Medical Oncology and Home Care in Italy

Aims and Background

Home care programs are designed to provide care for cancer patients in their homes. Aim of the study is to describe the activities of home care program, to examine the organization and efficiency of this type of care in Italy.

Methods

A questionnaire was sent to the regional representatives of the National Society of Medical Oncology and to the regional health departments.

Results

a) the home care program is uniformly distributed throughout the country; b) the number of personnel in the different centers varies greatly from one area to another; c) approximately 50 % of the centers do not cover emergency situations (at night or on holidays); and d) there is little involvement of the public sector.

Conclusions

In spite of these problems, the home care system is taking on a fundamental role, especially for advanced cancer patients.

Human Mena (hMena), estrogen receptor-β (ER-β), and epidermal growth factor receptor (EGFR) expression as prognostic factors in node-negative non-small-cell lung cancer (NSCLC)

e22105

Background: hMena is a cytoskeleton regulatory protein involved in adhesion and cell motility, particularly in response to EGFR activation. In addition, a possible correlation between ER-β and EGFR expression has been recently suggested in NSCLC. We therefore investigated the potential relationship and prognostic value of hMena, ER-β, and EGFR expression in node-negative NSCLC patients (pts) who underwent surgery at our institution. Methods: hMena, ER-β (isoforms 1, 2), and EGFR expression, analyzed on Tissue Micro Array, were correlated to disease-free, cancer-specific, and overall survival (DFS/CSS/OS) using a Cox model including sex, stage, age, grading, histology, number of resected nodes (RN). Logistic and generalized linear models were used to evaluate predictors of significant Cox-model variables. Receiver Operative Curve (ROC) analysis identified optimal cutoff values. Internal cross-validation (100 simulations with 80% of the dataset) was accomplished. Results: 248 pts were gathered (median follow-up 26 months, range 1–75; male/female 71/29%; adeno/other 43/57%; grading G1–2/G3 45/55%; Stage I/II 82/8%; RN ≤10/>10 34/66%). Multivariate analysis, highlighting the prognostic role of RN and hMena, is shown in the table . ER-β/2 and EGFR strongly predicted hMena overexpression (p=0.009, p=0.01); indeed, when hMena was removed from the multivariate model, both factors were independent predictors of DFS/CSS. Cross-validation analysis confirmed the prognostic role of hMena with a replication rate of 43/66% for DFS/CSS. Conclusions: hMena expression is prognostic in early NSCLC undergoing curative surgery. ER-β/2 and EGFR strongly correlate with hMena status and their prognostic role deserves further investigation.

[Table: see text]

No significant financial relationships to disclose.

Short-term (ST) versus long-term (LT) hormone treatment (HT) in combination with radiotherapy (RT) for locally advanced prostate cancer (LAPC): Meta-analysis of randomized trials (RCTs)

5128

Background: Hormone suppression plus RT is able to significantly decrease the recurrences and the mortality of patients (pts) affected by LAPC. In order to determine if difference exists between ST-HT (HT ≤6 months), and LT-HT (HT ≥8 months) in combination with RT for LAPC, a literature-based meta-analysis was conducted. Methods: Event-based relative risks (RR) with 95% confidence intervals (CI) were derived through a random-effect model. Differences in primary (biochemical failure, BF, and cancer-specific survival, CSS), and secondary outcomes (overall survival, OS, and pattern of recurrence, local or distant, LR/DM) were explored. Absolute differences (AD) and the number of patients needed to treat (NNT) were calculated. Heterogeneity test, a meta-regression analysis with clinico-pathological predictors for outcomes and a correlation analysis for surrogate end-points were conducted as well. Results: Four trials (3,148 patients) were gathered. Data were available for all RCTs only for BF; patient population ranged from 297 to 1,521 pts. Three predictors were identified: median PSA (range 9.5–20.35), Gleason score 7–10 (27–55% pts/trial) and T3–4 (13–77% pts/trial). None of the selected predictors did significantly affect any outcomes. A significant correlation and trend between the log of the BF-RR and DM and OS were found (p=0.029 and p=0.07, respectively). Conclusions: Although with significant heterogeneity (reflecting different patient’ risk stratifications), LT-HT seems to significantly decrease biochemical, local and distant recurrences, and increase cancer specific survival in comparison with ST-HT. Balancing these advantages with toxicities and costs represents the next step of the current analysis.

[Table: see text]

No significant financial relationships to disclose.

Magnitude of benefit of the addition of bevacizumab (BEVA) to first-line chemotherapy (CT) for advanced/metastatic colorectal cancer (MCRC): Meta-analysis of randomized clinical trials

e15021

Background: The monoclonal antibody against vascular endothelial growth factor BEVA has recently demonstrated to improve survival for MRC patients (pts). Nevertheless, the magnitude of the provided benefit in the daily practice is still controversial. In order to quantify the benefit of adding BEVA to CT for MCRC, a literature-based meta-analysis was conducted. Methods: Survival Hazard Ratios (HR) were extracted from prospective, randomized clinical trials (RCTs, either phase II/III) reports. HR and event-based relative risks (RR) with 95% confidence intervals (CI) were derived through a random-effect model. Differences in primary (progression-free- and overall-survival, PFS/OS) and secondary outcomes (overall, partial and complete response rates, ORR/PR/CR) were explored. Absolute differences (AD) and the number of patients needed to treat (NNT) were calculated. Heterogeneity test and a meta-regression analysis with clinical predictors for outcomes were conducted as well. A sensitivity analysis according to the trial phase-design was accomplished. Results: Five trials (2,728 pts), 2 phase II (313 pts) and 3 phase III (2,415 pts), were gathered. No significant interaction was found in the sensitivity analysis between phase II and III, although a trend showed a better PFS results for BEVA in phase II trials (p=0.057). At the meta-regression analysis female gender and rectal primary site were significant predictors for PFS (p=0.003, p=0.005). Toxicity analysis is ongoing. Conclusions: Although concerns regarding costs and toxicities still exist, BEVA significantly improves the outcome of untreated MCRC pts. The absolute benefit provided into an unselected population for molecular features should be considered of paramount importance for advanced disease.

[Table: see text]

No significant financial relationships to disclose.

P53 and bcl-2 in colorectal cancer arising in patients under 40 years of age: distribution and prognostic relevance

Young people (40 years of age) with colorectal cancer (CRC) represent a distinct subgroup with more aggressive disease behaviour compared to older patients. We evaluate whether p53 and bcl-2 could be useful in identifying young patients at higher risk of tumour progression. We reviewed 1340 CRC patients with 58 patients 40 years (4.2%). They had more frequent moderately or poorly differentiated mucinous adenocarcinomas (26% versus 12.3%, p=0.03); higher advanced stage at diagnosis; shorter 5-year overall survival (49.8% versus 71%; p=0.02); more frequent p53 positive (89.8% versus 72.6%, p<0.05) and bcl-2 negative (88.0% versus 66.2%, p<0.05) tumours; no difference in DNA content or proliferation indexes. Moreover, p53+ and bcl-2- resulted in being independent predictors of survival with shorter survival for the p53+/bcl-2- patients. Combining p53 and bcl-2, we could identify young CRC patients at higher risk of progression, who probably require development of a more sophisticated therapeutic approach based on identification of predictive factors.

Disease-free survival (DFS) as surrogate end point for overall survival (OS) in adjuvant aromatase inhibitors (AIs) trials for breast cancer (BC): Meta-analysis of 10 randomized clinical trials (RCTs) exploring the magnitude of the benefit

539

Background. The issue regarding the eventual correlation of DFS with OS has not actually been explored in trials addressing the role of AIs. For this purpose, we meta-analyzed all RCTs in which patients were randomized to receive standard tamoxifen or AIs, whatever applied strategies. Methods. A literature-based meta-analysis was accomplished, and event-based relative risk ratios (RRs) with 95% confidence interval (CI) were derived. A fixed- (FEM) and a random-effect (REM) model and heterogeneity test were applied as well. Absolute benefits (AB) and the Number of patients Needed to Treat (NNT) were calculated. A linear regression model considering both each single outcome pair (5-years DFS and OS) has been adopted to explore for correlation, estimated according to Pearson, R2 (parametric) and Spearman (non-parametric) coefficients. Results. Ten RCTs were gathered (27,653 patients); two RCTs did not report the OS result, so they were not evaluable. DFS was significantly improved with AIs, with a AB of 2.3–3.5%, which translate into 29–43 NNT. OS was significantly improved in both overall and early switch strategy, with an AB of 0.8–1.61%, which translate into 120 and 62 NNT, respectively. A strong correlation was found between DFS and OS in the overall (r=0.78, R2=0.60, p=0.001; Rho=0.77, p=0.001) and in the early switch strategy (r=0.83, R2=0.68, p=0.003; Rho=0.84, p=0.002). Although a stronger correlation was found in the upfront strategy, the low number of RCTs did not allow to reaching statistical significance. Conclusions. The strong correlation between DFS and OS in AIs adjuvant endocrine treatment for early BC underlines the choice of DFS as a surrogate end-point for OS. The predictive value of earlier DFS (3-years) estimation for overall survival deserves a further analysis.

[Table: see text]

No significant financial relationships to disclose.

Meta-analysis of adjuvant trastuzumab for early breast cancer: Cardiotoxicity and brain metastases incidence

543

Background: The introduction of adjuvant trastuzumab (T) for early breast cancer overexpressing HER-2 has extraordinarily decreased the risk of both recurrence and death in 5 randomized clinical trials (RCTs). Nevertheless, the issue regarding the long-term safety profile of such drug is still open; in particular, questions remain about long-term cardiotoxicity, and specific pattern of relapse such as brain metastases (BM). In order to quantify the magnitude of these 2 risks, together with the survival outcome, a literature-based meta-analysis was performed. Methods: All phase III trials were considered eligible. A literature-based meta-analysis was accomplished, and event-based relative risk ratios (RR) with 95% confidence interval (CI) were derived. A fixed- and a random-effect model according to the inverse variance and the Mantel-Haenzel method were applied. Heterogeneity test was applied as well. Absolute differences (AD) and the number of patients needed to treat or to harm (NNT/NNH) were calculated. Primary end-points were: 1) chronic heart failure grade III-IV rate (CHF), 2) 10% reduction of L-FEV rate (L-FEV) and 3) BM rate. In order to quantify the magnitude of the significant benefit already found in the original RCTs, secondary end-points were: 1) disease-free survival (DFS) and 2) overall survival (OS). Results: Five RCTs were gathered (11,187 patients); at an average 2-yrs follow-up, all data were available for the cardiotoxicity and outcome end-points, while 3 RCTs reported results for BM analysis (6,738 patients). Conclusions: The overall outcome stresses that trastuzumab is likely to be one of the most important discovery in clinical oncology. Nevertheless, the biological activity of trastuzumab needs to be investigated more extensively to explore both long-term safety and specific relapse pattern.

[Table: see text]

No significant financial relationships to disclose.

Cardiotoxicity of weekly trastuzumab (T) plus epirubicin (E) and paclitaxel (P) for HER2-positive locally advanced (LA) and/or metastatic (M) breast cancer (BC): A feasibility phase II study

11509

Background: The introduction of T for patients (pts) overexpressing HER-2 changed the natural history of BC. The adjunction of T to anthracyclines and taxanes for both LABC and MBC provided a significant incidence of unexpected cardiotoxicity. Given the low cardiac toxicity in our previous experience with weekly ET in unselected MBC pts, a feasibility phase II study aimed to cardiotoxicity was planned. Methods: Pts affected by untreated LABC/MBC overexpressing HER-2 by FISH/CISH amplification or 3-positive Dako- Test, underwent weekly T (4–2 mg/kg/week), day 1, and E (25 mg/m2/week) plus P (80 mg/m2/week), day 2, plus G-CSF support, for 16/24 consecutive weeks in absence of progression or toxicity, in LA/M pts, respectively. Pts with significant cardiac disease/L-FEV<50% were excluded. Primary endpoint was the rate of pts with L-FEV reduction >10% after 12 weeks. An optimal 2-stage Simon design was applied. With a power of 90% at a 5% significance level, assuming a toxicity rate of 30% as unacceptable, and less than 10% as acceptable, an initial group of 15 pts was required; with 11 pts with no toxicity, a second step with further 21 pts (total 36) was planned. Non-cardiac toxicity and activity were evaluated as secondary end-points. Results: From May 2004 to November 2006, 15 pts entered the study. Patient characteristics: median age=47 (range 37–69); LABC/MBC=4/11; positive hormonal receptor 8/7; menopausal pre/post=7/8; PS 0/1=14/1; number of met sites 1/2/3=7/6/2. Median baseline- and post-week-12-L-FEV was 69% (range 64–77) and 65% (range 61–76), respectively. With a median number of courses of 13 (range 8–24), 3 pts had a >10% L-FEV reduction (20%), with an overall median L-FEV reduction of 5.2%. No EKG alteration or specific symptoms were registered. With a 17-months median follow-up, 13 pts were evaluable for response. Eight response (61.5%, 95% CI 9- 87) were documented, with a median response duration of 9 months. No grade 3–4 toxicity were registered, with the exception of severe alopecia. Conclusions: The weekly administration of T plus E and P is extremely tolerable, also with regard to L-FEV reduction. The low L- FEV reduction rate allowed entering the second step of the study.

No significant financial relationships to disclose.

Does progression-free-survival (PFS) correlate with overall- and cancer-specific survival (OS/CSS) in randomized clinical trials (RCTs) exploring the addition of hormonal therapy (HT) to radiotherapy (RT) for early prostate cancer (EPC)? Analysis of six RCTs

5056

Background: Although PFS is considered the standard primary end-point in EPC, the correlation with OS has never been explored in RCTs randomizing patients (pts) to HT plus radiotherapy (RT) versus RT. Given the relatively long prognosis in this disease setting, the correlation between PFS and CSS should be investigated as well. Methods: All phase III trials reporting all outcome’ data were considered eligible. The correlation has been explored according to a linear regression model considering both each single outcome pair (PFS, OS and CSS rates) for all arms, and each reported Hazard Ratio (HRs). The correlation was estimated according to both the Pearson- (r) and R2-coefficient (parametric) and the Spearman coefficient (Rho, non-parametric). A sensitivity analysis in 2 subgroups (long- and short-term HT) to test for effect robustness has been accomplished as well. A model to determine the target sample size to determine CSS benefit of 3%, 4%, 6% and 7% months, respectively, was calculated as well. Results: Six RCTs (4,212 pts) were collected (follow-up range: 4.5–7.6 years). In the overall population, when considering the crude rates, a linear stronger correlation was found between PFS and CSS (r=0.71, R2=0.51, p=0.003; Rho=0.75, p=0.005), rather than with OS (r=0.55, R2=0.30, p=0.06; Rho=0.78, p=0.11). Again, when considering HRs, a linear stronger correlation was found between PFS and CSS (r=0.87, R2=0.76, p=0.02; Rho=0.94, p=0.005), rather than with OS (r=0.75, R2=0.56, p=0.08; Rho=0.77, p=0.07). Similar correlations were found whatever subgroups was explored. The sample size model (on the basis of the beta-coefficient=0.71), calculate 4,575, 2,006, 1,115 and 700 pts to improve PFS of 4%, 6%, 8%, and 10% months, which means to improve CSS of 2.8%, 4.3%, 5.7% and 7.1%, respectively. Conclusions: The correlation between PFS and CSS in RCTs exploring the benefit of adding HT to RT for EPC is significant, and suggests its further investigation as surrogate end-point. The natural history of the disease clearly explains the stronger correlation of PFS with CSS rather than with OS.

No significant financial relationships to disclose.

Three-year disease-free survival (DFS) as surrogate end-point for predicting five-year overall survival (OS) benefit in adjuvant taxane-based chemotherapy for breast cancer (BC): Analysis of 10 randomized clinical trials (RCTs)

584

Background: The issue regarding the eventual correlation between DFS at earlier follow-up (i.e. 3-yrs) with 5-yrs OS has not actually been explored in trials addressing the role of taxanes in BC. All RCTs in which patients were randomized to receive a standard or a taxane-based regimen for early BC were analyzed to evaluate this topic. Methods: All phase III trials with at least 60 month follow-up were considered eligible. The correlation has been explored according to a linear regression model considering both each single outcome pair (DFS/OS) for all arms (extracted by curves), their differences, and each outcome Hazard Ratio (HR) or calculated Relative Risk (RRs), following 2 steps: 1) correlation between 5-yrs DFS and OS (to confirm the evidence); 2) correlation between 3-yrs DFS and 5-yrs OS (predictive role). The correlation was estimated according to Pearson (r) and R2 coefficients (parametric) and Spearman (Rho) coefficient (non- parametric). A model to calculate the target sample size to determine 5-yrs OS benefit of 3%, 5% and 7%, respectively, was calculated as well. Results: Ten RCTs (17,067 patients) with available data for outcomes were gathered. For 5-yrs DFS/OS, a linear correlation was found between rates (r=0.74, R2=0.55; p<0.0001; Rho=0.83; p<0.0001), and HRs (r=0.90, R2=0.81; p<0.0001; Rho=0.91; p<0.0001). Three-yrs DFS correlates with 5-yrs OS, with both rates (r=0.81, R2=0.66; p<0.0001; Rho=0.92; p<0.0001), and RRs (r=0.84, R2=0.71; p=0.002; Rho=0.85; p=0.002). Three-yrs DFS and 5-yrs OS absolute differences strongly correlate (r=0.86, R2=0.74; p=0.001; Rho=0.84; p=0.002). The sample size model (on the basis of the r-coefficient=0.81), calculates 2,733, 863, and 389 pts to improve 3-yrs DFS of 4%, 7% and 10%, which means to improve 5-yrs OS of 3.2%, 5.7% and 8.1%, respectively. Conclusions: By these data, 3-yrs DFS is a reliable surrogate end-point for OS when testing new drugs in early BC, and is able to predict a late survival benefit. Thanks to the smaller patient sample size, RCTs with this design will provide early results in a shorter time period, allowing a faster data transfer to clinical practice.

No significant financial relationships to disclose.

Impact of epidermal growth factor receptor (EGFR) pathway alterations on the outcome of non-small cell lung cancer (NSCLC) patients (pts) treated with first-line chemotherapy (CHT)

7607

Background: Molecular alterations along the EGFR pathway have been proposed to be the major determinant of clinical outcome in response to EGFR tyrosine kinase inhibition in NSCLC pts. However, their potential impact on sensitivity to CHT has not been studied in detail. Methods: Advanced NSCLC pts undergoing CHT were screened for EGFR gene mutations (by SSCP and sequencing) and/or increased copy number (by FISH), EGFR protein expression (by IHC), and HER-2, phosphorylated AKT (pAKT), and total AKT protein expression (by IHC). Correlation between specific molecular alterations and clinical outcome (ORR, PFS, and OS) was then retrospectively explored using both the Cox regression model as well as classification and regression trees (CART) analysis. Results: One hundred and twenty seven pts were screened and 93 received 1st-line CHT. The frequency of EGFR pathway alterations is shown in Table 1 . At a median follow up of 13 mos, survival analysis revealed that true EGFR gene amplification is the only significant predictor of worst OS (p=0.004). No significant correlation was found with PFS. ORR was significantly worse in HER-2-positive pts (p=0.03). CART analysis confirmed that true EGFR gene amplification negatively affect OS, followed by EGFR gene mutation and chromosome 7 polysomy in non-amplified and non-amplified/non-mutated pts, respectively. Conclusions: EGFR pathway alterations significantly impact on outcome following 1st-line CHT for advanced NSCLC. HER-2 overexpression negatively impacts on ORR, but not on PFS and OS. This information maybe useful in selecting appropriate treatment algorithm for advanced NSCLC pts.

No significant financial relationships to disclose.

[Table: see text]

Surrogate endpoints for overall survival (OS) in advanced pancreatic cancer (APC): Analysis of randomized clinical trials (RCTs) exploring gemcitabine (G)-based combinations

4575

Background: G-based combinations often result in an improved overall response rate (ORR) in APC; this improvement in ORR, however, seldom translates into a significant OS advantage. We therefore evaluated the appropriateness of ORR and progression-free survival (PFS) as surrogate endpoints for OS in RCTs comparing single-agent G and G-based combinations as first-line treatment for APC. Methods: Phase III trials reporting ORR or PFS and OS data were considered eligible. Potential correlations were explored according to a linear regression model considering both the actual outcome (ORR or PFS and OS) for each single arm and the calculated relative risk (RR) for each outcome in paired comparisons. Correlation was estimated according to Pearson’s (r) and R2 coefficients (parametric) and Spearman’s (Rho) coefficient (non-parametric). A model to calculate the target sample size to correctly identify 0.4, 0.7, and 1.5 mos benefits in OS was derived as well. Results: Nineteen (6,288 pts) and 17 (4,882 pts) RCTs were identified for the ORR/OS and PFS/OS correlation, respectively. When considering ORR rates and medians, ORR did not significantly correlate with OS (r=0.23, R2=0.06, p=0.14; Rho=0.16, p=0.33), while PFS showed a strong linear correlation (r=0.75, R2=0.56, p<0.0001; Rho=0.90, p<0.0001). Similarly, when considering RRs, ORR did not significantly correlate with OS (r=-0.17, R2=0.03, p=0.46; Rho=-0.18, p=0.44), while PFS showed a strong linear correlation (r=0.91, R2=0.82, p<0.0001; Rho=0.59, p=0.01). Based on these data, we derived a sample size model (beta-coefficient=0.75) to calculate how many patients would be necessary to demonstrate a significant OS advantage of 0.4, 0.7 and 1.5 mos, respectively, using PFS as a surrogate endpoint; according to this model, 0.5, 1, and 2 months improvements in PFS would be necessary to translate into the target OS advantages, requiring 2,370, 678 and 222 pts, respectively. Conclusions: In APC, ORR does not seem to correlate with OS. Conversely, PFS could be a reliable surrogate endpoint for survival in this setting, although the detection of relatively small differences in PFS would require a remarkably large sample size.

No significant financial relationships to disclose.

Adjuvant LH-RH agonists for premenopausal early breast cancer: A meta-analysis of randomized clinical trials (RCTs) exploring the magnitude of the disease-free and overall survival (DFS/OS) benefit

592

Background: LH-RH agonists are considered as a milestone for adjuvant treatment for premenopausal early breast cancer patients (pts). All RCTs in which ovarian ablation (OA) with/without tamoxifen (TAM) and/or chemotherapy (CT) was compared with tamoxifen (TAM) and/or chemotherapy (CT) were pooled to estimate the magnitude of the benefit in both DFS and OS. Methods: A literature-based meta-analysis was accomplished, and event-based relative risk ratios (RRs) with 95% confidence interval (CI) were derived. A fixed- (FEM) and a random-effect (REM) model according to the inverse variance and heterogeneity (Het) test were applied as well. Absolute benefits (AB) and the number of pts needed to treat (NNT) were calculated. A sensitivity analysis to test for effect robustness in 4 sub-populations (OA/OS vs CT; OA/OS + CT vs CT; OA + TAM vs CT; OA + TAM vs observation) was accomplished. Results: Fifteen RCTs were gathered (12,545 pts); one RCT did not report the OS result. Results are depicted in the table . Conclusions: Although differences across RCTs exist in median follow-up time (as demonstrated by heterogeneity), OA seems to significantly improve DFS when combined with CT over CT alone, when combined with TAM versus CT alone and when combined with TAM versus observation. Actually, these DFS benefits do not translate into an OS benefit, with the exception of the last subgroup.

[Table: see text]

No significant financial relationships to disclose.

Activity and tolerability of mitomycin-C (MMC) and chronomodulated capecitabine (C) in advanced colorecatal cancer (ACC) patients

13563

Background: MMC plus continuous infusion (CI) 5-fluorouracil (5-FU) showed activity with acceptable toxicity profile in ACC patients (pts). Nocturnal infusion of 5-FU was shown to reduce hematological and gastrointestinal toxicity. Capecitabine (C) is an oral pro-drug converted to 5-FU which mimics 5-FU CI activity. C is effective as single drug and in combination, providing equivalent activity and efficacy. Aim of the study was to evaluate activity and tolerability of MMC plus C in ACC patients. Methods: fifty-one pts received MMC 7 mg/mq i.v on day 1 followed by C 2000 mg/mq /die for 14 days out of 21 days; 20% of C dose was given at 8:00 while 80% was given at 20:00; each course (c)was repeated q 6 weeks. Pts data: M/F 33/18; median age: 64 (41–88); WHO PS0: 36, 1: 11, ≥2 :2; metastatic sites: liver (35), lung (17), lymphonodes (9), peritoneum (8), other (14); no measurable disease 1; site: colon/rectum 40/11; previuos lines: 0 (17), 1(18), ≥2(16); 43% and 29% of patients had been previously treated by 5-FU with oxaliplatin or irinotecan. Results: Toxicity was evaluated in 45 out of 51 pts and in 94 courses. Grade 2–3 neutropenia occurred in 5 pts/8 c (10/6%), G2-G3 thrombocitopenia in 4 pts/8 c (8/6%). One pt (2%) experienced G3 anemia. G2–3 nausea and vomiting occurred in 5 pts/5 (10/5%), G2–3 diarrhea in 8 pts/12 c (15/13%) and only 1 pt experienced G4 diarrehea. Mucositis of grade 2 was observed in 3 pts/ (6%). G2–3 hand foot syndrome and G2–3 asthenia both occurred in 5 pts (10%). No differences in toxicity were observed between pre-treated and untreated pts. At this time of the study 45 out of 51 pts were evaluated for response: stable disease was observed in 16 pts (31%), partial response in 5, untreated, patients (10%), progression in 23 (45%). Median time to progression (TTP) was 6,0 months (3,0- 8,5 mo) for both groups. Conclusions: Chronomodulated administration of C plus MMC seems to have an excellent toxicity profile even in pre-treated population, with a TTP similar to more expensive treatments.

No significant financial relationships to disclose.

Ten-year experience with weekly chemotherapy in metastatic breast cancer patients: Multivariate analysis of prognostic factors

10652

Introduction: Weekly administration of chemotherapy represents an emerging option for the treatment optimization of metastatic breast cancer (MBC). Moreover, evidences suggest a intriguing mechanism of action for weekly paclitaxel, which involves pro-apoptotic and anti-angiogenetic pathways. In order to identify clinical and biological prognostic factors for weekly chemotherapy outcome, we performed a multivariate analysis in a 10-years experience of weekly 1st line chemotherapy for MBC patients. Methods: The original databases of phase II trials of MBC patients undergone 1st line weekly chemotherapy were collected. Clinical and biological co-variables were screened for the eventual relationship with time to progression (TTP) and overall survival (OS) into a Cox model. Results: From 1990 to 2003, 184 patients were enrolled in 3 consecutive phase II studies, to evaluate activity and tolerability of weekly epirubicin with lonidamine, or vinorelbine or paclitaxel, for 24 weeks. All patients were evaluable for clinical variables, while histological samples were available in only 40 patients. At a median follow-up of 24 months, median TTP was 9 months (95% CI 8–10) and median OS 34 (95% CI 24–42). Independent variables were: response (HR 2.34, p < 0.0001), receptor status (HR 1.62, p = 0.01) Performance Status (PS) (HR 2.31, p < 0.0001) for TTP, and response (HR 1.86, p = 0.005), PS (HR 2.81, p < 0.0001), dominant metastatic site (HR 2.27, p < 0.0001), enrollment period (HR 2.51, p = 0.001) for OS. Although no biological factors entered the Cox model due to the small sample size, some sub-populations showed negative trend in survival. Conclusions: In our series of patients undergone weekly chemotherapy for MBC, independent prognostic factors for survival improvement were responders, PS 0–1, non-visceral dominant metastatic site, and enrollment period. Further greater populations are needed to extensively screen for biological prognostic factors.

No significant financial relationships to disclose.

Current status of targeted agents in advanced pancreatic cancer (APC): A pooled analysis of 2,361 patients (pts) enrolled in six phase III trials

4126

Background: Molecular targeting of pathways that are deregulated in pancreatic cancer is a promising approach aimed at improving the dismal prognosis of APC pts. However, the clinical impact of novel “biological” drugs (ND) remains to be defined. Methods: All prospective phase III trials comparing single-agent Gemcitabine (G) with either a ND or a combination of ND and G (ND+G) were considered eligible. A pooled analysis was performed and event-based relative risk ratios (RR) with 95% CI were derived through both a fixed- and a random-effect model approach, exploring OS as the primary outcome and PFS and ORR as secondary outcomes. Heterogeneity between different trials was also taken into account. Results: Six trials involving 2361 pts were identified; ND tested included: FTI inhibitors (1 trial), MMP inhibitors (3 trials), EGFR inhibitors (1 trial), and anti-gastrin vaccine (1 trial). The analysis was conducted considering three different subgroups: 1) overall population (2361 patients, 6 trials), 2) ND+G vs G (1879 patients, 4 trials), and 3) ND vs G (482 patients, 2 trials). As shown in the table, no significant differences in either the primary outcome (OS) or the secondary outcome of PFS were observed in the overall population as well as in ND+G vs G trials, while a significant negative trend for ND was found in ND vs G trials with regard to both endpoints. Conversely the evaluation of the secondary endpoint of ORR significantly favored G in the overall population as well as in ND vs G trials, while a not significant negative trend for ND was observed in ND+G vs G trials. Conclusions: G remains the treatment of choice in APC pts. The ND tested, either alone or combined with G, do not seem to add any benefit over G. A better understanding of pancreatic cancer biology and further clinical evaluation of new agents and is needed to improve prognosis in APC pts.

[Table: see text]

No significant financial relationships to disclose.

Gemcitabine-based polychemotherapy for advanced pancreatic cancer (APC): Is it ready for prime time? A pooled analysis of 3,682 patients (pts) enrolled in 12 phase III trials

4118

Background: Since the introduction of gemcitabine (G), attempts have been made to develop G-based combination regimens to improve the dismal outcome of APC pts. Results of randomized trials, however, have been conflicting and single-agent G presently remains the standard of care for such pts. Methods: All prospective phase III trials comparing single-agent G with G-based polychemotherapy regimens (poly-G) were considered eligible. A pooled analysis was performed and event-based relative risk ratios (RR) with 95% CI were derived through both a fixed- and a random-effect model approach, exploring OS as the primary outcome and PFS and ORR as secondary outcomes. Heterogeneity between different trials was also taken into account. Results: Twelve trials involving 3682 pts were identified. The analysis was conducted considering three different subgroups: 1) overall population (3682 patients, 12 trials), 2) platinum-containing poly-G (PG) vs G (768 pts, 5 trials), and 3) fluoropyrimidine-containing poly-G (FG) vs G (1640 pts, 4 trials). As shown in the table, no significant differences in the primary outcome (OS) were observed in any of the three groups analyzed. Conversely, a significant advantage for poly-G was evident with regard to both PFS and ORR in the overall population as well as in the PG vs G subgroup, although with some heterogeneity. A heterogeneous non-significant trend towards a better PFS and ORR outcome was also observed in the FG vs G subgroup. Conclusions: Single-agent G remains the treatment of choice in APC pts. However, the addition of platinum compounds to G appears to significantly improve PFS and ORR, possibly justifying the use of platinum-based poly-G in younger and fit patients.

[Table: see text]

No significant financial relationships to disclose.

Fixed dose-rate gemcitabine infusion as first-line treatment for advanced-stage carcinoma of the pancreas and biliary tree: series of 106 consecutive patients

14099

Background: Our group recently published a phase II trial of GEM infused at fixed dose-rate of 10 mg/m2/min over 100 min in patients with advanced PDAC and BTC. (Cancer September 15,2005). Given the promising results obtained in the first 40 pts, we expanded the cohort under an observational protocol and this is the report of such experience. Methods: From April 2002 to September 2005, 106 advanced PDAC (n = 75) or BTC (n = 31) pts (median age: 63 yrs, range 28–82; M/F: 48/58; PDAC/BTC: 75/31; LA/Met: 36/70; PS 0/1/2/3: 31/53/17/5) were treated with GEM 1000 mg/m2 at the fixed dose-rate of 10 mg/m2/min for 7 consecutive wks and weekly × 3 q4 wks thereafter (FDR-GEM). All patients and 1154 treatment weeks were evaluable for toxicity, 100 were evaluable for response, 87 patients were evaluable for clinical benefit response (CBR) according to Burris criteria, and 56 patients had elevated CA19.9 serum levels at entry. Results: From April 2002 to September 2005, 106 advanced PDAC (n = 75) or BTC (n = 31) pts (median age: 63 yrs, range 28–82; M/F: 48/58; PDAC/BTC: 75/31; LA/Met: 36/70; PS 0/1/2/3: 31/53/17/5) were treated with GEM 1000 mg/m2 at the fixed dose-rate of 10 mg/m2/min for 7 consecutive wks and weekly × 3 q4 wks thereafter (FDR-GEM). All patients and 1154 treatment weeks were evaluable for toxicity, 100 were evaluable for response, 87 patients were evaluable for clinical benefit response (CBR) according to Burris criteria, and 56 patients had elevated CA19.9 serum levels at entry. Conclusions: The results obtained with FDR-GEM in a series of 106 consecutive pts confirm previous results obtained in smaller series and suggest that pharmacokinetically rationale GEM scheduling may improve its therapeutic index. FDR-Gem may constitute a viable alternative to standard Gem infusion as first-line treatment in advanced PDAC and BTC.

No significant financial relationships to disclose.

Hormonal adjuvant treatment plus radiotherapy versus exclusive radiotherapy in locally advanced prostate cancer: Pooled analsys of 6 randomized trials

4642

Background: The magnitude of the benefit of adding adjuvant hormonal treatment to radiotherapy for locally advanced prostate cancer is still unclear. We performed a pooled-analysis of phase III trials, to quantify the eventual benefit in recurrence decrease. Methods: All prospective phase III trials were considered eligible. A pooled analysis was accomplished, and event-based relative risk ratios (RR) with 95% confidence interval (CI) were derived through both a fixed- (FEM) and a random-effect model (REM) approach. Significant differences in primary outcome (recurrence rate), and secondary outcomes (overall survival), were explored. Magnitude outcome measures were: absolute benefits and number of patients needed to treat (NNT) for 1 patient to benefit. Heterogeneity test was applied as well. Results: Six trials designed to look if hormonal treatment plus radiotherapy decreases recurrence rate (3,571 patients) were gathered. In the primary outcome, the combined approach significantly improves the recurrence rate when applying the FEM (RR 0.72, 95% CI 0.68, 0.77, p < 0.0001), with an absolute benefit of 10.7%. The NNT was 9 patients. Although significant heterogeneity was found (p = 0.00001), the benefit remains significant at the REM as well (RR 0.67, 95% CI 0.54, 0.82, p < 0.0001). Although significant at FEM (RR 0.93, 95% CI 0.86, 1.00, p = 0.039) but heterogeneous (p = 0.0007), the overall survival demonstrated a not-significant trend in favour of the combined strategy at REM (RR 0.90, 95% CI 0.75, 1.10, p = 0.263). Conclusions: Considered all the available phase III trials, the combination of adjuvant hormonal treatment with radiotherapy over standard exclusive radiotherapy significantly decreases the recurrence rate in patients affected by localized prostate cancer. The significant heterogeneity in the analysis underscores the existing difference in patient’ characteristics. No significant benefit in overall survival was found.

No significant financial relationships to disclose.

Early switch with aromatase inhibitors as adjuvant hormonal therapy for postmenopausal breast cancer: Pooled-analysis of 8,794 patients

635

Background: The magnitude of the survival benefit of aromatase inhibitors (AIs) after 2–3 years of tamoxifen as adjuvant hormonal therapy for early breast cancer is still unclear. We performed a pooled-analysis of phase III trials, to look how much advantages adjuvant the “early switch” strategy add over standard tamoxifen for 5 years. Methods: All phase III trials were considered eligible. A pooled analysis was accomplished, and event-based relative risk ratios (RR) with 95% confidence interval (CI) were derived. Significant differences in primary outcome (EFS and RFS, event- and relapse-free survival), and secondary outcomes (OS, overall survival, deaths in absence of progression, other cancers and toxicities), were explored. Magnitude outcome measures were: absolute benefits (AB) and number of patients needed to treat (NNT). Heterogeneity test was applied as well. Results: Four trials designed to look if AIs after 2–3 yrs of TAM improve EFS (8794 patients) were gathered. Conclusions: Considered all the available phase III trials, the early switch strategy improves survival over standard tamoxifen for 5 years, with a different toxicity profile. The lack of significant heterogeneity in the analysis underscores the homogenous effect across all trials.

[Table: see text]

No significant financial relationships to disclose.

Epidermal growth factor gene amplification is not frequent and cannot account for antitumor activity of cetuximab plus chemotherapy in advanced colorectal cancer patients

3561

Cetuximab has been shown to be active in the metastatic colorectal cancer, but EGFR detection by immunohistochemistry is not predictive for tumor response. Moroni et al (Lancet Oncology 2005) showed that, in patients responsive to Cetuximab, EGFR gene copy number, assessed by FISH, was increased. On this basis, copy number and protein status of EGFR were investigated in 70 primary and/or metastatic colorectal carcinomas. Protein expression was assessed by immunohistochemistry (IHC) using DAKO EGFRPharmDX kit. Gene and chromosome 7 copy numbers were identified by fluorescent in situ hybridization (FISH). Dual-target, dual-color FISH assays were performed using the LSI EGFR SpectrumOrange/CEP 7 Spectrum Green probe. EGFR gene copy number, chromosome 7 copy number and the average EGFR gene to chromosome 7 signal ratio were reported as FISH genetic variables. Chromosome 7 was polysomic when cancer cells showed multiple centromere signals: low polysomy (2 to 5 signals), high polysomy (>5 signals). Samples with a ratio value ≥ 2.0 were considered to be amplified. EGFR protein was overexpressed in 57 out of 70 patients (81%). In the group of 58 patients evaluated as polysomic, 48 (82,7%) had a low polysomy level, whereas 20 (12.7%) had a high polysomy level. Gene amplification was seen only in 3/70 patients. High polysomy was evidenced only in the group of patients displaying an EGFR IHC score 2+/3+. Forty-six pretreated patients received a cetuximab-based treatment. Response to treatment has been already evaluated in 26 FISH-negative patients while for the other 20 it is still too early. We observed 7 PR (27%), 9 SD (35%) and 10 PD (38%). This study shows that in this series of advanced colorectal cancer patients, EGFR amplification, measured by FISH, is a rare event (4%) and could be considered together with chromosome 7 polysomy for the antitumor activity.

No significant financial relationships to disclose.

Second- and third-generation aromatase inhibitors as first-line endocrine therapy in postmenopausal metastatic breast cancer patients: a pooled analysis of the randomised trials

The purpose of this study was to estimate in all randomised trials the relative risk of overall response rate (ORR), clinical benefit (CB), time to progression (TTP), overall survival (OS), and toxicity of aromatase inhibitors (AI), compared with tamoxifen (Tam) as first-line endocrine therapy in postmenopausal metastatic breast cancer (PMBC) women. Prospective randomised studies were searched through computerised queries of MEDLINE, EMBASE, and the American Society of Clinical Oncology (ASCO) abstract database. Relative risk, 95% confidence interval, and heterogeneity were derived according to the inverse variance and Mantel–Haenszel method and Q statistics. Six phase III prospective randomised trials including 2787 women were gathered. A significant advantage in ORR (P=0.042), TTP (P=0.007), and CB (P=0.001) in favour of AI over Tam was detected at the fixed effects model. These results were not significant at the random effects model, owing to the significant heterogeneity. On the contrary, no difference was registered for OS (P=0.743) with no significant heterogeneity. Regarding toxicity, Tam caused more frequently thromboembolic events (P=0.005) and vaginal bleeding (P=0.001) compared with AI. Aromatase inhibitors appear to be superior to Tam as first-line endocrine option in PMBC women. Owing to a component of variability between the six studies analysed, the random effects estimates differed from corresponding fixed ones. Investigators should assess heterogeneity of trial results before deriving summary estimates of treatment effect.

Malignant glucagonoma. New options of treatment

Few cases of malignant glucagonomas have been described in the literature. In this paper we present a case of a 77-year-old woman with necrolytic migratory erythema and high plasma glucagon and chromogranin A levels caused by a neuroendocrine tumour. An abdominal CT scan suggested a pancreatic lesion and two liver metastases. The patient underwent pancreatic debulking and liver metastasectomy. Histological and immunohistochemical investigations revealed a well differentiated neuroendocrine tumour with vascular invasion and scattered immunopositivity for somatostatin receptors. The patient was treated with octreotide (20 mg i.m. every 28 days) for three years without side effects. Three months after surgery symptoms of disease recurred accompanied by hyperglucagonaemia and newly diagnosed liver lesions. The patient was treated with octreotide (30 mg i.m. every 28 days) and interferon-alpha (6 MU s.cc 3 times per week) plus three cycles of hepatic chemoembolisation. Symptoms resolved after the first month of therapy, hormone levels decreased compared to untreated levels and metastatic growth slowed as observed by radiographic evidence. The patient is now asymptomatic with persistent hepatic disease and normal serum glucagon levels forty months after primary treatment. So far, only few immunohistochemical studies are reported on malignant glucagonoma and combined treatment schedules. We demonstrated, for the first time, a scattered immunopositivity for somatostatin receptors in a malignant glucagonoma. For this reason, the somatostatin analogs therapy was instituted. A combined antiproliferative medical treatment and the hepatic chemoembolization have been able to control tumor growth and disease symptoms for a long time after surgery.

Darbepoetin alfa for the treatment of anemic patients with low- and intermediate-1-risk myelodysplastic syndromes

BACKGROUND

The hematological and quality of life (QoL) changes associated with darbepoetin alfa (DA) therapy were assessed in anemic patients with previously untreated low- and intermediate-1-risk myelodysplastic syndrome (MDS).

PATIENTS AND METHODS

Fifty-three patients received DA administered subcutaneously once a week for 24 weeks. Treatment was initiated at 150 microg fixed dose and was doubled if after the first 12 weeks there was no or suboptimal erythroid response.

RESULTS

The final response rate was 24/53 (45%), with 21 major and three minor responses. Most of the responses (21/24; 87.5%) were obtained at the dose of 150 microg. With a median follow-up of 9.4 months, 17 patients maintain their response. Treatment was well tolerated with no relevant side-effects. MDS progression was observed in one case. Increases in hemoglobin levels were positively correlated with improved QoL scores using both the linear analog scale assessment (energy level, r = 0.429, P = 0.036; daily activities, r = 0.653, P < 0.001; overall well-being, r = 0.457, P = 0.024) and the Functional Assessment of Cancer Therapy-Anemia questionnaire (r = 0.247, P = 0.025). In multivariate analysis, only low levels (<200 IU/l) of endogenous erythropoietin predicted response to DA therapy.

CONCLUSIONS

DA is an active, safe and well tolerated treatment for anemia in a substantial proportion of patients with low- and intermediate-1-risk MDS, and has a positive impact on the patients' QoL.

Once-weekly dosing of recombinant human erythropoietin alpha in patients with myelodysplastic syndromes unresponsive to conventional dosing

BACKGROUND

Once-weekly dosing of recombinant human erythropoietin (rhEPO) in patients with myelodysplastic syndromes (MDS) has not been investigated thoroughly. We performed a clinical trial to evaluate the effects of this new dosing regimen in patients with MDS who were unresponsive to the conventional three-times-weekly schedule.

PATIENTS AND METHODS

Forty-eight patients with low- or intermediate-risk MDS were enrolled in a 12-week study. rhEPO alpha (rhEPOalpha) was administered once-weekly by subcutaneous injection with a starting dose of 40,000 U fixed dose. The drug dosage was increased to 60,000 U fixed dose if after 6 weeks there was no or suboptimal erythroid response.

RESULTS

Clinically significant responses were seen in 13 (27%) patients, with 11 improving their response after dose escalation of rhEPOalpha. Only one patient (case 23) maintains a response after a follow-up period of 14 months. All other patients had responses lasting between 10 and 43 weeks, with a median time to relapse of 20 weeks. Treatment was well tolerated, with no relevant adverse events. Response to therapy was associated with significantly higher concentrations of circulating erythroid blast-forming units and a decrease of the bone marrow fraction of apoptic CD34+ cells.

CONCLUSIONS

Once-weekly rhEPOalpha therapy results in an improvement of erythropoiesis in a subset of MDS patients who are unresponsive to conventional dosing, and may act by inhibiting apoptosis of erythroid precursors. These results warrant further investigation of this dosing regimen either alone or in combination with other agents.

Single-agent vinorelbine in pretreated breast cancer patients: comparison of two different schedules

This retrospective study compared toxicity and activity of vinorelbine according to two schedules with different projected dose intensities in heavily pretreated breast cancer patients. Forty patients were assessable for toxicity and activity in each group; group A received vinorelbine 25 mg/m2 week + lenograstim (150 microg/m2 s.c. on day 3); group B received 25 mg/m2 on days 1 and 8 every 3 weeks. The projected dose intensity was 25 mg/m2/week and 16.6 mg/m2/week, and delivered dose intensity 95.2% and 94.5% in group A and B, respectively. Grade 3-4 afebrile neutropenia was recorded in 25% and 37.5% of patients in A and B, respectively. Overall response rate, 52.5% and 35%; no change, 35% and 40%; progression of disease, 12.5% and 25% in A and B, respectively. Median duration of the response was 10 months for group A and 7 months for B. Median time to progression: 9.0 months and 4.0 months for A and B, respectively. At a median follow-up of 45 months for group A and 19 months for group B, median overall survival was 19 months and 16, respectively. In conclusion the results of the study showed that dose intensity of vinorelbine could have an improvement in terms of time to progression in pretreated advanced breast cancer.

A randomized phase II study of combination, alternating and sequential regimens of doxorubicin and docetaxel as first-line chemotherapy for women with metastatic breast cancer

BACKGROUND

This randomized phase II study was conducted to evaluate the efficacy of doxorubicin and docetaxel (DOC) administered either as a combination, an alternating or a sequential regimen in women with metastatic breast cancer. Secondary objectives included overall response, time to progression, survival and safety.

PATIENTS AND METHODS

Patients with breast cancer (n=123) were randomized to receive doxorubicin and DOC either in combination (60 mg/m2 of each drug), or by alternated or sequential schedule (100 mg/m2 DOC and 75 mg/m2 doxorubicin) every 3 weeks for a maximum of eight cycles as first chemotherapy for stage IV disease. A second randomization allocated patients from each arm to receive prophylactic oral ciprofloxacin or no therapy to prevent febrile neutropenia.

RESULTS

Patients received a median of eight cycles. In an intention-to-treat analysis, the overall response was 63%, 52% and 61% in the combination, alternating and sequential schedules, respectively. Corresponding rates of complete response were 15%, 14% and 11%. Grade 4 neutropenia was common in all arms (81%) and, together with febrile neutropenia, was significantly more frequent with the combination. Prophylaxis with ciprofloxacin did not reduce the incidence of febrile neutropenia or infection. Other frequent non-hematological adverse events included alopecia, nausea, vomiting, stomatitis and asthenia. Congestive heart failure only occurred in the combination arm (10%).

CONCLUSION

All three schedules are feasible and endowed of good therapeutic activity. In view of the more pronounced toxicity and the risk of cardiac events because of the higher exposure to doxorubicin, the combination should be least favored when treating women with metastatic breast cancer. Prophylaxis with ciprofloxacin was ineffective and is not recommended.

A phase II study of irinotecan plus chronomodulated oxaliplatin, 5-fluorouracil and folinic acid in advanced colorectal cancer patients

The combination of irinotecan (CPT-11), oxaliplatin (L-OHP), 5-fluorouracil (5-FU) and folinic acid (FA) is one of the possibilities to overcome chemoresistance in advanced colorectal cancer (ACRC) patients. The aim of this study was to determine the tolerability and activity of CPT-11 plus chronomodulated infusion of L-OHP, 5-FU and FA in ACRC patients. A total of 35 patients (91% pretreated, 77% with CPT-11, 54% with L-OHP, 42% with both) were treated every 3 weeks with CPT-11, 180 mg m⁻² day 1 i.v., plus L-OHP, 20 mg m⁻² day⁻¹, 5-FU, 700 mg m⁻² day⁻¹ and FA, 150 mg m⁻² day⁻¹, all three drugs from day 2 to day 5 by chronomodulated infusion. The patients' (pt) data were as follows: male/female 21/14; median age 58 years (range: 38–70); PS 0: 26 pts (74%), PS 1: 8 pts (23%), PS 2: 1 pt (3%); primary tumour colon/rectum 26/9; involved organs: 1, 14 pts (40%); 2, 17 pts (48%); ⩾3: 4 pts (11%); previous chemotherapy lines 1: 12 pts (34%), 2: 10 pts (28%), ⩾3: 10 pts (28%). A total of 221 courses (c) were performed; no grade 4 toxicity was observed with only one grade 3 (G3) neutropenia and thrombocytopenia (3%) in one out of 221 courses (<1%). Maximal toxicity (G3) was nausea and diarrhoea in 10 pts (28%), occurring in 14 out of 221 c (6%) and 12 out of 221 c (5%) respectively. Seven patients achieved a partial response (20%, confidence interval (c.i.) 6.8–33.3) and one patient a complete response (2.9%, c.i. 0–8.4), for a total overall response rate of 22.9% (c.i. 9–36.8); 15 out of 35 (42.9%, c.i. 26.5–59.3) had stable disease and 12 out of 35 (34.3%, c.i. 18.6–50) patients underwent a progression. In conclusion, this four-drug regimen is feasible in advanced pretreated ACRC patients with no significant haematological toxicity and acceptable diarrhoea. The activity of this combination is currently studied in EORTC 05011 study.