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Notini G, Naldini MM, Sica L, Viale G, Rognone A, Zambelli S, Zucchinelli P, Piras M, Bosi C, Mariani M, Aldrighetti D, Bianchini G, Licata L. Management of Trastuzumab Deruxtecan-related nausea and vomiting in real-world practice. Front Oncol 2024; 14:1374547. [PMID: 38529378 PMCID: PMC10961432 DOI: 10.3389/fonc.2024.1374547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
Background Nausea and vomiting are common side effects of Trastuzumab Deruxtecan (T-DXd), but guidelines for optimal management were not initially available. This retrospective single-center study aimed at evaluating the efficacy of two antiemetic regimens in patients receiving T-DXd. Methods Data from metastatic breast cancer patients receiving T-DXd were collected. Two groups were defined: patients treated with 5-HT3 receptor antagonists (RA) ± dexamethasone (5-HT3-group) and patients treated with a fixed oral combination of netupitant (NK1RA) and palonosetron ± dexamethasone (NK1 group). Physicians preferentially offered the NK1 regimen to patients at higher risk of nausea and vomiting based on internal recommendations. Only nausea and vomiting during cycles 1 and 2 were considered. Comparisons of nausea and vomiting by the antiemetic prophylaxis group were assessed using chi-square. Results A total of 53 patients were included in the analysis. At cycle 1, 72% and 28% of patients received the 5-HT3 and NK1 prophylaxis, respectively. Overall, 58% reported nausea, with no differences between groups (58% vs. 60%; p = 0.832), but with a trend for lower grade in the NK1 group (33.3% G1; 26.7% G2) compared to the 5-HT3 group (23.7% G1; 31.6% G2; 2.6% G3). Vomiting was reported by 21% and 0% of patients in the 5-HT3 and the NK1 group, respectively (p = 0.054). Among the 15 patients in the 5-HT3 group with nausea at cycle 1 who escalated to NK1 at cycle 2, nausea decreased from 100% to 53% (p = 0.022) and vomiting decreased from 47% to 13% (p = 0.046). Conclusions The NK1 regimen improved vomiting control at cycle 1 and, when introduced at cycle 2, significantly improved both nausea and vomiting. The biased NK1 selection for higher-risk patients may have dampened the differences between groups at cycle 1. These findings support enhanced control of T-DXd-related nausea and vomiting with NK1RA.
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Affiliation(s)
- Giulia Notini
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo Maria Naldini
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Sica
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Giulia Viale
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessia Rognone
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefania Zambelli
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Patrizia Zucchinelli
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Marta Piras
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Carlo Bosi
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Mariani
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Daniela Aldrighetti
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Giampaolo Bianchini
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Licata
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
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Viale G, Licata L, Sica L, Zambelli S, Zucchinelli P, Rognone A, Aldrighetti D, Di Micco R, Zuber V, Pasetti M, Di Muzio N, Rodighiero M, Panizza P, Sassi I, Petrella G, Cascinu S, Gentilini OD, Bianchini G. Personalized Risk-Benefit Ratio Adaptation of Breast Cancer Care at the Epicenter of COVID-19 Outbreak. Oncologist 2020; 25:e1013-e1020. [PMID: 32412693 PMCID: PMC7272798 DOI: 10.1634/theoncologist.2020-0316] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/06/2020] [Indexed: 12/26/2022] Open
Abstract
Northern Italy has been one of the European regions reporting the highest number of COVID-19 cases and deaths. The pandemic spread has challenged the National Health System, requiring reallocation of most of the available health care resources to treat COVID-19-positive patients, generating a competition with other health care needs, including cancer. Patients with cancer are at higher risk of developing critical illness after COVID-19 infection. Thus, mitigation strategies should be adopted to reduce the likelihood of infection in all patients with cancer. At the same time, suboptimal care and treatments may result in worse cancer-related outcome. In this article, we attempt to estimate the individual risk-benefit balance to define personalized strategies for optimal breast cancer management, avoiding as much as possible a general untailored approach. We discuss and report the strategies our Breast Unit adopted from the beginning of the COVID-19 outbreak to ensure the continuum of the best possible cancer care for our patients while mitigating the risk of infection, despite limited health care resources. IMPLICATIONS FOR PRACTICE: Managing patients with breast cancer during the COVID-19 outbreak is challenging. The present work highlights the need to estimate the individual patient risk of infection, which depends on both epidemiological considerations and individual clinical characteristics. The management of patients with breast cancer should be adapted and personalized according to the balance between COVID-19-related risk and the expected benefit of treatments. This work also provides useful suggestions on the modality of patient triage, the conduct of clinical trials, the management of an oncologic team, and the approach to patients' and health workers' psychological distress.
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Affiliation(s)
- Giulia Viale
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Luca Licata
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Lorenzo Sica
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Stefania Zambelli
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Patrizia Zucchinelli
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Alessia Rognone
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Daniela Aldrighetti
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Rosa Di Micco
- Breast Surgery Unit, IRCCS San Raffaele HospitalMilanItaly
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaplesItaly
| | - Veronica Zuber
- Breast Surgery Unit, IRCCS San Raffaele HospitalMilanItaly
| | | | - Nadia Di Muzio
- Radiotherapy Unit, IRCCS San Raffaele HospitalMilanItaly
- Vita‐Salute S. Raffaele UniversityMilanItaly
| | | | - Pietro Panizza
- Breast Imaging Unit, IRCCS San Raffaele HospitalMilanItaly
| | | | - Giovanna Petrella
- Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | - Stefano Cascinu
- Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
| | | | - Giampaolo Bianchini
- Breast Cancer Group, Department of Medical Oncology, IRCCS San Raffaele HospitalMilanItaly
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Licata L, Galbardi B, Győrffy B, Karn T, Sica L, Rognone A, Zucchinelli P, Aldrighetti D, Zambelli S, Gianni L, Bianchini G. Abstract P4-05-09: Molecular differences between high and low tumor mutational burden (TMB) across breast cancer (BC) subtypes. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p4-05-09] [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. High-TMB (HTMB) is an emerging promising agnostic biomarker for predicting benefit from immune-checkpoint inhibitors, independently of tumor type. At ASCO 2019, the TAPUR trial reported an interesting 21% ORR in heavily pretreated metastatic BC patients with very HTMB [vHTMB, ≥9 mutations/megabase (Muts/Mb)]. We aimed to define the differential gene expression and methylation landscape between low and high TMB in each BC subtype. Methods. In TCGA, we identified 848 patients with WES data available for TMB estimation. [ER+/HER2- (LumA by PAM50)) n = 364; ER+/HER2- (LumB by PAM50), n = 147; HER2+, n = 158; and TN, n = 179]. High TMB was defined according to two different cut-offs: ≥9 (vHTMB) and≥5 Muts/Mb (HTMB). The second arbitrary cut-off was used to define a larger group allowing to better characterize the different molecular landscapes associated with high and low TMB in each BC subtype. The HTMB group was compared with an equal number of tumors with low TMB. We assessed the differential RNA expression and methylation of single genes and pathways (defined using Gene Ontology - GO). “Common” genes and pathways were defined as recurrently associated with TMB (p<0.05) in all subtypes and with a combined p value ≤0.00001. Results. The overall prevalence of vHTMB (≥9) was 4.5%, with no substantial differences across subtypes (4.4%, LumA; 4.8% LumB; 5.7% HER2+; 3.3% TN). The prevalence of HTMB (≥5) was 13.7%, but it was different across BC subtypes (p=8.0E-07) (8.2%, LumA; 12.9% LumB; 13.3% HER2+; 25.7% TN). We found more “common” genes down-regulated (n=70) than up-regulated (n=3) in HTMB group. Two of these three genes (HSPE1 and FEZF1.AS1) have been associated with poor prognosis in BC. When we considered the “common” pathways, only 3 were up-regulated in HTMB, all implicated in post-transcriptional repression of gene expression (gene silencing by miRNA and mRNA binding involved in post-transcriptional gene silencing). Conversely, 66 were significantly down-regulated (including transcription coregulator and coactivator activity, protein serine/threonine kinase activity and ubiquitin-protein transferase activity and binding). Some genes and pathways were associated with TMB only in a specific BC subtype (p ≤0.00001). For instance, 16 pathways were down-regulated in the HTMB group of TNBC. These inlcuded 12 pathways implicated in immune response. Conversely, in LumB, 11 pathways were up-regulated in HTMB group and implicated in immune response. Intrestingly, these pathways were all significantly down-regulated in the HTMB group of LumA and TN. In HTMB group, we found 7 and 4 “common” genes hypermetylated and hypomethylated, respectively. Four pathways were commonly hypermethylated (chromatin silencing at rDNA, telomere organization and positive regulation of G1/S transition of mitotic cell cycle) and five were hypomethilated (including mitotic sister chromatid segregation). Considering private alterations, in TNBC, 23 of 27 significant pathways were hypermetylated in HTMB group including double-strand break repair via nonhomologous end joining, epigenetic negative regulation of gene expression, and regulation of gene silencing by miRNA. Conclusions. Very-high TMB which is considered potentially druggable (≥9 Muts/Mb) is rare in BC, and equally frequent in all subtypes. Instead, HTMB (≥5 Muts/Mb) is more frequent in TNBC. BCs with HTMB had a different molecular landscape. Overall, several genes are recurrently down-regulated in HTMB group, and this is at least partly due to miRNA regulated post-trascriptional silencing, which might rapresents a new mechanism of immune escape. The positive association between TMB and immune genes in LumB, as well as the negative association in TN and LumA, suggest that immune editing and surveillance might be dependent on the molecular context.
Citation Format: Luca Licata, Barbara Galbardi, Balázs Győrffy, Thomas Karn, Lorenzo Sica, Alessia Rognone, Patrizia Zucchinelli, Daniela Aldrighetti, Stefania Zambelli, Luca Gianni, Giampaolo Bianchini. Molecular differences between high and low tumor mutational burden (TMB) across breast cancer (BC) subtypes [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 P4-05-09.
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Affiliation(s)
| | | | - Balázs Győrffy
- 2Institute of Enzymology, Hungarian Academy of Sciences, Budapest, Hungary
| | - Thomas Karn
- 3University Hospital Frankfurt, Frankfurt, Germany
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Cardoso F, Canon JL, Amadori D, Aldrighetti D, Machiels JP, Bouko Y, Verkh L, Usari T, Kern KA, Giorgetti C, Dirix L. An exploratory study of sunitinib in combination with docetaxel and trastuzumab as first-line therapy for HER2-positive metastatic breast cancer. Breast 2012; 21:716-23. [DOI: 10.1016/j.breast.2012.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022] Open
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Giovannini M, Aldrighetti D, Zucchinelli P, Belli C, Villa E. Antiangiogenic strategies in breast cancer management. Crit Rev Oncol Hematol 2010; 76:13-35. [PMID: 20702105 DOI: 10.1016/j.critrevonc.2009.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 10/28/2009] [Accepted: 12/17/2009] [Indexed: 01/13/2023] Open
Abstract
Angiogenesis is considered one of the key mechanisms of tumour growth and survival. Therefore it represents an ideal pharmaceutical target. Many antiangiogenic agents have been developed so far in several solid tumours and also in breast cancer. Vascular endothelial growth factor (VEFG) is the main target and both monoclonal antibodies and small molecules belonging to the tyrosine kinase inhibitors directed against VEGF(R) have been developed. Some other therapeutic approaches have shown to exert some antiangiogenic activity, such as hormonal agents, metronomic chemotherapy, bisphosphonates and others. In this paper we provide an introduction of the current data supporting the angiogenesis in breast cancer and a review of the most relevant antiagiogenic therapies which have been investigated so far.
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Affiliation(s)
- Monica Giovannini
- Medical Oncology Unit, Oncology Dept, San Raffaele Scientific Institute-University Hospital, Milan, Italy.
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Rugo HS, Campone M, Amadori D, Wardley AM, Aldrighetti D, Conte PF, Liu D, Mudenda B, McHenry MB, Pivot XB. Randomized phase II study of weekly versus every 3 week ixabepilone plus bevacizumab (ixa/bev) versus paclitaxel plus bev (pac/bev) as first-line therapy for metastatic breast cancer (MBC): Final results. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.1040] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Dirix L, Canon J, Amadori D, Villa E, Aldrighetti D, Machiels J, Verkh L, Bouko Y, Kern K, Giorgetti C, Cardoso F. An Exploratory Study of Sunitinib (SU) Plus Docetaxel (D) and Trastuzumab (T) for First-Line Therapy of HER2+ Advanced Breast Cancer (ABC). Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-09-6088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: T + D is a standard 1st-line treatment (tx) for HER2+ ABC (locally recurrent or metastatic BC). SU is an oral, multitargeted tyrosine kinase inhibitor of VEGFRs, PDGFRs, KIT, RET, and FLT3 with single-agent activity in previously treated ABC. In this study, a SU/D/T combination was investigated as 1st-line tx for pts with HER2+ ABC.Materials and methods: Female pts (≥18 yrs, ECOG PS ≤1) with HER2+ ABC were enrolled. Starting doses were D: 75 mg/m2, q3w, iv, day 1; T q1w: 4 mg/kg, day 1, followed by 2 mg/kg q1w, iv or q3w: 8 mg/kg, day 1, followed by 6 mg/kg q3w, iv; SU: 37.5 mg/d, Schedule 2/1, po, day 2. The primary objective was safety. Antitumor activity and pharmacokinetics were secondary endpoints. On discontinuation of D, responsive pts (PR or SD) could continue SU + T until disease progression.Results: As of Mar 2009, 25 pts were enrolled. 1 pt did not receive tx, 1 pt received a dose of D/T (pt died from multiorgan failure after T administration), and 23 pts received ≥1 dose of SU/D/T; data from the latter group are reported. 12 pts (52%) were chemo-naïve. 5 pts continue on study tx; 18 have discontinued (8 due to PD, 2 due to pt decision, 7 due to AEs, 1 due to global deterioration). Pts received 201/128/211 cycles of SU/D/T, respectively, with a median of 9/6/10 cycles/pt (range: 1–18/1–12/1–18). The 37.5 mg/d SU dose was reduced to 25 mg/d in 14/23 pts and interrupted in 17/23 pts. AEs led to SU dose reductions/interruptions in 17 pts, most frequently grade (G) 3/4 neutropenia (n=8) and G3 febrile neutropenia, G3 fatigue, and G3 diarrhea (each n=2). In 23 evaluable pts, the most frequent non-hematologic G3 AEs were fatigue/asthenia (26%), diarrhea (13%), and stomatitis, vomiting, and dyspnea (each 9%). G4 AEs were transaminase increase, accidental overdose of SU, and intestinal perforation (each n=1). 1 cardiac AE was reported (G3 supraventricular tachycardia) and transient G1/2 LVEF decline was seen in 2 pts (9%). G3/4 neutropenia was reported in 20 pts (91%); 5 pts (22%) had febrile neutropenia. 2 pts (9%) had G3 anemia and 1 pt (4%) had G3 thrombocytopenia. G-CSF was administered to 11 pts without complications. Preliminary median steady-state levels of SU and its metabolite: 40.6 and 15.6 ng/mL, respectively; end D infusion: 993 ng/mL; T levels: <20 µg/mL. In 19 evaluable pts, ORR was 79% (1 CR [5%], 14 confirmed PRs [74%], 2 SD [11%]). Preliminary median PFS was 10.5 months (95% CI: 8.1–13.6) and median DR was 9.0 months (95% CI: 7.3–12.3).Conclusions: The combination of SU/D/T, given as 1st-line tx to HER2+ pts with ABC, is feasible. AEs were manageable through dose delay/reduction, and no new, unexpected AEs occurred. SU and D levels were consistent with known single-agent levels; evaluation of T levels is ongoing. Preliminary evidence of antitumor activity is encouraging and warrants further evaluation.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6088.
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Affiliation(s)
| | - J. Canon
- 2Grand Hôpital de Charleroi, Belgium
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Boccardo F, Rubagotti A, Aldrighetti D, Buzzi F, Cruciani G, Farris A, Mustacchi G, Porpiglia M, Schieppati G, Sismondi P. O-54 Switching to an aromatase inhibitor provides mortality benefit in early breast-carcinoma: Pooled analysis of 2 consecutive trials. EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)71744-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Moliterni A, Mansutti M, Aldrighetti D, Merlini L, Zuccarino L, Bari M, Farris A, Mariani P, Fava S, Gianni L. Anthracycline-based sequential adjuvant chemotherapy in operable breast cancer: Five-year results of a randomized study by the Michelangelo Foundation. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
535 Background: Anthracycline-based sequential chemotherapy significantly improves efficacy outcomes compared to CMF alone. Methods: 806 eligible patients with operable breast cancer were enrolled into a randomized study (ratio 1:1:1:1) of sequential chemotherapy. In a 2×2-type design patients were allocated to first receive 4 cycles of AT (doxorubicin, A 60 mg/m2 iv + paclitaxel, T 200 mg/m2 as 3 h inf q 3wks) or EV (epirubicin, E 75 mg/m2 iv + vinorelbine, V 25 mg/m2 iv D1,8 q3wks) followed either by 4 monthly cycles of iv CMF or 6 cycles of q3w T alone (100 mg/m2 as 1h inf D1,8). Tamoxifen was recommended for 5 yr after chemotherapy in patients with HR+ tumors. Patients with tumors > 2 cm in diameter were allowed to start primary chemotherapy with 4 cycles of either AT or EV followed by surgery and postoperative systemic treatment as detailed above. Aim of the study was to test the role of T vs V when combined with an anthracycline during the first 4 cycles of the regimen as well as the role of CMF vs T during the last 4 cycles. Results: At a median follow-up of approximately 48 months, the 5 year freedom from progression (FFP) and overall survival (OS) for the main endpoints were as in the Table : The four treatment sequences were fairly well tolerated, with only 1 treatment-related death after EV. Type and severity of hematological toxicities were similar in all treatment arms. The incidence of reversible G2–3 neurotoxicity was 21.9% after AT, 5.3% after EV and 29.1% after sequential T. Chemical phlebitis was more frequent after EV (6.5%) then after AT (0.3). Conclusions: The results indicate that vinorelbine-epirubicin and classical CMF when appropriately used in a sequential modality for high-risk breast cancer are as valid and less neurotoxic an option of adjuvant therapy than the more widely used taxane-containing adjuvant regimens. Supported in part by Bristol-Myers Squibb, Pierre Fabre and Pharmacia. [Table: see text] [Table: see text]
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Affiliation(s)
- A. Moliterni
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - M. Mansutti
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - D. Aldrighetti
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - L. Merlini
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - L. Zuccarino
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - M. Bari
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - A. Farris
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - P. Mariani
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - S. Fava
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
| | - L. Gianni
- Istituto Nazionale Tumori, Milan, Italy; Ospedale S. Maria della Misericordia, Udine, Italy; Ospedale San Raffaele, Milano, Italy; Azienda Unità Locale Socio Sanitaria N. 6, Vicenza, Italy; Regione Veneto ULSS n. 5 Ovestvicentino, Arzignano (VI), Italy; Azienda Unità Locale Socio Sanitaria N. 13, Noale, Italy; Università - Istituto Clinica Medica, Sassari, Italy; Ospedale Civile di Legnano, Legnano (MI), Italy
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Boccardo F, Rubagotti A, Aldrighetti D, Buzzi F, Cruciani G, Farris A, Mustacchi G, Porpiglia M, Schieppati G, Sismondi P. Switching to an aromatase inhibitor provides mortality benefit in early breast carcinoma. Cancer 2007; 109:1060-7. [PMID: 17295293 DOI: 10.1002/cncr.22513] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The superiority of new generation aromatase inhibitors over tamoxifen in the adjuvant treatment of early breast carcinoma has emerged from several randomized trials. However, until now not all previous studies have shown a mortality benefit. METHODS A pooled analysis of 2 prospective multicentric trials, sharing the same study design and nearly identical inclusion criteria, was performed. In both trials, women treated previously with tamoxifen for 2 or 3 years were randomly assigned to either continuing tamoxifen for an additional 2 or 3 years or to having their treatment switched to aminoglutethimide or anastrozole for a comparable time period. Mortality was analyzed according to allocated treatment and other patient and tumor variables. RESULTS In all, 828 postmenopausal women, mostly with estrogen receptor (ER)-positive and node-positive tumors who had been monitored for a median time of 78 months (range, 6-141 months) were analyzed. Of these women, 415 were randomly selected to continue tamoxifen and 413 switched to aminoglutethimide or anastrozole. All-cause mortality and breast cancer-specific mortality were significantly improved by the switch: all-cause mortality: hazard ratio (HR) = 0.61 (0.42-0.88) P = .007; breast cancer-specific mortality: HR = 0.61 (0.39-0.94) P = .025. No increase was recorded in breast cancer-unrelated mortality in women after switching. Multivariate analysis showed that patient age, tumor size, allocated treatment, and nodal status, in that order, were independent mortality predictors. CONCLUSIONS Switching to an aromatase inhibitor after 2 or 3 years of tamoxifen therapy significantly improves survival compared with continuing 2 or 3 years of additional tamoxifen treatment.
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11
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Baldini E, Prochilo T, Salvadori B, Bolognesi A, Aldrighetti D, Venturini M, Rosso R, Carnino F, Gallo L, Giannessi P, Conte PF, Orlandini C, Bruzzi P. Multicenter randomized phase III trial of epirubicin plus paclitaxel vs epirubicin followed by paclitaxel in metastatic breast cancer patients: focus on cardiac safety. Br J Cancer 2004; 91:45-9. [PMID: 15173858 PMCID: PMC2364750 DOI: 10.1038/sj.bjc.6601883] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The aim of the study was to evaluate cardiac safety of two different schedules of Epirubicin and Paclitaxel in advanced breast cancer patients enrolled into a multicenter randomized phase III trial. Patients received Epirubicin 90 mg m−2 plus Paclitaxel 200 mg m−2 (3-h infusion) on day 1 every 3 weeks for eight courses (arm A), or Epirubicin 120 mg m−2 on day 1 every 3 weeks for four courses followed by four courses of Paclitaxel 250 mg m−2 on day 1 every 3 weeks (arm B). Left ventricular ejection fraction was evaluated by bidimesional echocardiography at baseline, after four and eight courses of chemotherapy and every 4 months during follow-up. Baseline median left ventricular ejection fraction was 60% in arm A and 65% in arm B; after four courses, figures were 57 and 60%, respectively. After eight courses, the median left ventricular ejection fraction in arm A declined to 50% while no further reduction was detected in arm B by adding four courses of high-dose Paclitaxel. Seven episodes of congestive heart failure were observed during treatment in arm A. Present monitoring demonstrated that the risk of congestive heart failure or impairment in the cardiac function correlated only with the cumulative dose of Epirubicin; no impact on cardiotoxicity can be attributed to high-dose Paclitaxel.
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Affiliation(s)
- E Baldini
- Medical Oncology Department, S. Chiara University-Hospital, Via Roma 67, 56132 Pisa, Italy.
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12
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Conte PF, Guarneri V, Bruzzi P, Prochilo T, Salvadori B, Bolognesi A, Aldrighetti D, Venturini M, Rosso R, Mammoliti S, Carnino F, Giannessi P, Costantini M, Moyano A, Baldini E. Concomitant versus sequential administration of epirubicin and paclitaxel as first-line therapy in metastatic breast carcinoma. Cancer 2004; 101:704-12. [PMID: 15305399 DOI: 10.1002/cncr.20400] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The authors performed a randomized trial comprising patients with metastatic breast carcinoma (MBC). They used a noninferiority design to evaluate whether the results of sequential administration of epirubicin and paclitaxel were not markedly worse than the concomitant administration in terms of objective response rates (ORRs). Toxicity profile, quality of life (QOL), and pharmacoeconomic evaluations were evaluated as well. METHODS In the current study, 202 patients with MBC were randomized to receive either the combination of epirubicin at a dose of 90 mg/m2 plus paclitaxel at a dose of 200 mg/m2 for 8 cycles (concomitant arm, n = 108) or epirubicin at a dose of 120 mg/m2 for 4 cycles followed by paclitaxel at a dose of 250 mg/m2 over 3 hours for 4 cycles every 21 days (sequential arm, n = 94). RESULTS The authors rejected the null hypothesis that the sequential treatment is less active than the standard concomitant regimen (ORRs: concomitant = 58.5%, sequential = 57.6%). The median progression-free and overall survival periods were 11.0 months (95% confidence interval [95% CI], 9.7-12.3) and 20.0 months (95% CI, 17.2-22.6), respectively, in the concomitant arm and 10.8 months (95% CI, 7.9-13.6) and 26 months (95% CI, 18.1-33.8), respectively, in the sequential arm (P = not significant). Patients who received the sequential regimen experienced a higher incidence of Grade 3/4 (according to the World Health Organization grading system) neutropenia (62.2% of courses vs. 50.62%; P = 0.003) and Grade > or = 2 neuropathy (45.5% vs. 30.4% of patients; P = 0.03), whereas 6 patients who received the concomitant regimen developed Grade II cardiotoxicity according to New York Heart Association criteria. QOL analyses failed to provide clear differences. CONCLUSIONS The sequential administration of epirubicin and paclitaxel at full doses was found to be as active as their association. Therefore, both the sequential and the combined administration were acceptable options.
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Affiliation(s)
- Pier Franco Conte
- Division of Medical Oncology, St. Chiara University Hospital, Pisa, Italy.
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Boccardo F, Rubagotti A, Amoroso D, Mesiti M, Romeo D, Sismondi P, Giai M, Genta F, Pacini P, Distante V, Bolognesi A, Aldrighetti D, Farris A. Cyclophosphamide, methotrexate, and fluorouracil versus tamoxifen plus ovarian suppression as adjuvant treatment of estrogen receptor-positive pre-/perimenopausal breast cancer patients: results of the Italian Breast Cancer Adjuvant Study Group 02 randomized trial. boccardo@hp380.ist.unige.it. J Clin Oncol 2000; 18:2718-27. [PMID: 10894871 DOI: 10.1200/jco.2000.18.14.2718] [Citation(s) in RCA: 149] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the efficacy of chemotherapy versus that of tamoxifen plus ovarian suppression in pre-/perimenopausal estrogen receptor-positive patients with early breast cancer. PATIENTS AND METHODS Patients were randomly assigned to receive either six cycles of a standard regimen of cyclophosphamide 100 mg/m(2) orally days 1 to 14, methotrexate 40 mg/m(2) intravenously (IV) days 1 and 8, and fluorouracil 600 mg/m(2) IV days 1 and 8 (CMF), with all drugs restarted on day 29, or 5 years of tamoxifen, 30 mg/d, plus ovarian suppression with surgical oophorectomy, ovarian irradiation, or monthly goserelin 3.6-mg injections. Disease-free survival was the main study end point. Overall survival and toxicity were additional end points. RESULTS Between 1989 and 1997, 120 patients were assigned to CMF and 124 to tamoxifen and ovarian suppression (oophorectomy, n = 6; ovarian irradiation, n = 31; and goserelin injections, n = 87). At the time of analysis (median follow-up time, 76 months; range, 9 to 121 months), 82 patients had relapsed and 39 had died. No difference between groups had emerged with respect to either disease-free or overall survival. Treatments were comparable even in respect to age, tumor size, and nodal status, although a nonsignificant trend favored patients with poorly differentiated tumors treated with CMF. Leukopenia, nausea, vomiting, stomatitis, and alopecia were significantly more common in patients treated with CMF. There were few patients who developed benign gynecologic changes in either group, and numbers were comparable. CONCLUSION The combination of tamoxifen with ovarian suppression seems to be safe and to yield comparable results relative to standard CMF.
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Affiliation(s)
- F Boccardo
- Professorial Unit of Medical Oncology and Biostatistics Unit, University and National Cancer Institute, Genoa, Italy
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Redaelli A, Baldini E, Salvadori B, Aldrighetti D, Conte P, Quattrocchio M, Svanosio M, Bergamino T, Tibaldi C, Lionetto R. Epirubicin (E) plus paclitaxel (P) vs epirubicin followed by paclitaxel in metastatic breast cancer (MBC): an ongoing pharmacoeconomic study. Eur J Cancer 1999. [DOI: 10.1016/s0959-8049(99)81702-x] [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: 10/27/2022]
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Boccardo F, Rubagotti A, Amoroso D, Mesiti M, Geraci O, Delia P, Villa E, Aldrighetti D, Genta F, Sismondi P, Irtelli L, Donati D, Paccini P, Farris A, Schieppati G. 0.31. CMF vs tamoxifen (TAM) plus goserelin (GOS) as adjuvant treatment of ER positive (+VE) preperimenopausal breast cancer patients (pts). Preliminary results of an ongoing Italian breast cancer adjuvant study group (GROCTA) trial. Breast 1997. [DOI: 10.1016/s0960-9776(97)90612-3] [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: 10/26/2022] Open
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Boccardo F, Rubagotti A, Amoroso D, Mesiti M, Geraci O, Delia P, Villa E, Aldrighetti D, Genta F, De Sanctis C, Irtelli L, Donati D, Pacini P, Scotto T, Schieppati G. PP-5-5 CMF vs Tamoxifen (TAM) Plus Goserelin (GOS) as Adjuvant Treatment of ER Positive (+VE) Pre-Perimenopausal Breast Cancer Patients (PTS). Preliminary Results of an Ongoing Italian Breast Cancer Adjuvant Study Group (GROCTA) Trial. Eur J Cancer 1996. [DOI: 10.1016/0959-8049(96)84168-2] [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: 10/18/2022]
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Volterrani F, Aldrighetti D, Bolognesi A, Di Muzio N, Reni M, Ronzoni M, Fossati V, Villa E, Marassi A, Veronesi P. [Analysis of the results of 264 cases of small breast carcinoma treated with conservative surgery and radiotherapy]. Radiol Med 1991; 82:322-7. [PMID: 1947269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
From January 1981 to December 1987, 264 patients affected with small breast cancers were treated with quadrantectomy plus axillary dissection and radiation therapy on the breast remnant (QUART). Mean age of the patients was 53 years; 124 of them were less than or equal to 50 years old (46.9%); 85 had axillary nodal metastases (32.2%), and 58 presented a primary tumor with pathologic size (greater than 2 cm) (22.9%). Overall actuarial survival at 3 and 7 years, according to the Kaplan and Meyer method, was 95.5% and 85.3%, respectively; NED survival was 85.9% and 77.4%. Twenty patients died (19 of cancer). Local relapses were 6 (2.3% on the whole and 13.3% on the whole of recurrences observed at follow-up). Local relapses were central in the quadrantectomy scar in 4/6 patients. Histology and site of the primary lesion were not correlated with a major risk of local failure. Isolated recurrences in the breast did not worsen survival. Nodal failures were 5 (1.9% on the whole of cases; 11.1% on the whole of failures). Our study confirms the role of QUART as an effective and reliable method in the treatment of small breast carcinomas.
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Affiliation(s)
- F Volterrani
- Istituto e Scienze Radiologiche, Università degli Studi, Ospedale S. Raffaele, IRCCS, Milano
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