Abstract OT1-11-02: PRAEGNANT - Real world evidence, translational research, big and smart data: A prospective academic translational research network for the optimization of the oncological health care quality in the adjuvant and advanced/ metastatic setting (NCT02338167)

Background

During the last decades the treatment of advanced breast cancer (ABC) patients has improved due to a variety of new treatment strategies. Nevertheless, many ABC patients are faced with limited prognosis, and their treatment remains a challenge. New targeted therapies complement the well-established treatment options for ABC (CDK4/6 inhibition, anti-endocrine, chemotherapy, antibody based and bone related therapies), leading to improved treatment regimens tailored to the needs of special patient sub-populations.

SPECIFIC AIMS/TRIAL DESIGN

The PRAEGNANT network study is conducted as an academic, prospective registry and diagnostic translational study, accompanied by biomaterial collection. The pilot phase in more than 60 centers aims at including 3500 ABC patients. The primary objective is to discover biomarkers, which predict progression free survival (PFS). Secondary objectives include overall survival (OS), breast cancer specific survival, objective response rate, patient reported outcomes (PRO), description of therapies used in the metastatic setting, therapy adherence, health economics for patients with ABC, incidence of (serious) adverse events and big data/ machine learning algorithms. The exploratory objectives comprise correlations of gene alterations and their influence on OS, PFS, side effects and PRO. Exploratory biomarkers are assessed at baseline and at every change of therapy. These biomarkers include gene expression profiling of the primary tumor and corresponding metastasis, somatic mutations (measured in the tumor and in circulating tumor DNA), germline genetic variations, epigenetic changes and miRNA variations. Furthermore, plasma and serum markers are assessed. If actionable molecular alterations are detected patients are informed and recruited into suitable studies if available.

ELIGIBILITY CRITERIA:

Any adult patient (>18 years) with the diagnosis of ABC and who is willing and able to sign the informed consent can be enrolled.

STATISTICAL METHODS/TARGET ACCRUAL:

The PRAEGNANT study as a prospective real world registry and diagnostic translational study aims to identify biomarkers in ABC patients, which may predict PFS. Target accrual for the pilot phase is 3500 patients. Each patient will be documented for up to 36 months with an estimated median PFS for all patients of 11 months across all treatment lines.

Citation Format: Müller V, Huober J, Volz B, Overkamp F, Kolberg H-C, Hadji P, Haeberle L, Ettl J, Hartkopf AD, Lux MP, Lüftner DI, Wallwiener M, Taran F-A, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Lermann J, Abenhardt A, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Janni W, Fehm TN, Brucker SY, Wallwiener D, Schneeweiss A, Fasching PA, Tesch H. PRAEGNANT - Real world evidence, translational research, big and smart data: A prospective academic translational research network for the optimization of the oncological health care quality in the adjuvant and advanced/ metastatic setting (NCT02338167) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-11-02.

Abstract P6-17-37: Therapy landscape of patients with metastatic, HER2 positive breast cancer - Data from the real world breast cancer registry PRAEGNANT (NCT02338167)

Purpose:

This analysis describes comprehensive real-world data concerning the use of anti-HER2 therapies in HER2 positive metastatic breast cancer (MBC). Specifically, it describes the therapy patterns of treatments with trastuzumab (TZM), pertuzumab+trastuzumab (PTZ/TZM), lapatinib (LAP) and trastuzumab emtansine (T-DM1).

Methods:

The PRAEGNANT study is a real-time, real-world registry for patients with MBC. Patients can be registered for PRAEGNANT at any time during the course of their metastatic disease and are followed up until death. All therapy lines are documented. This analysis presents the utilization of anti-HER2 therapies as well as therapy sequences.

Results:

Of 1936 patients within PRAEGNANT at the time of database closure 451 were HER2 positive (23.3%). Within the analysis set (417 patients after an unilateral breast cancer diagnosis), of which 53% were included in PRAEGNANT in the 1stline setting, 241 were treated with TZM (58%), 237 with PTZ (57%), 85 with LAP (20%) and 125 with T-DM1 (30%) during the course of their therapies. The sequence PTZ/TZMàT-DM1 was given to 51 patients (12%). Worse ECOG, negative hormone receptor status, and visceral or brain metastases were associated with a more frequent use of this therapy sequence. Most patients received T-DM1 after a therapy with pertuzumab.

Conclusions:

Both novel therapies (PTZ/TZM and T-DM1) are utilized in a high proportion of HER2 positive breast cancer patients. As most patients receive T-DM1 after pertuzumab real world data might help to understand whether this sequence has similar efficacy like in the approval study.

Citation Format: Lux MP, Hartkopf AD, Huober J, Volz B, Taran F-A, Overkamp F, Hadji P, Tesch H, Haeberle L, Ettl J, Lueftner DI, Wallwiener M, Müller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Lermann J, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Fasching PA, Janni W, Fehm TN, Wallwiener D, Brucker SY, Schneeweiss A, Kolberg H-C. Therapy landscape of patients with metastatic, HER2 positive breast cancer - Data from the real world breast cancer registry PRAEGNANT (NCT02338167) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-37.

Abstract P6-17-22: Progression free survival (PFS) and overall survival (OS) of patients treated with trastuzumab emtansine (T-DM1) after previous treatment with pertuzumab in patients with advanced breast cancer (NCT02338167)

Background

Studies leading to the approval of trastuzumab emtansine (T-DM1) have been conducted without pertuzumab as previous therapy. Therefore data about patient characteristics and the efficacy of T-DM1 after a treatment with pertuzumab is scarce. Aim of this study was to analyze a real world patient cohort of advanced breast cancer (aBC) patients, who were treated with T-DM1 after a treatment containing pertuzumab in the metastatic setting with regard to patient characteristics and progression free survival (PFS).

Methods

The PRAEGNANT metastatic breast cancer registry (NCT02338167) is a prospective registry for metastatic breast cancer patients with focus on molecular biomarkers. Patients of all therapy lines with any kind of treatment are eligible for this registry. Collected data comprises all relevant patient and tumor characteristics, therapies, adverse events, quality of life, patient reported outcomes, response and survival (PFS/OS). Here we report on the patient characteristics and PFS data for HER2 positive patients treated with T-DM1 after a treatment with pertuzumab. Patients had to be included before or at the beginning of the T-DM1 therapy.

Results

A total of 58 patients could be identified, who were suitable for the analysis. Of those 34 were treated in the second line, 14 in the third line and 10 in the fourth line or higher. Most of the pertuzumab therapies before T-DM1 were conducted in first line (n=46; 79.3%). Median PFS for all patients was 4.8 months (95% CI: 3.0-7.8 months). Median PFS for patients treated in the 3rdline and 4thline or higher was 4.2 months(95%CI: 2.3 - NA) and 4.0 months (95%CI: 1.8-N.A.), respectively. In patients treated 2ndline with T-DM1 PFS was 7.7 months (95%CI: 2.8 – 12.2).

Conclusion

T-DM1 is effective as 2ndand further line therapy following pretreatment with pertuzumab. Overall PFS was about 5 months with 7.7 months as 2nd-line therapy. The PFS in higher therapy lines might be shorter. As the sample size of this real world cohort was rather low and analyses have to be considered exploratory, this data need to be confirmed in studies with a larger sample size.

Citation Format: Schneeweiss A, Lux MP, Hartkopf AD, Volz B, Kolberg H-C, Hadji P, Tesch H, Haeberle L, Ettl J, Lüftner DI, Wallwiener M, Müller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Lermann J, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Overkamp F, Huober J, Taran F-A, Janni W, Wallwiener D, Brucker SY, Fasching PA, Fehm TN. Progression free survival (PFS) and overall survival (OS) of patients treated with trastuzumab emtansine (T-DM1) after previous treatment with pertuzumab in patients with advanced breast cancer (NCT02338167) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-22.

Gemcitabine combined with the monoclonal antibody nimotuzumab is an active first-line regimen in KRAS wildtype patients with locally advanced or metastatic pancreatic cancer: a multicenter, randomized phase IIb study

Background

This randomized study was designed to investigate the superiority of gemcitabine (gem) plus nimotuzumab (nimo), an anti-epidermal growth factor receptor monoclonal antibody, compared with gem plus placebo as first-line therapy in patients with advanced pancreatic cancer.

Patients and methods

Patients with previously untreated, unresectable, locally advanced or metastatic pancreatic cancer were randomly assigned to receive gem: 1000 mg/m2, 30-min i.v. once weekly (d1, 8, 15; q29) and nimo: fixed dose of 400 mg once weekly as a 30-min infusion, or gem plus placebo, until progression or unacceptable toxicity. The primary end point was overall survival (OS), secondary end points included time to progression, overall response rate, safety and quality of life.

Results

A total of 192 patients were randomized, with 186 of them being assessable for efficacy and safety (average age 63.6 years). One-year OS/progression-free survival (PFS) was 34%/22% for gem plus nimo compared with 19%/10% for gem plus placebo (HR = 0.69; P = 0.03/HR = 0.68; P = 0.02). Median OS/PFS was 8.6/5.1 months for gem plus nimo versus 6.0/3.4 mo in the gem plus placebo group (HR = 0.69; P = 0.0341/HR = 0.68; P = 0.0163), with very few grade 3/4 toxicities. KRAS wildtype patients experienced a significantly better OS than those with KRAS mutations (11.6 versus 5.6 months, P = 0.03).

Conclusion

This randomized study showed that nimo in combination with gem is safe and well tolerated. The 1-year OS and PFS rates for the entire population were significantly improved. Especially, those patients with KRAS wildtype seem to benefit. The study was registered as protocol ID OSAG101-PCS07, NCT00561990 and EudraCT 2007-000338-38.

Abstract P3-11-07: Factors associated with first line chemotherapy use in patients with hormone receptor positive, HER2 negative metastatic breast cancer – data from the PRAEGNANT breast cancer registry

Background

For breast cancer patients with metastases which are not life threatening national and international guidelines recommend the exhaustion of all antihormonal therapeutic options before recommending chemotherapy. In Germany up to now only everolimus was an additional option to overcome endocrine resistance. CDK4/6 inhibitors recently became available in Germany (Nov 2011). Aim of this analysis was the identification of predictors for a decision against an antihormonal treatment.

Methods

The PRAEGNANT metastatic breast cancer registry (NCT02338167) is a prospective registry for metastatic breast cancer patients. Besides biomarker research the description of real-world treatment data was one of the main study aims. This analysis was restricted to first line metastatic patients who were hormone receptor (HR) positive and HER2 negative. First, predictors were identified with a multiple logistic regression model. Then patients, who received chemo or not ,were compared with regard to overall survival using Cox regression analysis with the predictors for chemotherapy from above and additionally chemo status (yes/no)

Results

A total of 389 HR-positive and HER2-negative patients with detailed treatment information were included during the 1st line therapy into PRAEGNANT. Of those 173 (44.5%) received a chemotherapy, 190 an antihormone therapy (AHT) (48.8%), and 26 (6.7%) everolimus+AHT. In the multiple logistic regression model, older patients, lower graded tumors, bone only disease and previous adjuvant chemotherapy were associated with a lower rate of first line chemotherapies. BMI and number of concomitant diseases had no influence on the choice of first line metastatic therapy. In patients with visceral metastases 58.1% were treated with a 1st line chemo, while in patients with brain metastases or bone only metastases these numbers were 55.6% and 26.9%. Grading had an influence with patients having a G1, G2 and G3 tumor receiving 1st line chemo in 28.0%, 38.4% and 63.2% of the cases respectively. Patients who received chemo seemed to have a worse overall survival than patients who did not receive chemo (adjusted HR 1.58; 95% CI, 0.89 to 2.18). However, this result was not signifcant (p = 0.12). Overall survival was primarily influenced by ECOG and location of metastasis

Conclusion

The usage of chemotherapy can be predicted with age, metastasis pattern, grading and previous use of chemotherapy. However, we could not show that patients benefited from chemotherapy. On contrary, there was a tendency that patients treated with chemotherapy had poorer overall survival. Further studies with larger sample sizes are needed to confirm this claim.

Citation Format: Huober J, Fasching PA, Taran F-A, Volz B, Overkamp F, Kolberg HC, Hadji P, Tesch H, Haeberle L, Ettl J, Hartkopf AD, Lux MP, Lueftner D, Wallwiener M, Mueller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Fersis N, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Janni W, Wallwiener D, Brucker SY, Schneeweiss A, Fehm TN. Factors associated with first line chemotherapy use in patients with hormone receptor positive, HER2 negative metastatic breast cancer – data from the PRAEGNANT breast cancer registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-11-07.

Abstract P1-07-20: Developing prognostic indicators of poor outcomes in PRAEGNANT metastatic breast cancer cohort

Background: Despite novel, targeted therapies, metastatic breast cancer patients have an extremely unfavourable prognosis. Prognostic and predictive factors for patients with advanced breast cancer are not well understood. Molecular assessment of the patient and the tumor in the metastatic situation is not routinely performed despite advances in molecular precision medicine indicating great benefit to this patient group. Here we present early findings from the first 142 patients of a prospective molecular breast cancer registry with completed transcriptomic profiling.

Methods: The PRAEGNANT study proctocol (NCT02338767) is a molecular registry designed to provide an infrastructure for the real-time comprehensive analysis of tumor and patient molecular characteristics under study conditions. Formalin fixed paraffin embedded tumors have been used from this registry to identify molecular, transcriptomic predictors for overall survival (OS).

Known clinical correlates for OS (e.g. hormone-receptor status, age at diagnosis, and BMI) were analyzed by Cox proportional hazard ratios, and compared to transcriptomic markers of outcomes. Transcriptomes for all patient tumors were sequenced on the Illumina sequencing platform, and analyzed by RSEM to estimate transcripts per million (TPM) values for each gene isoform. Log-TPM values were used in established (PAM50) and novel (hierarchical clustering) expression-based subtyping of tumor samples. Expression-based subtypes were demonstrated to be strong prognostic indicators by Cox analysis. A Lasso regression machine learning algorithm was used to develop an expression-based predictive model of OS.

Results: Hormone receptor positivity (HR=0.7, p<0.006) and TNBC status (HR=1.4, p<0.01) were significantly associated with outcomes. PAM50 subtypes were also strong indicators of outcomes (e.g. Basal disease compared to Luminal-A subtype has HR=1.4, p<0.017). A novel expression-based high-risk cluster in this cohort was more indicative of poor prognosis than clinical variates or Basal-type, with a HR=2.7 (p<0.009) when compared to Luminal-A subtype. An expression-based survival prediction model achieved a concordance-index of 0.65 in an unseen validation cohort. Patients predicted as having the shortest survival times were in the high-risk cluster.

Conclusions: Here we demonstrate using molecular profiling to develop prognostic signatures that out-perform standard clinical correlates of poor outcomes, even in a small subset of the total cohort. As the PRAEGNANT cohort expands these prognostic tools will continue to improve and supplement physician knowledge to improve patient outcomes.

Citation Format: Szeto C, Benz S, Nguyen A, Rübner M, Wallwiener D, Tesch H, Hadji P, Fehm TN, Janni W, Overkamp F, Lueftner D, Lux MP, Wallwiener M, Beckmann MW, Huebner H, Ettl J, Hartkopf AD, Mueller V, Taran FA, Belleville E, Schneeweiss A, Soon-Shiong P, Rabizadeh S, Fasching PA. Developing prognostic indicators of poor outcomes in PRAEGNANT metastatic breast cancer cohort [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-20.

Abstract P5-21-09: Overall survival of metastatic breast cancer patients – data from the PRAEGNANT breast cancer registry

Background

Breast Cancer registries can help to understand how patient groups are treated outside clinical trials and what outcome is to expected for specific patient groups and therapy lines, which are not included into clinical trials. Here we present overall survival data according to therapy lines, patient and tumor characteristics.

Methods

The PRAEGNANT metastatic breast cancer registry (NCT02338167) is a prospective registry for breast cancer patients with focus on molecular biomarkers. Patients of all therapy lines with any kind of treatment are eligible for this registry. Collected data comprises therapies, adverse events, quality of life and other patient reported outcomes. Here we report on the comparison of overall survival data for different patient groups. For that analysis was restricted to patients included in the first therapy line for subgroup comparisons. Only for the analysis of the effect of therapy line on overall survival the complete dataset was used.

Results

A total of 1854 patients took part in this analysis. Of those 1016 were included first line, and 340, 213 and 285 patients 2nd line, 3rd lin4 and 4th line or higher respectively. A total of 339 deaths were observed. Two year survival rates (2Y-OS) for these groups were 75%, 65%, 57% and 36% (p(log-rank)<0.001). All further analyses were done only for the subset of first line treated patients with a total of 127 events. HER2 positive patients had the highest 2Y-OS rate of 84% and TNBC had the worst with 60% (see figure 1). Absolute numbers of deaths for TNBC, luminal A like, luminal B like and HER2 posives were 21, 48, 25, and 21. According to metastastic pattern the following survival rates were seen: brain (48%), other locations (69%), visceral (78%) and bone only (81%). ECOG was another factor that had a large influence on OS with ECOG 0: 83%, ECOG 1: 67% and EGOG 2+: 63% 2Y-OS. Age, BMI, number of concomitant diseases, and primary metastatic status did not have an influence on 2Y-OS.

Conclusion

This breast registry included patients over all therapy lines however mainly during the 1st line of therapy. Simple patient and tumor characteristics can classify patients into patients with differently favourable prognosis. Patients with HER2 positive disease had the best overall survival, while TNBC and luminal B like patients had the worst prognosis. As most of the patients were luminal A like 43% of all deaths occured within the group of luminal A like patients, which will need further focus for therapy development in the future.

Citation Format: Taran F-A, Fasching PA, Volz B, Huober J, Overkamp F, Kolberg HC, Hadji P, Tesch H, Haeberle L, Ettl J, Lux MP, Hartkopf AD, Lueftner D, Wallwiener M, Müller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Fersis N, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Janni W, Fehm TN, Wallwiener D, Brucker SY, Schneeweiss A. Overall survival of metastatic breast cancer patients – data from the PRAEGNANT breast cancer registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-09.

Abstract P6-11-10: Impact of disease progression on health-related quality of life in patients with metastatic breast cancer in the PRAEGNANT breast cancer registry

Background: Improved progression-free survival is considered as treatment goal for patients with metastatic breast cancer (MBC) since it is assumed to delay or prevent deterioration of quality of life.Aim of our analysis was to examine the influence of disease progression on health-related quality of life (HRQoL).

Methods: The PRAEGNANT study comprises a real-life registry for patients with MBC. HRQoL was assessed with the EORTC-QLQ-C30 Version 3.0 questionnaire at study entry and every 3 months thereafter. The primary endpoint was minimally important deterioration (MID) in global HRQoL score by ≥ five points between baseline and any follow-up assessment. A logistic regression model was built with MID (yes/no) at a follow-up timepoint as outcome variable and several covariates as predictors.

Results: In total, 329 patients were included in this analysis, with disease progression in 63 patients. Concerning the primary study aim, progression status predicted MID of global HRQoL status in addition to the other covariates. The adjusted odds ratio for the effect of progression status on MID was 2.22 (95% CI: 1.04 – 4.73). Comparisons of mean differences of QoL domains/scales yielded no differences.

Conclusions: We provide evidence that disease progression in patients with metastatic breast cancer in a real-world registry has a significant negative impact on HRQoL as measured by MID of HRQoL. This study emphasizes the relevance of avoiding progression and prolonging PFS to maintain QoL.

Citation Format: Wallwiener M, Nabieva N, Haeberle L, Taran FA, Hartkopf AD, Volz B, Overkamp F, Brandl AL, Kolberg H-C, Hadji P, Tesch H, Ettl J, Lux MP, Lueftner D, Belleville E, Fasching PA, Janni W, Beckmann MW, Wimberger P, Hielscher C, Fehm T, Brucker SY, Wallwiener D, Schneeweiss A, Mueller V. Impact of disease progression on health-related quality of life in patients with metastatic breast cancer in the PRAEGNANT breast cancer registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-11-10.

Final efficacy and updated safety results of the randomized phase III BEATRICE trial evaluating adjuvant bevacizumab-containing therapy in triple-negative early breast cancer

Background

The purpose of this analysis was to assess the long-term impact of adding bevacizumab to adjuvant chemotherapy for early triple-negative breast cancer (TNBC).

Methods

Patients eligible for the open-label randomized phase III BEATRICE trial had centrally confirmed triple-negative operable primary invasive breast cancer (pT1a-pT3). Investigators selected anthracycline- and/or taxane-based chemotherapy for each patient. After definitive surgery, patients were randomized 1:1 to receive ≥4 cycles of chemotherapy alone or with 1 year of bevacizumab (5 mg/kg/week equivalent). Stratification factors were nodal status, selected chemotherapy, hormone receptor status, and type of surgery. The primary end point was invasive disease-free survival (IDFS; previously reported). Secondary outcome measures included overall survival (OS) and safety.

Results

After 56 months' median follow-up, 293 of 2591 randomized patients had died. There was no statistically significant difference in OS between treatment arms in either the total population (hazard ratio 0.93, 95% confidence interval [CI] 0.74-1.17; P = 0.52) or pre-specified subgroups. The 5-year OS rate was 88% (95% CI 86-90%) in both treatment arms. Updated IDFS results were consistent with the primary IDFS analysis. Five-year IDFS rates were 77% (95% CI 75-79%) with chemotherapy alone versus 80% (95% CI 77-82%) with bevacizumab. From 18 months after first study dose to study end, new grade ≥3 adverse events occurred in 4.6% and 4.5% of patients in the two arms, respectively.

Conclusion

Final OS results showed no significant benefit from bevacizumab therapy for early TNBC. Late-onset toxicities were rare in both groups. Five-year OS and IDFS rates suggest that the prognosis for patients with TNBC is better than previously thought.

ClinicalTrials.gov

NCT00528567.

ABC3 Consensus Commented from the Perspective of the German Guidelines: Third International Consensus Conference for Advanced Breast Cancer (ABC3), Lisbon, 07. 11. 2015

The Third International Consensus Conference for Advanced Breast Cancer ABC3 on the diagnosis and treatment of advanced breast cancer was held in Lisbon from 5 to 7 November 2015. This year the focus was the treatment of metastatic breast cancer (stage IV) - including the patient perspectives. Important topics were questions relating to quality of life, the care for long-term survivors as well as the management of disease-related symptoms and treatment-based side effects. The use of standardised tools to assess individual treatment success and the benefits of new substances were important points for discussion. The diagnosis and treatment of inoperable locally advanced breast cancer were discussed two years ago during the ABC2 consensus 1. A working group of German breast cancer experts commented on the results of the ABC panellists, paying particular attention to the German guidelines (AGO, S3, DGHO) on the diagnosis and treatment of breast cancer 2, 3, 4, 5 in Germany.

Biomarkers in Patients with Metastatic Breast Cancer and the PRAEGNANT Study Network

Progress has been made in the treatment of metastatic breast cancer in recent decades, but very few therapies use patient or tumor-specific characteristics to tailor individualized treatment. More than ten years after the publication of the reference human genome sequence, analysis methods have improved enormously, fostering the hope that biomarkers can be used to individualize therapies and offer precise treatment based on tumor and patient characteristics. Biomarkers at every level of the system (genetics, epigenetics, gene expression, micro-RNA, proteomics and others) can be used for this. This has led to changes in clinical study designs, with drug developments often only focusing on small or very small subgroups of patients and tumors. The screening and registration of patients and their molecular tumor data has therefore become very important for the successful completion of clinical studies. This new form of medicine presents particular challenges for patients and physicians. Even in this new age of genome-wide analysis, the focus should still be on the patients' quality of life. This review summarizes recent developments and describes how the PRAEGNANT study network manages the aforementioned medical challenges and changes to create a professional infrastructure for patients and physicians.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

P4-08-01: Predictive Value of HER2 Serum Levels in Patients Treated with Lapatinib or Trastuzumab – A Translational Project in the Neoadjuvant “Geparquinto” Trial

Background

Neoadjuvant chemotherapy (NT) has become an important approach to assess therapeutic efficacy of new treatment strategies. We observed a predictive role of of serum HER2 (sHER2) with neoadjuvant trastuzumab treatment in the previous trial “Geparquattro”. Predictive markers for response to new HER2−targeted therapies are still lacking. Therefore, we investigated the role of sHER2 in the context of trastuzumab and lapatinib treatment.

Methods: The clinical trial Geparquinto incorporated either trastuzumab or lapatinib treatment combined with chemotherapy for HER2−positive breast cancer patients. Serum samples were taken at three different time points: before initiation of NT, after 4 cycles of chemotherapy with epirubicin and cyclophophamide and after finalization of NT with 4 cycles of docetaxel (pre-surgery). Only those patients were included in the analysis with serum available at all three time points. sHER2 levels were measured by a commercially available ELISA in 159 patients with a HER2−positive primary tumor, 77 (48%) patients were treated with trastuzumab, 82 (52%) with lapatinib. Pathological complete remission (pCR) was defined as no microscopic evidence of invasive residual tumor cells in the breast and lymph nodes.

Results: Overall pCR rate in this cohort was 28%. sHER2 levels were higher in patients with larger tumors (> 5cm, p=0.012) and positive nodal status (p=0.001). Higher pre-chemotherapy sHER2 levels were associated with higher pCR rates in the entire study cohort (OR 2.9, 95% CI 1.3−6.7, p=0.012). Additionally, in the lapatinib treated patient group, a decrease of serum levels of more than 20% after 4 cycles of chemotherapy showed a tendency to be associated with higher pCR rates (OR 7.7, 95% CI 0.8- 70, p=0.071). In contrast to the finding of the previous trial Geparquattro, this was not the case in the trastuzumab-treated patient group (p=n.s.).

Conclusion: Results of this study demonstrate pre-chemotherapy sHER2 levels to be an independent predictor of response to NT with both trastuzumab and lapatinib treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-08-01.

Sequential therapies with sorafenib and sunitinib in advanced or metastatic renal cell carcinoma

PURPOSE

To investigate whether patients with metastatic renal cell carcinoma benefit from sequential therapies with the tyrosine kinase inhibitors (TKIs) sorafenib and sunitinib.

PATIENTS AND METHODS

A total of 89 patients were treated in nine German centres between 2002 and 2009. The TKI sequence started as first-, second- or third-line therapy after prior chemo- or immunotherapy. When progression was diagnosed, treatment was switched to the second TKI until further progression.

RESULTS

Overall progression-free survival (PFS) of patients receiving sunitinib followed by sorafenib shows no statistically significant difference to patients receiving sorafenib followed by sunitinib (15.4 months vs. 12.1 months). The secondary use of sorafenib resulted in a median PFS of 3.8 months if the TKI sequence had been started as a first-line treatment and of 3.5 months if the TKI sequence had been started second-line treatment. The secondary use of sunitinib resulted in a median PFS of 3.4 and 4.0 months, respectively. OS was 28.8 months for all patients, without a statistically significant difference between the two groups.

CONCLUSIONS

This study endorses the notion of a clinical benefit of the sequential use of sorafenib and sunitinib and supports observations from previous studies. In terms of the optimal succession of the two TKIs, the study does not allow a definite answer.

Results of the German fulvestrant in practice evaluation programme to evaluate the efficacy, safety, tolerability and acceptance of fulvestrant under daily routine conditions

Abstract #6132

Material and Methods: Fulvestrant is an estrogen receptor (ER) antagonist with a distinct mode of action used in the treatment of postmenopausal women with advanced breast cancer progressing or recurring on an antiestrogen. 848 postmenopausal women with ER+ advanced mamma carcinoma, relapsed during or after adjuvant anti-estrogene treatment, or with a disease progression under an anti-estrogene therapy, were enrolled in this Fulvestrant In Practice Evaluation Programme (IPEP). Under daily routine conditions and without intervention by the sponsor regarding selection of subjects, diagnostic procedures or therapeutic decisions relevant data of the fulvestrant therapy was documented over a period of 9 months. Results: The median patient age was 64 years, 52 % of patients had a co-morbidity, 78 % one or more prior palliative therapies. Efficacy: Clinical benefit was observed in 627/848 patients, including 62 complete and 177 partial remissions. Best response was delayed in 115 patients (not seen at 3 months but at 6 months). Estimated 9-month overall survival (OS) was 89%; 9-month event-free survival (EFS) was 71%. Safety: 244 non-serious adverse events by patient were recorded, most commonly General disorders and administration site conditions, gastrointestinal and musculo-sceletal symptoms. Excluding deaths, 7 serious adverse events were recorded (none attributed to fulvestrant); no new or unexpected safety issues arose. 20 patients died during observation. Tolerability: Tolerability was judged as good to very good by the majority of both specialists and patients with stable values at 3, 6 and 9 months. Acceptance of injection: The vast majority of both doctors and patients found the application via injection to be acceptable or very acceptable, the handling was judged by the doctors as mostly good to very good. Conclusion: Fulvestrant treatment was well tolerated and well accepted in this palliative patient collective, no new safety findings occurred. The treatment showed good efficacy with any patient, who had achieved disease stabilization or better after three months being likely to gain survival benefit from prolonged Fulvestrant therapy. Best response often occured delayed.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6132.

[Breast cancer: analysis of treatment quality in Germany 2004: retrospective survey by Arbeitsgemeinschaft Gynäkologische Onkologie (AGO)]

The Organgruppe Mamma der Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) conducted a nationwide 3-phase analysis of the care structure and standard of therapy given to patients with breast cancer from 2002 (4th quarter) to 2004 (4th quarter). The analysis includes 1069 patients from 257 institutions; 34% with early breast cancer and 66% with metastatic disease. No reliable data on the pattern of care of these patients have been published to date in Germany. The extent to which national and international therapy recommendations were implemented in routine clinical practice was unclear. Evaluation of the data shows that treatment based on the guidelines is now being implemented very reliably in certain sectors. This is of particular relevance to the pattern of adjuvant treatment in early breast cancer. At that time 68 % of the patients received an anthracyclin based chemotherapy and in addition 18% received an anthracycline and taxane based chemotherapy. Participation in clinical trials peaked with 30% in the neoadjuvant setting. The problem with metastatic breast cancer is the complexity of the interdisciplinary treatment involved. The present analysis conducted by the AGO was the first attempt to analyse the treatment given to metastatic patients and to systematise the approach to treatment. The fundamental problem remains, irrespective of the stage of the tumour, namely that too few patients are treated in randomised clinical studies.

Breast cancer patients' expectations in respect of the physician-patient relationship and treatment management results of a survey of 617 patients

BACKGROUND

The following study was conducted to explore patients' information needs and preferences with a special focus on doctor-patient communication.

PATIENTS AND METHODS

A 62-item questionnaire developed by a multidisciplinary team and validated in a phase-I study was given to breast cancer patients via the Internet (homepage) or in a hard copy version.

RESULTS

A total of 617 patients responded, 552 on line and 65 via the hard copy questionnaire. The median age of the on-line group was 47 (21-85) and 55 (40-92) in the hard copy group. Sixty-five per cent of the patients were treated with the intention of achieving a cure and 35% of the patients had metastatic disease. The median length of the consultation communicating the information 'You have breast cancer' was 15 min (0-300). The most effective and patient-relevant source of information about the disease and the treatment options was consultation with the physician (84%). When asked to suggest areas for improvement, patients' most common answers were: more complementary therapies should be offered by the physician (54%); physicians should take more time to explain things (51%); and cooperation between the physicians involved in the patient's care should be improved (39%). The questions most relevant to patients were: 'Am I getting the right therapy?' (89%); 'How many patients with my condition does my doctor treat?' (46%) and 'Can I be enrolled into a trial?' (46%). An independent second opinion centre was desired by 94% of the respondents but only 20% knew of any such resource.

CONCLUSIONS

This study underlines the need to give patients with breast cancer the full details on treatment options and cancer management. The results provide a suitable basis for a broader interdisciplinary discussion of the patient-physician relationship and should be useful in generating hypotheses for subsequent prospective studies.

What do adjuvant and metastatic breast cancer patients (BC) expect from their doctors? Final results of a german survey in 617 patients:

6085

Background: An increasing number of breast cancer patients in western countries are accessing the Internet for medical information. The following study was condcuted to explore the information needs and preferences with special focus on doctor-patient communication. Methods: A questionnaire was developed and validated in a phase-I study and was than administered to breast cancer patients both via internet (online) or via a print-version consisting of 62 questions. Results: A total of 617 patients were interviewed, 552 by online version (online group) and 65 by printed questionnaire (print group). The median age of the online group was 47 years (21–85), for the print group 53 years (40–92). 65% of the patients were treated with the intention of cure, 35% of the patients had a metastatic disease. The median time of consultation communicating the information “You have breast cancer”, was 15 minutes (0–300). The most effective and “patient-relevant source of information and explanations of treatment options was the consultation with their physician (84%). When asked to suggest areas for improvement, most frequent answers were: more alternative therapies should be offered by physician (54%); physicians should have more time for explanations (51%); cooperation between involved physicians should be optimized (39%). Most relevant questions for patients are: “Do I receive the adequate treatment?” (89%); “How many patients with my disease does my physician treat?” (46%); “Can I be enrolled into a trial?” (46%). An independent second opinion centre was desired by 94% of the patients, but only 20% know such an institution. Conclusions: This study underlines the need to give patients with breast cancer all details on treatment options and cancer managements.

No significant financial relationships to disclose.

Recombinant human granulocyte-macrophage colony-stimulating factor and low-dose cytosine-arabinoside in the treatment of patients with myelodysplastic syndromes. A phase II study

As part of a multicenter trial 12 patients with myelodysplastic syndromes (MDS) were treated with 14-day-cycles of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF; 250 micrograms/m2 day s.c.). In addition, all patients received 20 mg/m2/day s.c. cytosine-arabinoside (Ara-C) 12 h after GM-CSF except for patients suffering from refractory anemia (RA) according to FAB classification. Courses were repeated after 4 weeks. In 11 evaluable patients, results according to FAB-classified MDS were as follows: RA, 1/2 response (R), 1/2 stable disease (SD); RAEB, 2/3 R, 1/3 SD; RAEB-T, 1/6 CR, 1/6 PR, 2/6 R, 2/6 progression; CMML, 1/2 SD. In 2 patients with RAEB-T, overt acute myeloid leukemia was observed 2 and 10 weeks after initiation of treatment. With few exceptions, treatment resulted in a prompt increase in granulocytes and eosinophiles. This was associated with improvement of infectious complications. Increases in red cells and platelets occurred variably and was apparently associated with responses of the underlying disease. Dose limiting side effects consisted of fever, severe fatigue and dolent local reactions at the site of GM-CSF injection. In addition, nausea and diarrhoea occurred frequently. Less often, respiratory and cardiovascular side effects were encountered. In summary, GM-CSF +/- Ara-C in MDS results in objective remission with manageable toxicity. Conceivably, this regimen will serve as a base for future treatment strategies against MDS.

[Factitious disease. Observations on 44 cases at a medical clinic and recommendation for a subclassification]

From 1971 to 1985, 44 cases of self-induced factitious disorders were observed in the Medical Department of a University Hospital. The diseases were often severe, one patient even died. The various symptoms and diseases presented by the patients, the methods of producing them, and the diagnostic and therapeutic aspects of these cases are described. Patients were analysed with regard to age, sex, profession, psychosocial adaptation, number and duration of hospitalisations, presentation of complaints, behaviour on the ward, relation to the doctor, self-destructive tendencies, readiness to suffer and possible motivations. According to the criteria of the DSM-III, seven patients were malingerers (DSM-III: V 65.20) and 37 had a "chronic factitious disorder with physical symptoms" (DSM-III: 301.51). However, the findings in the patients of the latter group strongly suggest that they form an extremely heterogeneous population. Therefore we propose a subclassification of the DSM-III category 301.51 as follows: Type A. Muenchausen syndrome in the proper sense; dramatic deception of mainly acute illness; pseudologia fantastica; social maladaptation, chaotic life situations; many, mostly short hospitalisations; many interventions; at first well adapted, later hostile; mostly men. Type B. Self-induced, mainly chronic illness; behaviour adequate, highly compliant; often little emotion, contrasting with the sometimes severe illness; socially adapted; history remarkably blank with regard to psychosocial stress; several often longlasting hospitalisations and many interventions; almost exclusively younger women from (para-)-medical professions. Type C. Willfull interference with the healing of wounds, cutaneous ulcers, abscesses or dermatological artefacts; history with marked personal losses or severe chronic medical problems; at first well adapted, later hostile, passive/aggressive; women prevail. A conversion syndrome (DSM-III: 300.11) was not observed. In contrast to malingering, the basis of the disorder in types A, B and C is unconscious in origin, thus similar to the conversion syndrome. Contrary to the latter, however, the production of physical symptoms is under voluntary control. The proposed subclassification represents a hypothesis for testing which might facilitate the analysis of the basic personality disorder, so far lacking. The investigation of the psychopathology of these patients and their treatment is difficult if not impossible because most refuse psychiatric exploration and therapy. Consequently follow-up studies and data on the prognosis are rare.