Real Life Clinical Management and Survival in Advanced Cutaneous Melanoma: The Italian Clinical National Melanoma Registry Experience

Background

Cutaneous melanoma (CM) is one of the most aggressive types of skin cancer. Currently, innovative approaches such as target therapies and immunotherapies have been introduced in clinical practice. Data of clinical trials and real life studies that evaluate the outcomes of these therapeutic associations are necessary to establish their clinical utility. The aim of this study is to investigate the types of oncological treatments employed in the real-life clinical management of patients with advanced CM in several Italian centers, which are part of the Clinical National Melanoma Registry (CNMR).

Methods

Melanoma-specific survival and overall survival were calculated. Multivariate Cox regression models were used to estimate the hazard ratios adjusting for confounders and other prognostic factors.

Results

The median follow-up time was 36 months (range 1.2-185.1). 787 CM were included in the analysis with completed information about therapies. All types of immunotherapy showed a significant improved survival compared with all other therapies (p=0.001). 75% was the highest reduction of death reached by anti-PD-1 (HR=0.25), globally immunotherapy was significantly associated with improved survival, either for anti-CTLA4 monotherapy or combined with anti-PD-1 (HR=0.47 and 0.26, respectively) and BRAFI+MEKI (HR=0.62).

Conclusions

The nivolumab/pembrolizumab in combination of ipilimumab and the addition of ant-MEK to the BRAFi can be considered the best therapies to improve survival in a real-world-population. The CNMR can complement clinical registries with the intent of improving cancer management and standardizing cancer treatment.

Clinical analysis of multiple primary malignancies in the elderly

BACKGROUND

Cancer incidence raises progressively during life span; it is estimated that by the year 2030 almost 70% of all neoplasms will occur in people over 65 years old. As carcinogenesis is a multistep, time-requiring process, it is expected that as people live longer they are more likely to develop cancer, and therefore, the prevalence of multiple primary malignancies (MPM) is destined to increase with age.

PATIENTS AND METHODS

Records of all consecutive cancer patients referred to our center from January 2004 to January 2007 were reviewed. We chose the definition of MPM proposed by Warren and Gates. Multiple malignancies were assessed for elderly (>or=70 years old) and younger patients. t-Test and Mc Nemar test were used; subgroup analysis was also performed according to age stratification.

RESULTS

A total of 1,503 consecutive patients were considered; 566 were 70 years old or more (mean age 76.5 years, range 70-96 years) and 878 were younger (mean age 57 years, range 18-69 years). The prevalence of multiple malignancies in the elderly people versus younger ones was 15% and 6%, respectively (P = 0.001). As far as the elderly population is concerned, 21% (56/271) of males compared with 14% (42/295) of females had developed MPM; no significant difference was found between the subgroups with MPM or not as far as age (P = 0.16), comorbidities (P = 0.79), medications (P = 0.76), CIRS-G score and index (P = 0.47, P = 0.54), and PS (P = 0.93) are concerned. Most frequent associations among cancer types were prostate with lung (10/87, 11%), prostate with colorectal cancer (10/87, 11%), and smoking-related cancer, namely lung and head and neck cancer (X/Y, 6%).

CONCLUSIONS

Elderly patients are more likely to develop MPM compared to younger ones. Significant cancer association according to field cancerogenesis concept was the one of smoking-related cancer; other MPM patterns were apparently a random phenomenon.

Do elderly cancer patients achieve an adequate dose intensity in common clinical practice?

BACKGROUND

Elderly patients rarely receive adequate dose intensity (DI) using conventional regimens. Possible causes are improper patient assessment, the chemotherapy (CT) regimen chosen, the number and severity of comorbidities, patient compliance and physician experience. To explore this issue, DI was retrospectively analyzed in elderly patients treated with conventional CT regimens for advanced solid cancer.

PATIENTS AND METHODS

Patients > or =69 years were evaluated. All patients had metastatic solid tumors. Comorbidities, performance status (PS), toxicities, number of CT cycles, dose reduction and discontinuation of treatment were recorded. Relative DI (RDI) was calculated and regressed against these parameters.

RESULTS

108 patients were eligible. The most frequent diagnoses were: lung, head-and-neck and colorectal cancer. In 48 patients (44%), their initially scheduled treatment was modified. Mean RDI was 79% (range 19-100%, SD 20.6). Grade 3/4 non-hematological and hematological toxicity occurred in 27 (35/130) and 8% of patients (11/130), respectively. In regression analysis, RDI was significantly associated with hematological toxicity. RDI affected response rate but not overall survival.

CONCLUSIONS

RDI is significantly affected by toxicity. These data suggest the importance of the treatment schedule and patient selection as predictorsof adequate treatment. Some non-ratable variables, however, might also play a role regarding the dose intensity delivered.

Repeat hepatic resection and chemotherapy for recurrent colorectal liver metastases

14590

Background: An aggressive surgical approach combined with chemotherapy (CHT) is the best way to prolong survival in patients with colorectal cancer and synchronous resectable metastatic disease. Reintervention followed by systemic CHT is often a safe and effective procedure for fit patients with metastatic liver recurrence. Methods: Patients with resectable metastatic liver disease who underwent at least two surgical operations were included in the study. At diagnosis they had a median number of 6 measurable liver metastases (range 1–16), and median sum of largest diameters of lesions was 35 mm (range 10–70) from CT scan. Hepatic resection was followed each time by systemic CHT. Radiofrequency (RF) was added as needed to reach a curative intent . The aim of our study was to evaluate DFS and OS combining surgery, RF and CHT in this high-risk group. Results: Between November 2003 and July 2006 13 patients (median age 52 yrs, range 36–73; PS 0) with metastatic colorectal cancer underwent surgery on primary tumour and liver metastases followed by adjuvant CHT consisting of FOLFOX4 (oxaliplatin 85 mg/m2 and LV5FU) or FOLFIRI (irinotecan 180 mg/m2 and LV5FU) for 6 months. Free margins were obtained in 12 patients (92.3%). The second relapse was treated by liver surgery and systemic CHT (either FOLFIRI or FOLFIRI + Cetuximab in EGFR expressing tumours). Eight patients were offered concomitant radiofrequency (RF) for smaller lesions. Five patients (38.5%) underwent a third operation + RF followed by third-line CHT consisting of capecitabine alone or associated to oxaliplatin. After second and third hepatectomy there was no intraoperative or early postoperative mortality. With a median follow-up of 24 months (range 6–37) 6 patients are free of disease and all patients are still alive. Two-year DFS and OS are 46.2% and 100% respectively. Conclusions: Patients with metastatic colorectal cancer should be treated aggressively by surgery and CHT. In a small group of fit patients operated at least two times we obtained excellent 2-year DFS and OS. The benefit of adding adjuvant CHT as second-line or even third-line treatment seems to be justified by good long-term results. Our promising data from a single institution prompt further evaluation for aggressive surgery associated to CHT and new target molecules.

No significant financial relationships to disclose.