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Davis AA, Luo J, Zheng T, Dai C, Dong X, Tan L, Suresh R, Ademuyiwa FO, Rigden C, Rearden TP, Clifton K, Weilbaecher K, Frith A, Tandra PK, Summa T, Haas B, Thomas S, Hernandez-Aya LF, Peterson LL, Wang X, Luo SJ, Zhou K, Du P, Jia S, King BL, Krishnamurthy J, Ma CX. Genomic Complexity Predicts Resistance to Endocrine Therapy and CDK4/6 Inhibition in Hormone Receptor-Positive (HR+)/HER2-Negative Metastatic Breast Cancer. Clin Cancer Res 2023; 29:1719-1729. [PMID: 36693175 PMCID: PMC10150240 DOI: 10.1158/1078-0432.ccr-22-2177] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/29/2022] [Accepted: 01/20/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE Clinical biomarkers to identify patients unlikely to benefit from CDK4/6 inhibition (CDK4/6i) in combination with endocrine therapy (ET) are lacking. We implemented a comprehensive circulating tumor DNA (ctDNA) analysis to identify genomic features for predicting and monitoring treatment resistance. EXPERIMENTAL DESIGN ctDNA was isolated from 216 plasma samples collected from 51 patients with hormone receptor-positive (HR+)/HER2-negative (HER2-) metastatic breast cancer (MBC) on a phase II trial of palbociclib combined with letrozole or fulvestrant (NCT03007979). Boosted whole-exome sequencing (WES) was performed at baseline and clinical progression to evaluate genomic alterations, mutational signatures, and blood tumor mutational burden (bTMB). Low-pass whole-genome sequencing was performed at baseline and serial timepoints to assess blood copy-number burden (bCNB). RESULTS High bTMB and bCNB were associated with lack of clinical benefit and significantly shorter progression-free survival (PFS) compared with patients with low bTMB or low bCNB (all P < 0.05). Dominant APOBEC signatures were detected at baseline exclusively in cases with high bTMB (5/13, 38.5%) versus low bTMB (0/37, 0%; P = 0.0006). Alterations in ESR1 were enriched in samples with high bTMB (P = 0.0005). There was a high correlation between bTMB determined by WES and bTMB determined using a 600-gene panel (R = 0.98). During serial monitoring, an increase in bCNB score preceded radiographic progression in 12 of 18 (66.7%) patients. CONCLUSIONS Genomic complexity detected by noninvasive profiling of bTMB and bCNB predicted poor outcomes in patients treated with ET and CDK4/6i and identified early disease progression before imaging. Novel treatment strategies including immunotherapy-based combinations should be investigated in this population.
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Affiliation(s)
- Andrew A. Davis
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Jingqin Luo
- Division of Public Health Science, Department of Surgery, Biostatistics Shared Resource, Washington University in St. Louis, Missouri
| | | | - Chao Dai
- Predicine, Inc., Hayward, California
| | | | - Lu Tan
- Predicine, Inc., Hayward, California
| | - Rama Suresh
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Foluso O. Ademuyiwa
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Caron Rigden
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Timothy P. Rearden
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Katherine Clifton
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Katherine Weilbaecher
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Ashley Frith
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Pavan K. Tandra
- Division of Oncology/Hematology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Tracy Summa
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Brittney Haas
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Shana Thomas
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Leonel F. Hernandez-Aya
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | - Lindsay L. Peterson
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
| | | | | | | | - Pan Du
- Predicine, Inc., Hayward, California
| | | | | | - Jairam Krishnamurthy
- Division of Oncology/Hematology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Cynthia X. Ma
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri
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Davis AA, Luo J, Zheng T, Dong X, Tan L, Wang A, Suresh R, Ademuyiwa F, Rigden C, Rearden T, Clifton K, Weilbaecher K, Frith A, Tandra PK, Summa T, Haas B, Thomas S, Hernandez-Aya L, Peterson L, Dai C, King BL, Du P, Jia S, Krishnamurthy J, Ma CX. 70. Assessment of circulating tumor DNA tumor mutational burden to define resistance in HR+ HER2- metastatic breast cancer. Cancer Genet 2022. [DOI: 10.1016/j.cancergen.2022.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Davis A, Luo J, Zheng T, Dai C, Suresh R, Ademuyiwa F, Rigden C, Clifton K, Weilbaecher K, Frith A, Tandra P, Summa T, Thomas S, Peterson L, Wang X, Du P, Jia S, King B, Krishnamurthy J, Ma C. 108P Copy loss enrichment at metastatic disease progression in hormone receptor-positive (HR+)/HER2-negative metastatic breast cancer patients treated with endocrine therapy and CDK4/6 inhibition. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Clifton KK, Luo J, Tao Y, Saam J, Rich T, Rearden T, Roshal A, Frith A, Rigden C, Ademuyiwa F, Weilbaecher K, Aya LH, Peterson L, Bagegni N, Suresh R, Bose R, Wildes T, Opyrchal M, Ma C. Abstract PS2-09: Next generation sequencing (NGS) in older adults with breast cancer using tissue-based and circulating tumor DNA (ctDNA) assays. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps2-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: With advances in next generation sequencing (NGS) and now approved targeted therapy in breast cancer, genomic testing to identify potentially actionable mutations has become a common practice in patients (pts) with advanced breast cancer using both ctDNA and traditional tissue-based assays. Less is known regarding physician practice patterns in obtaining NGS testing and the practical implications of testing in older adults with breast cancer.Methods: Pts with advanced breast cancer underwent molecular profiling using a plasma-based ctDNA NGS assay (Guardant360® or Tempus®) between 5/2015 and 5/2020 at Siteman Cancer Center. Pts with advanced breast cancer who underwent genomic profiling using a tissue-based NGS assay (Tempus®) between 12/2017 and 5/2020 at this institution were also included. Clinicopathological histories were obtained from the medical record. Correlations were examined using a Fisher’s exact test.Results: During 5/15-5/20, 244 pts underwent ctDNA testing and 147 pts had a tissue-based NGS assay performed. There was no significant difference between the number of pts ≥ 65 years-old who underwent ctDNA testing (n=78, 32.0%) and tissue testing (n=37, 25.2%). There was no statistically significant difference between date of metastatic diagnosis and date of NGS testing between the older and younger cohorts. In pts who underwent tissue-based NGS testing, there was no significant difference between site of tissue tested (distant recurrence vs local) in the older and younger cohorts. The most common clinical managements following both ctDNA and tissue-based testing are presented in Table 1. Out of the 391 pts who underwent testing, 27 pts had both ctDNA and tissue-based NGS performed. Pts ≥ 65 were less likely to have both assays performed (n=3, 11.1%; p<0.05). In pts undergoing both assays, there were high concordance rates of ESR1 (81.5%) and PIK3CA (81.5%) mutations. Mean time between tissue and plasma collection for NGS testing in pts undergoing both assays was 356.4 days.
Conclusion: Older adults, who are typically less likely to be included in clinical trials, may still benefit from NGS to reveal potentially targetable mutations. It is reassuring in our cohort that older adults had ctDNA and tissue-based NGS performed at similar rates as part of standard of care treatment. The clinical management following NGS testing was also not significantly different in the older adult cohort. Older adults were less likely to have both tissue and ctDNA testing performed however, given the high concordance rates between tests, this may be less clinically relevant.
Table 1clinical management following NGS testing≥65 years-old<65 years-oldp valueno actionable mutations41 (35.7%)123 (44.6%)p=0.1testing results saved for potential future use27 (23.5%)45 (16.3%)p=0.1change in management15 (13.0%)41 (14.9%)p=0.6
Citation Format: Katherine K Clifton, Jingqin Luo, Yu Tao, Jennifer Saam, Thereasa Rich, Timothy Rearden, Anna Roshal, Ashley Frith, Caron Rigden, Foluso Ademuyiwa, Katherine Weilbaecher, Leonel Hernandez Aya, Lindsay Peterson, Nusayba Bagegni, Rama Suresh, Ron Bose, Tanya Wildes, Mateusz Opyrchal, Cynthia Ma. Next generation sequencing (NGS) in older adults with breast cancer using tissue-based and circulating tumor DNA (ctDNA) assays [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-09.
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Affiliation(s)
| | - Jingqin Luo
- 1Washington University in Saint Louis, Saint Louis, MO
| | - Yu Tao
- 1Washington University in Saint Louis, Saint Louis, MO
| | | | - Thereasa Rich
- 1Washington University in Saint Louis, Saint Louis, MO
| | | | - Anna Roshal
- 1Washington University in Saint Louis, Saint Louis, MO
| | - Ashley Frith
- 1Washington University in Saint Louis, Saint Louis, MO
| | - Caron Rigden
- 1Washington University in Saint Louis, Saint Louis, MO
| | | | | | | | | | | | - Rama Suresh
- 1Washington University in Saint Louis, Saint Louis, MO
| | - Ron Bose
- 1Washington University in Saint Louis, Saint Louis, MO
| | - Tanya Wildes
- 1Washington University in Saint Louis, Saint Louis, MO
| | | | - Cynthia Ma
- 1Washington University in Saint Louis, Saint Louis, MO
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Adkins D, Ley J, Atiq O, Powell S, Spanos WC, Gitau M, Rigden C, Palka K, Liu J, Oppelt P. Nanoparticle albumin-bound paclitaxel with cetuximab and carboplatin as first-line therapy for recurrent or metastatic head and neck cancer: A single-arm, multicenter, phase 2 trial. Oral Oncol 2021; 115:105173. [PMID: 33548860 DOI: 10.1016/j.oraloncology.2020.105173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Macropinocytosis promotes internalization of albumin into cells to serve as a nutrient supply and is constitutively driven by signaling pathways frequently hyperactivated in head and neck squamous-cell carcinoma (HNSCC). In this way, drugs bound to albumin may selectively target HNSCC. nab-paclitaxel is a nanoparticle albumin-bound formulation of paclitaxel that improves drug delivery into tumor compared to paclitaxel. The primary aim of this single-arm, multicenter, phase 2 trial was to determine if nab-paclitaxel, cetuximab, and carboplatin (CACTUX regimen) would result in longer progression-free survival (PFS) than the historical regimen (EXTREME: 5-fluorouracil, cetuximab, and a platinum). MATERIALS AND METHODS Patients with untreated recurrent or metastatic HNSCC received six, three-week cycles of nab-paclitaxel, cetuximab, and carboplatin, followed by maintenance nab-paclitaxel and cetuximab until progression. We hypothesized the median PFS with CACTUX would be 35% longer than with EXTREME (corresponding to 7.6 vs 5.6 months; power 0.80, α = 0.05, one-sided test, n = 70). Secondary outcomes included objective response rate (ORR) and overall survival (OS). RESULTS Seventy-four patients enrolled into the trial; seventy were evaluable. The median PFS was 6.1 months (95% CI, 4.1-7.4). The ORR was 60%. Median follow-up was 18 months (IQR: 4.7-23). The median OS was 17.8 months (95% CI, 8.5-21.7) for all patients, and 19.8 months (95% CI, 10.9-22.0) for human papillomavirus (HPV)-related oropharynx SCC and 14.0 months (95% CI, 4.6-23.3) for HPV-unrelated HNSCC. CONCLUSION Among patients with recurrent or metastatic HNSCC, CACTUX did not result in a longer PFS than historical EXTREME. However, CACTUX did result in a more favorable ORR and OS.
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Affiliation(s)
- Douglas Adkins
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States.
| | - Jessica Ley
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Omar Atiq
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas Medical System, Little Rock, AR, United States
| | - Steven Powell
- Sanford Cancer Center, Sanford Health, Sioux Falls, SD, United States
| | - William C Spanos
- Sanford Cancer Center, Sanford Health, Sioux Falls, SD, United States
| | - Mark Gitau
- Sanford Cancer Center, Sanford Health, Fargo, ND, United States
| | - Caron Rigden
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Kevin Palka
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Jingxia Liu
- Biostatistics Shared Resource, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
| | - Peter Oppelt
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States; Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, United States
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Park H, Jin RU, Wang-Gillam A, Suresh R, Rigden C, Amin M, Tan BR, Pedersen KS, Lim KH, Trikalinos NA, Acharya A, Copsey ML, Navo KA, Morton AE, Gao F, Lockhart AC. FOLFIRINOX for the Treatment of Advanced Gastroesophageal Cancers: A Phase 2 Nonrandomized Clinical Trial. JAMA Oncol 2021; 6:1231-1240. [PMID: 32469386 DOI: 10.1001/jamaoncol.2020.2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Standard first-line regimens for patients with metastatic gastroesophageal adenocarcinomas have an approximate 40% objective response rate (ORR). The combination of leucovorin, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) has been efficacious as first-line therapy for other gastrointestinal cancers, such as pancreatic and colon cancers. Objective To evaluate the clinical activity and safety of FOLFIRINOX as first-line treatment for patients with advanced gastroesophageal adenocarcinoma. Design, Setting, and Participants This is an open-label, single-arm phase 2 study of first-line FOLFIRINOX in patients with advanced gastroesophageal adenocarcinoma. Estimated sample size included 41 patients with ERBB2-negative disease with 90% power to detect an ORR of 60% or greater with α of .10. No enrollment goal was planned for ERBB2-positive patients, but they were allowed to receive trastuzumab in combination with FOLFIRINOX. Interventions Starting doses were fluorouracil, 400 mg/m2 bolus, followed by 2400 mg/m2 over 46 hours; leucovorin, 400 mg/m2; irinotecan, 180 mg/m2; and oxaliplatin, 85 mg/m2. Trastuzumab was administered as a 6 mg/kg loading dose, followed by 4 mg/kg every 14 days in patients with ERBB2-positive disease. Main Outcomes and Measures The primary end point was ORR by the Response Evaluation Criteria in Solid Tumors, version 1.1. Secondary end points included safety profile, progression-free survival (PFS), overall survival (OS), and duration of response. Results From November 2013 to May 2018, 67 patients were enrolled (median [range] age, 59.0 [34-78] years; including 56 [84%] men), and 26 of 67 (39%) had ERBB2-positive disease. Median follow-up was 17.4 months. The ORR was 61%(95% CI, 44.5%-75.8%) (25 of 41) in the ERBB2-negative group and 85% (95% CI, 65.1%-95.6%) (22 of 26) in the ERBB2-positive group, including 1 patient with complete response. For ERBB2-negative patients, median PFS was 8.4 months and median OS was 15.5 months; for ERBB2-positive patients, median PFS was 13.8 months and median OS was 19.6 months. Fifty-six patients (84%) had dose modifications or treatment delays. The most common toxic effects were neutropenia (91%, n = 61), diarrhea (63%, n = 42), peripheral sensory neuropathy (61%, n = 41), and nausea (48%, n = 32), with no unexpected toxic effects. Conclusions and Relevance The FOLFIRINOX regimen with or without trastuzumab was associated with improved ORR and PFS in patients with advanced gastroesophageal adenocarcinoma in the first-line setting. This regimen may be a reasonable therapeutic option for patients with preserved performance status. Trial Registration ClinicalTrials.gov Identifier: NCT01928290.
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Affiliation(s)
- Haeseong Park
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ramon U Jin
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Andrea Wang-Gillam
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Rama Suresh
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Caron Rigden
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Manik Amin
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Benjamin R Tan
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Katrina S Pedersen
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kian-Huat Lim
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nikolaos A Trikalinos
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Abhilasha Acharya
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Megan L Copsey
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Katherine A Navo
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ashley E Morton
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Feng Gao
- Division of Public Health Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - A Craig Lockhart
- Sylvester Comprehensive Cancer Center, Division of Medical Oncology, Department of Internal Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
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Clifton K, Luo J, Tao Y, Saam J, Rich T, Roshal A, Frith A, Rigden C, Ademuyiwa F, Weilbaecher K, Hernandez-Aya L, Peterson LL, Bagegni N, Suresh R, Bose R, Opyrchal M, Wildes TM, Ma C. Mutation profile differences in younger and older patients with advanced breast cancer using circulating tumor DNA (ctDNA). Breast Cancer Res Treat 2020; 185:639-646. [PMID: 33219484 DOI: 10.1007/s10549-020-06019-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Little is known regarding the mutation profiles of ctDNA in the older adult breast cancer population. The objective of this study is to assess differences in mutation profiles in the older adult breast cancer population using a ctDNA assay as well as assess utilization of testing results. METHODS Patients with advanced breast cancer underwent molecular profiling using a plasma-based ctDNA NGS assay (Guardant360) between 5/2015 and 10/2019 at Siteman Cancer Center. The profiling results of a multi-institutional database of patients with advanced breast cancer who had undergone molecular profiling were obtained. Associations between mutations and age group (≥ 65 vs. < 65) were examined using a Fisher's exact test. RESULTS In the single-institutional cohort, 148 patients (69.2%) were < 65 years old and 66 patients (30.8%) ≥ 65 years old. ATM, BRAF, and PIK3CA mutations were found more frequently in older patients with ER + HER2- breast cancers (p < 0.01). In the multi-institutional cohort, 5367 (61.1%) were < 65 years old and 3417 (38.9%) ≥ 65 years old. ATM, PIK3CA, and TP53 mutations were more common in the older cohort (p < 0.0001) and MYC and GATA3 mutations were less common in the older cohort (p < 0.0001). CtDNA testing influenced next-line treatment management in 40 (19.8%) patients in the single-institutional cohort. CONCLUSION When controlling for subtype, results from a single institution were similar to the multi-institutional cohort showing that ATM and PIK3CA were more common in older adults. These data suggest there may be additional molecular differences in older adults with advanced breast cancers.
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Affiliation(s)
- Katherine Clifton
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA.
| | - Jingqin Luo
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Yu Tao
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | | | | | - Anna Roshal
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Ashley Frith
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Caron Rigden
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Foluso Ademuyiwa
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Katherine Weilbaecher
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Leonel Hernandez-Aya
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Lindsay L Peterson
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Nusayba Bagegni
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Rama Suresh
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Ron Bose
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Mateusz Opyrchal
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Tanya M Wildes
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
| | - Cynthia Ma
- Washington University, 660 South Euclid Avenue, Campus Box 8056, Saint Louis, MO, 63110, USA
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Krishnamurthy J, Luo J, Ademuyiwa F, Suresh R, Rigden C, Reardon T, Weilbaecher K, Frith A, Roshal A, Tandra P, Cherian M, Summa T, Thomas S, Hernandez-Aya L, Peterson L, Ma C. Abstract P1-19-13: A phase II trial assessing the safety of an alternative dosing schedule of palbociclib (palbo) in hormone receptor positive (HR+), HER2 negative (HER2-) metastatic breast cancer (MBC): Alt Dose Palbo. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p1-19-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Palbo is approved in combination with an aromatase inhibitor or fulvestrant (FUL) for the treatment of HR+ HER2- MBC. The incidence of grade (G) 3/4 neutropenia (ANC) approaching 66% has been observed in phase 3 trials of palbo. We hypothesize that an alternative schedule of palbo, 5 days on/2 days off every 7 days, reduces the severity of neutropenia, therefore allowing continued weekly dosing and less dose reduction and discontinuation. Methods: A single arm phase II study (Alt Dose Palbo) was conducted in patients (pts) with HR+ HER2- MBC who had ≤1 prior systemic therapy in the metastatic setting (NCT03007979). Pts were treated with palbo 125 mg daily on a 5 days on/2 days off every 7-day schedule, along with letrozole (LET) or FUL per treating physician. Goserelin was administered if premenopausal. The primary objective was to determine the rate of G3/4 ANC within the first 29 days of treatment. Secondary objectives included determining the rate of G3/4 ANC during all cycles, rate of palbo dose reduction/interruption/discontinuation, adverse event (AE) profile per CTCAE v5, progression free survival (PFS), objective response rate (ORR) and clinical benefit rate (CBR) by RECIST 1.1. The sample size of 47 was calculated to provide 90% power based on one-sample binomial exact test at a 5% alpha level to test the one-sided null hypothesis of G3/4 ANC rate >62% versus the alternative of <40%. If G3/4 ANC was not observed in 24 or more pts, this alternative dosing will be deemed to have a better toxicity profile than standard schedule. Results: Between July 2017 to June 2019, 48 pts were enrolled at 2 institutions. 3 pts withdrew/went off during cycle 1 unrelated to the study, leaving 45 pts (33 LET, 12 FUL) with a median age of 63 (range: 34-87) years and visceral metastases in 23 (51%). Prior (neo) adjuvant chemotherapy and endocrine therapy (ET) were received in 20 (44%) and 25 (56%) pts, respectively. Six (13%) had 1 prior ET in the metastatic setting. 19 (42%) had primary or secondary endocrine resistance defined according to the ESMO advanced breast cancer guideline prior to enrollment to the study. As of July 1, 2019, with a median follow up of 9.5 months, 28 (62%) pts are still receiving study drug. 42 pts were evaluable for toxicities. There were no G4 AEs. Nine (21%) and 15 (36%) pts experienced G3 ANC in cycle 1 (up to day 29), and all cycles, respectively. 33 pts in cycle 1 and 27 pts in all cycles, did not experience G3/4 ANC during all cycles, exceeding the predefined boundary for better tolerability of this schedule. Palbo was dose reduced in 10 (23.8%) pts. Two (4.8%) discontinued palbo due to AE (one with G3 ANC not recovering to G1 in 2 wks and the other died (G5 event) with acute subdural hematoma with concurrent G3 thrombocytopenia). The common treatment related AEs are shown in the Table 1. The ORR was 48% (2 CR, 10 PR, 95% Wilson CI: 30-66.5%) among 25 evaluable pts. The CBR (defined by CR or PR or stable disease for at least 24 wks) was 76.74% (33 of 43 evaluable pts, 95% Wilson CI: 62.3-86.9%). PFS has not been evaluated. Conclusion: The Alt Dose Palbo trial with palbo scheduled at 5 days on/2 days off every 7 days, with no weeks off therapy, met its primary endpoint with reduced G3/4 ANC. Survival data is not yet mature and will be updated at the presentation. However, preliminary efficacy data appears comparable to prior report. Encouraging data from this study should be confirmed in a randomized study.
Table 1C1 D1-29 AEG1G2G3TotalWBC decreased26%50%17%93%ANC decreased10%43%21%74%Anemia38%12%0%50%Fatigue29%0%0%29%Platelets decreased14%0%2%17%Nausea12%2%0%14%All cycle AEG1G2G3TotalWBC decreased19%50%26%95%ANC decreased5%40%36%81%Anemia50%21%2%74%Fatigue36%5%0%40%Nausea26%2%0%29%Platelets decreased24%0%2%26%Alopecia21%0%0%21%Mucositis19%0%0%19%Hot flashes17%2%0%19%Constipation14%0%0%14%Arthralgia12%2%0%14%AST elevated10%0%2%12%Anorexia12%0%0%12%ALT elevated7%0%5%12%
Citation Format: Jairam Krishnamurthy, Jingqin Luo, Foluso Ademuyiwa, Rama Suresh, Caron Rigden, Timothy Reardon, Katherine Weilbaecher, Ashley Frith, Anna Roshal, Pavan Tandra, Mathew Cherian, Tracy Summa, Shana Thomas, Leonel Hernandez-Aya, Lindsay Peterson, Cynthia Ma. A phase II trial assessing the safety of an alternative dosing schedule of palbociclib (palbo) in hormone receptor positive (HR+), HER2 negative (HER2-) metastatic breast cancer (MBC): Alt Dose Palbo [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-19-13.
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Affiliation(s)
| | - Jingqin Luo
- 2Washington University School of Medicine, St. Louis, MO
| | | | - Rama Suresh
- 2Washington University School of Medicine, St. Louis, MO
| | - Caron Rigden
- 2Washington University School of Medicine, St. Louis, MO
| | | | | | - Ashley Frith
- 2Washington University School of Medicine, St. Louis, MO
| | - Anna Roshal
- 2Washington University School of Medicine, St. Louis, MO
| | - Pavan Tandra
- 1University of Nebraska Medical Center, Omaha, NE
| | - Mathew Cherian
- 2Washington University School of Medicine, St. Louis, MO
| | - Tracy Summa
- 2Washington University School of Medicine, St. Louis, MO
| | - Shana Thomas
- 2Washington University School of Medicine, St. Louis, MO
| | | | | | - Cynthia Ma
- 2Washington University School of Medicine, St. Louis, MO
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9
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Niravath P, Hilsenbeck SG, Wang T, Jiralerspong S, Nangia J, Pavlick A, Ademuyiwa F, Frith A, Ma C, Park H, Rigden C, Suresh R, Ellis M, Kent Osborne C, Rimawi MF. Randomized controlled trial of high-dose versus standard-dose vitamin D3 for prevention of aromatase inhibitor-induced arthralgia. Breast Cancer Res Treat 2019; 177:427-435. [PMID: 31218477 DOI: 10.1007/s10549-019-05319-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/08/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Half of hormone receptor-positive (HR+) breast cancer patients will develop joint pain, termed aromatase inhibitor-induced arthralgia (AIA), while taking aromatase inhibitor therapy. Though there is no universally accepted effective treatment for AIA, there has been some evidence to support high-dose vitamin D as a treatment. METHODS We randomized post-menopausal women who were beginning adjuvant AI therapy to receive standard-dose vitamin D3 (800 IU daily for 52 weeks), or high-dose vitamin D3 (50,000 IU weekly for 12 weeks, followed by 2000 IU daily for 40 weeks). The primary end point was development of AIA. The trial was designed to enroll 184 patients. This futility analysis was performed after 93 patients were enrolled. RESULTS The high-dose vitamin D regimen was effective in raising serum vitamin D levels, but there was no significant difference in development of AIA between the two arms. In the high-dose arm, 25 patients (54%) developed AIA, compared to 27 patients (57%) in the standard-dose arm. The planned futility analysis was positive; thus, the study was terminated. Neither baseline vitamin D nor 12-week vitamin D level was predictive of AIA development. CONCLUSION Although vitamin D levels were increased in the high-dose arm, there was no significant signal for benefit of high-dose vitamin D supplementation for AIA prevention in this unblinded trial. This study, along with several others, implies that vitamin D likely does not play a significant role in AIA for the majority of patients.
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Affiliation(s)
- Polly Niravath
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA.
| | - Susan G Hilsenbeck
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | - Tao Wang
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | - Sao Jiralerspong
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | - Julie Nangia
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | - Anne Pavlick
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | | | | | - Cynthia Ma
- Washington University, St. Louis, MO, USA
| | | | | | | | - Matthew Ellis
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | - C Kent Osborne
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
| | - Mothaffar F Rimawi
- Baylor College of Medicine, 6445 Main Street, OPC 24-346, Houston, TX, 77030, USA
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10
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Niravath P, Wang T, Hilsenbeck SG, Lipscomb K, Pavlick A, Jiralerspong S, Nangia J, Ellis M, Ademuyiwa F, Cherian M, Frith A, Ma C, Park H, Rigden C, Suresh R, Osborne CK, Rimawi MF. Abstract PD6-02: A randomized, controlled trial of high dose vs. standard dose vitamin D for aromatase inhibitor-induced arthralgia in breast cancer survivors. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd6-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Approximately half of women on aromatase inihbitor (AI) therapy develop AI-induced arthralgia (AIA), and many discontinue the medication because of this common side effect. While Vitamin D has been studied as a treatment for AIA, trial results have been conflicting thus far.
Patients and Methods: All subjects were post menopausal women who were beginning adjuvant AI therapy for stage I-III hormone receptor positive breast cancer. Patients were randomized 1:1 to receive standard dose vitamin D3 (800 IU daily for 52 weeks) or high dose vitamin D3 (50,000 IU weekly for 12 weeks, followed by 2000 IU daily for 40 weeks). All patients also took oral calcium 600 mg daily. The primary endpoint was development of AIA, as defined by pre-specified changes in the Health Assessment Questionnaire II (HAQ-II). Secondary endpoints include compliance with AI therapy, and correlation between grip strength and development of AIA. Exploratory endpoint was measurement of inflammatory cytokine reduction in each arm. The trial was designed to enroll 184 patients, but this futility analysis was performed after 93 patients were enrolled. The futility boundary for stopping the trial early was calculated as p = 0.47.
Results: All 93 patients (46 in the high dose arm, and 47 in the standard dose arm) enrolled in the study at the time of the interim analysis were evaluable. The HAQ-II was completed at 12 weeks in 76% on the high dose arm, and 68% in the standard dose arm. Subjects who did not complete the questionnaire were deemed as study failures (i.e. development of AIA was assumed). In the high dose arm, 25 patients (54%) developed AIA, compared to 27 patients (57%) in the standard dose arm. The one-tailed p value is 0.3818, and the Z-score is 0.3, yielding only a 38% conditional power that that study would find a significant difference between the two arms. Thus, the study was terminated early for futility. There was no significant difference between the two arms in adherence to AI therapy. The grip strength and inflammatory cytokine data are pending at this time. They will be ready by the time of the conference.
Conclusions: There was no significant signal for benefit of high dose vitamin D supplementation, as compared to standard dose vitamin D, for AIA prevention in post menopausal women taking adjuvant AI therapy. These results further characterize the role of Vitamin D in AIA, and they inform future clinical trials in this arena. Further research is necessary, as this remains an important cause of non-adherence to this highly effective therapy.
Citation Format: Niravath P, Wang T, Hilsenbeck SG, Lipscomb K, Pavlick A, Jiralerspong S, Nangia J, Ellis M, Ademuyiwa F, Cherian M, Frith A, Ma C, Park H, Rigden C, Suresh R, Osborne CK, Rimawi MF. A randomized, controlled trial of high dose vs. standard dose vitamin D for aromatase inhibitor-induced arthralgia in breast cancer survivors [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 PD6-02.
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Affiliation(s)
- P Niravath
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - T Wang
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - SG Hilsenbeck
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - K Lipscomb
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - A Pavlick
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - S Jiralerspong
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - J Nangia
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - M Ellis
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - F Ademuyiwa
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - M Cherian
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - A Frith
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - C Ma
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - H Park
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - C Rigden
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - R Suresh
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - CK Osborne
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
| | - MF Rimawi
- Baylor College of Medicine, Houston, TX; Washington University School of Medicine, St. Louis, MO
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11
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Adkins D, Ley J, Atiq O, Rigden C, Trinkaus K, Wildes T, Oppelt P. Multicenter Phase 2 Trial of C is/Carboplatin, nAb -Paclitaxel, and C e TUX imab ( CACTUX ) as First-Line Therapy for Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2017.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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12
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Waqar SN, Baggstrom MQ, Morgensztern D, Williams K, Rigden C, Govindan R. A Phase I Trial of Temsirolimus and Pemetrexed in Patients with Advanced Non-Small Cell Lung Cancer. Chemotherapy 2016; 61:144-7. [PMID: 26780363 DOI: 10.1159/000442147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/03/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pemetrexed is an antifolate chemotherapeutic agent approved for use in non-small cell lung cancer (NSCLC). The mammalian target of rapamycin (mTOR) pathway is implicated in lung cancer development and inhibited by temsirolimus. METHODS We performed a phase I study evaluating the combination of pemetrexed and temsirolimus in advanced non-squamous NSCLC. RESULTS Eight patients were enrolled in this study. The dose-limiting toxicities included grade 4 thrombocytopenia, grade 3 leukopenia and grade 3 neutropenia. The maximum tolerated dose was determined to be pemetrexed 375 mg/m2 intravenously on day 1 and temsirolimus 25 mg intravenously on days 1, 8 and 15. No objective responses were noted and 3 patients had stable disease as the best response. CONCLUSION The combination of pemetrexed and temsirolimus is feasible and well tolerated. This combination may be further evaluated in patients with mTOR pathway activation, particularly in those with TSC1 or STK11 mutations.
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13
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Myerson RJ, Tan B, Hunt S, Olsen J, Birnbaum E, Fleshman J, Gao F, Hall L, Kodner I, Lockhart AC, Mutch M, Naughton M, Picus J, Rigden C, Safar B, Sorscher S, Suresh R, Wang-Gillam A, Parikh P. Five fractions of radiation therapy followed by 4 cycles of FOLFOX chemotherapy as preoperative treatment for rectal cancer. Int J Radiat Oncol Biol Phys 2014; 88:829-36. [PMID: 24606849 DOI: 10.1016/j.ijrobp.2013.12.028] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/15/2013] [Accepted: 12/18/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Preoperative radiation therapy with 5-fluorouracil chemotherapy is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents demonstrate increased morbidity with little benefit. We evaluate a template that: (1) includes the benefits of preoperative radiation therapy on local response/control; (2) provides preoperative multidrug chemotherapy; and (3) avoids the morbidity of concurrent radiation therapy and multidrug chemotherapy. METHODS AND MATERIALS Patients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for pelvic surgery, provided response was sufficient. Preoperative treatment was 5 fractions radiation therapy (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of FOLFOX [5-fluorouracil, oxaliplatin, leucovorin]. Extirpative surgery was performed 4 to 9 weeks after preoperative chemotherapy. Postoperative chemotherapy was at the discretion of the medical oncologist. The principal objectives were to achieve T stage downstaging (ypT < cT) and preoperative grade 3+ gastrointestinal morbidity equal to or better than that of historical controls. RESULTS 76 evaluable cases included 7 cT4 and 69 cT3; 59 (78%) cN+, and 7 cM1. Grade 3 preoperative GI morbidity occurred in 7 cases (9%) (no grade 4 or 5). Sphincter-preserving surgery was performed on 57 (75%) patients. At surgery, 53 patients (70%) had ypT0-2 residual disease, including 21 (28%) ypT0 and 19 (25%) ypT0N0 (complete response); 24 (32%) were ypN+. At 30 months, local control for all evaluable cases and freedom from disease for M0 evaluable cases were, respectively, 95% (95% confidence interval [CI]: 89%-100%) and 87% (95% CI: 76%-98%). Cases were subanalyzed by whether disease met requirements for the recently activated PROSPECT trial for intermediate-risk rectal cancer. Thirty-eight patients met PROSPECT eligibility and achieved 16 ypT0 (42%), 15 ypT0N0 (39%), and 33 ypT0-2 (87%). CONCLUSION This regimen achieved response and morbidity rates that compare favorably with those of conventionally fractionated radiation therapy and concurrent chemotherapy.
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Affiliation(s)
- Robert J Myerson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.
| | - Benjamin Tan
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Hunt
- Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Olsen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Elisa Birnbaum
- Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - James Fleshman
- Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Feng Gao
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Lannis Hall
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Ira Kodner
- Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - A Craig Lockhart
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew Mutch
- Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael Naughton
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Joel Picus
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Caron Rigden
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Bashar Safar
- Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Sorscher
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Rama Suresh
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Andrea Wang-Gillam
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Parag Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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14
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Myerson RJ, Parikh PJ, Tan B, Hunt S, Fleshman JW, Birnbaum EH, Mutch MG, Kodner IJ, Safar B, Naughton M, Picus J, Sorscher S, Lockhart AC, Rigden C, Suresh R, Wang-Gillam A, Hall L. A single-institution phase II trial of five fractions of radiotherapy followed by four courses of FOLFOX chemotherapy as preoperative therapy for rectal adenocarcinoma. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.553] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
553 Background: Preoperative radiotherapy (RT) with 5FU chemotherapy (CT) is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents have resulted in increased morbidity with little benefit. We evaluate a template that seeks to (1) include the known benefits of preoperative RT on local response/control, (2) provide for preoperative multi-drug CT, (3) avoid the morbidity of concurrent RT and multi-drug CT. Methods: Patients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for surgery, provided the response was sufficient. Preoperative treatment was 5 fractions RT (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of mFOLFOX6. Postoperative CT was at the discretion of the medical oncologist. The principal objectives are to demonstrate that this regimen can achieve T stage down staging (ypT < cT) and acute grade 3+ gastrointestinal (GI) morbidity equal to or better than historical controls. Results: Accrual opened late 2009, with 60 patients enrolled through 8/2011. Forty-six have had sufficient time to proceed to surgery with 4 having grade 3 preoperative GI morbidity. Two cases are inevaluable for response: one withdrew consent prior to CT and one received no surgery due to progression of cM1 disease (with local response). The 44 evaluable cases included 4 cT4 and 40 cT3; 32 (73%) cN+, 4 cM1. At surgery 33 (75%) had ypT0-2 residual disease including 13 (30%) ypT0, 14 (32%) were ypN+. Cases were sub-analyzed by whether disease was too advanced for the upcoming ACOSOG preoperative FOLFOX vs. 5FU-RT trial. By ACOSOG eligibility, response rates were (eligible first, ineligible second) ypT0: 10/22 (45%) vs. 3/22 (14%) (p = 0.05), ypT0-2: 19/22 (86%) vs. 14/22 (64%) (p = NS). Conclusions: This regimen achieves high response rates with acceptable morbidity. The response for ACOSOG eligible cases meets pre-determined stopping criteria for proceeding to a randomized trial. Our successor study will randomize to this regimen vs. FOLFOX alone for ACOSOG eligible cases, while initially continuing as a single arm trial for ACOSOG ineligible cases.
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Affiliation(s)
- Robert J. Myerson
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Parag J Parikh
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Benjamin Tan
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Steven Hunt
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - James W Fleshman
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Elisa H Birnbaum
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Matthew G Mutch
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Ira J Kodner
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Bashar Safar
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Michael Naughton
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Joel Picus
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Steven Sorscher
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Albert Craig Lockhart
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Caron Rigden
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Rama Suresh
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Andrea Wang-Gillam
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
| | - Lannis Hall
- Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine , St. Louis, MO
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