimen in the elderly patient with metastatic breast cancer, and is feasible, but yields relevant fatigue in a subset of patients.

Altered clearance of unbound paclitaxel in elderly patients with metastatic breast cancer

The pharmacokinetic behaviour of anticancer drugs may be altered with aging due to (for example) differences in body composition and decreased hepatic and renal function. To address this issue for paclitaxel, we studied the pharmacokinetics of the drug in eight elderly women (>or=70 years) with metastatic breast cancer (median age (range), 77 years (70-84 years)) and a control group of 15 patients aged <70 years (median age (range), 54 years (22-69 years)). Paclitaxel was administered as a 1-h intravenous (i.v.) infusion at a dose of 80 (elderly) or 100 mg/m(2) (<70 years), and serial blood samples were obtained at baseline, and up to 24 h after the end of infusion. Paclitaxel concentration-time profiles were fitted to a linear three-compartment model without any demonstration of saturable behaviour. The clearance of unbound paclitaxel was 124+/-35.0 (elderly) versus 247+/-55.4 l/h/m(2) (<70 years) (P=0.002), and was inversely related to the patient's age (R(2)=0.857; P<0.00001). Total plasma clearance of the formulation vehicle Cremophor EL (CrEL) was 150+/-60.7 (elderly) versus 115+/-39.2 ml/h/m(2) (<70 years) (P=0.04). These data indicate an approximately 50% change in total body clearance of unbound paclitaxel and a concomitant significant increase in systemic exposure with age, most likely as a result of altered CrEL disposition. The clinical relevance of these observations with respect to toxicity profiles and antitumour efficacy requires further evaluation.

Phase I pharmacokinetic and sequence finding study of the combination of docetaxel and methotrexate in patients with solid tumours

This phase I study was performed to assess the feasibility and possible enhanced antitumour activity of the sequential administration of methotrexate (MTX) and docetaxel (D) in patients with solid tumours. Pharmacokinetic analysis was performed to investigate the pharmacokinetic interaction of the two agents. A total of 22 patients were enrolled, a total of six dose levels were investigated. MTX (days 1+15) 30, 40 and 50 mg/m(2)+D (day 2 or day 1) 75 and 85 mg/m(2) with supportive care measures. Both haematological and non-haematological toxicities were significant, preventing dose escalation above MTX 40 mg/m(2)+D 75 mg/m(2). Four partial responses were documented, three in patients with breast cancer, one in a patient with urothelial cell cancer. Pharmacokinetic data did not give an explanation for the significant toxicity as they revealed no interaction of D and MTX kinetics. Methotrexate and 7-OH MTX kinetics seemed to be independent of the administration of D and the moment of D administration appeared not to influence MTX kinetics. The sequential administration of MTX and D results in significant toxicity without any evidence of a clinical benefit.

Combination chemotherapy of the taxanes and antimetabolites: its use and limitations

In an effort to improve response rates of chemotherapy, taxanes have been combined with other cytotoxic agents such as antimetabolites. However, the use of some of these combinations in patients has been restricted by severe toxicity. The significance of the sequence of drug administration in combining methotrexate (MTX) and taxanes was recognised in in vitro studies, showing synergistic effects for the sequence of MTX followed by paclitaxel, and antagonism for exposure in the reverse order. A possible explanation might be an MTX-induced synchronisation of cells in the S phase of the cell cycle, after which cells are more susceptible for the cytotoxic action of taxanes. Clinical studies using this sequence were hampered by severe neutropenia and mucositis at relatively low doses of both drugs. As no pharmacokinetic interactions were observed, the excess of toxicity may have been due to sequence-dependent synergistic actions on bone marrow and mucosa. In contrast, and confusingly, in vitro studies on 5-fluorouracil (5-FU) and taxanes indicate that 5-FU preceeding or simultaneously given to paclitaxel impairs cytotoxicity as compared with paclitaxel monotherapy, while the reverse sequence results in additive or synergistic cytotoxicity. While almost all clinical studies have used the sequence of a taxane followed by 5-FU, various schedules appeared feasible and effective. The combination of a 5-FU analogue, capecitabine and taxanes was supported by in vitro data. A large phase III trial confirmed the feasibility and superior efficacy of this combination in breast cancer patients relapsing after an anthracycline. Conflicting results exist on the benefit of combining gemcitabine and taxanes in tumour cell lines. Although the accumulation of gemcitabine triphosphate (dFdCTP) in mononuclear cells was significantly higher with an increasing dose of paclitaxel, no pharmacokinetic interactions for both agents were noticed. A pharmacokinetic analysis of the gemcitabine-docetaxel combination therapy has not been published in detail. Despite numerous trials, so far no optimum schedule has been established. Regarding data on actually delivered dose intensities, a 2- or 3-weekly cycle seems favourable and feasible. However, possible severe pulmonary toxicity warrants cautious monitoring of patients treated with this combination. Different outcomes of preclinical and clinical studies reveal that combining two chemotherapeutic agents is not simply a matter of putting antitumour activities together. Drug interaction may result in synergism, not only of efficacy but also of toxic side-effects. Adding two drugs may also implicate antagonism in drug efficacy due to unwanted interference in cytotoxicity or pharmacokinetics. For agents acting at a specific phase of the cell cycle, the sequence of administration may determine the efficacy and toxicity of a combination therapy. Because of an observed discrepancy between in vitro data and clinical studies, we would like to emphasise the need for adequate dose-finding clinical trials together with pharmacokinetic data analysis before examining any new combination chemotherapy in more detail in phase II studies.

Phase II study of weekly gemcitabine in patients with metastatic breast cancer relapsing or failing both an anthracycline and a taxane

A phase II study was performed to investigate the efficacy and tolerability of gemcitabine as third-line chemotherapy for patients with metastatic breast cancer, previously treated with both an anthracycline- and taxane-containing regimen. Twenty-three patients were treated with gemcitabine 1200 mg/m2 in a 30-min infusion on day 1, 8 and 15 of a 28 day cycle. Seventy-four percent of the patients had visceral metastases. No complete or partial responses were observed. Six patients (26%) had stable disease with a median duration of 4.0 months. The median time to progression was 1.9 months and the median survival time was 7.8 months. Neutropenia grade 3 and 4 was observed in four patients (18%). Non-hematological toxicity grade 3 included nausea and vomiting in 14%, skin toxicity in 9% and elevation of transaminases in 23% of the patients. Gemcitabine is ineffective as third-line single agent therapy in patients failing anthracycline and taxane treatment for metastatic breast cancer.

Capecitabine in breast cancer: current status

Anthracyclines, together with taxanes, are at present the most active agents in metastatic breast cancer, while single-agent, bolus 5-fluorouracil (5-FU) is not very active in this setting. In view of encouraging results and tolerable toxicity of continuous infusion of 5-FU in gastrointestinal cancer, innovative oral 5-FU agents such as capecitabine have been developed. Capecitabine is a prodrug that is converted into the active compound 5-FU preferentially at the tumor site. An intermittent dosing schedule of capecitabine twice daily at a dose of 2510 mg/m2/day on days 1-14 in a 3-week cycle appeared to be feasible and resulted in a high dose intensity. A large phase II study investigating capecitabine in 135 advanced breast cancer patients, pretreated with anthracyclines and taxanes, observed three complete and 24 partial responses (response rate, 20%), with a mean duration of 8.0 months. Preliminary results of a study comparing capecitabine with paclitaxel in 42 breast cancer patients failing anthracyclines indicate that the efficacy of capecitabine is comparable to that of paclitaxel, with response rates of 36% and 21%, respectively. Another study reported a response rate of 25% for capecitabine as first-line therapy for advanced breast cancer in women aged > or = 55 years, which tended to be better than combination chemotherapy with cyclophosphamide/methotrexate/5-FU. In all studies, capecitabine side effects were mainly mild, and treatment-related grade 3/4 toxicity consisted of diarrhea (8%-11%), nausea (4%-11%), hand-foot syndrome (10%-18%), neutropenia (3%-20%), and bilirubin elevation (6%). Capecitabine is clearly an active agent for the treatment of breast cancer. It is currently registered in various countries for use in third-line treatment of metastatic disease. Its further role will have to be defined from data of randomized phase III studies.

Phase II study of miltefosine 6% solution as topical treatment of skin metastases in breast cancer patients

Topical treatment of skin metastases with a cytotoxic agent is attractive for its easy self-administration and absence of major systemic interference. Miltefosine exerts its cytotoxicity by acting on cell membrane phospholipids and can be administered topically. Twenty breast cancer patients with progression of skin metastases were treated with a 6% solution of miltefosine, which was topically administered once daily during the first week and twice daily thereafter. Sixteen out of 20 patients also had metastatic disease at other sites. Concomitant systemic treatment when ongoing for at least 2 months prior to study entry was permitted, and consisted of chemotherapy and hormonal therapy in seven and nine patients, respectively. Prior palliative cytotoxic and hormonal therapy had been administered to 11 and 19 patients, respectively. No grade 3 and 4 toxicity occurred. Miltefosine therapy was discontinued in two patients due to nausea and in one patient due to skin toxicity. Grade 1 and 2 adverse skin reactions, and nausea and vomiting were seen in 11 and two patients, respectively. In 18 patients evaluable for response, four partial responses were noted (response rate 22%), while seven patients had stable disease. Three partial responses were observed in patients in whom the skin lesions were smaller than 1.5 cm2. Median duration of response was 2.5 months and median time to progression for all patients was 1.9 months. In this study topically applied miltefosine for metastatic skin lesions of breast cancer showed modest activity in a relatively heavily pretreated patient population, without serious systemic toxicity.

[Clinical application of albumin: a closer look at indications]

Albumin infusions are given far from always on the correct indications, and often there are alternatives that are cheaper and equally suitable. In septic or hypovolaemic shock, crystalline fluids are cheaper and equally efficacious for volume therapy. It is only in sporadic patients with a nephrotic syndrome that colloidal solutions such as albumin are indicated in hypovolaemia. Albumin infusion has no place in the combating of oedema. In decompensated hepatic cirrhosis with ascites, it appears useful to combine paracentesis with albumin infusion, to prevent renal insufficiency and hyponatraemia, but other colloidal fluids are probably equally suitable. Combating hypoalbuminemia as such is not useful in seriously ill patients; it is the underlying disease that should be treated.

Linear approximation for measurement errors in phase shifting interferometry

This paper shows how measurement errors in phase shifting interferometry (PSI) can be described to a high degree of accuracy in a linear approximation. System error sources considered here are light source instability, imperfect reference phase shifting, mechanical vibrations, nonlinearity of the detector, and quantization of the detector signal. The measurement inaccuracies resulting from these errors are calculated in linear approximation for several formulas commonly used for PSI. The results are presented in tables for easy calculation of the measurement error magnitudes for known system errors. In addition, this paper discusses the measurement error reduction which can be achieved by choosing an appropriate phase calculation formula.