Timing of last chemotherapy and the end of life in patients (pts) with metastatic cancer

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Background: Chemotherapy near the end of life is often associated with increased toxicity and poor outcome. The aim of this study was to assess the outcome of patients (pts) with metastatic cancer who received chemotherapy near the end of life. Methods: We conducted an observational, retrospective analysis of 77 consecutive cancer pts (aged ≥ 18 years) who died in hospice between January 2017 and July 2018. Median overall survival (OS) and the 95% confidence interval (CI) were estimated with the Kaplan -Meier method. Results: Of 77 pts (median age: 72 years [y]; male: 59.7%) with metastatic cancer, 51 pts (66.2%) received chemotherapies for metastatic disease (mean prior lines: 2.1 ) and 26 pts (33.8%) received best supportive care (BSC). The most represented histologies were lung (31.2%) and breast (11.7%) cancer. The median time from the last chemotherapy and the death was 67 days. The median progression free survival (PFS) of the last treatment was 45 days. According to Earle’s criteria, 6.5% of pts started a new chemotherapy regimen in the last 30 days of life and 2.6% of subjects received chemotherapy in the last 14 days of life. 11.7% and 3.9% of pts received chemotherapy within the last 30 and 15 days of life, respectively. Younger pts (< 70 years) had an increased probability of continuing chemotherapy within the last 1 month (p=0.004) and < 2 weeks (p=0.002) before death than elderly (> 70 years). Conclusions: This study shows that end-of-life chemotherapy is associated with poor outcome. The use of chemotherapy within 30 and 15 days before death was correlated with younger age.

Abstract CT109: Adjuvant ovarian suppression in high risk premenopausal breast cancer: ten-year follow-up of a phase I-II study

Background: Two randomized studies have shown the benefit of ovarian suppression in the adjuvant treatment of high risk premenopausal breast cancer, both with estrogen receptor positive (ER+) (Pagani et al. N Engl J Med 2014) and estrogen receptor negative (ER-) (Moore et al. N Engl J Med 2015). Nevertheless the median follow-up of these studies was limited to 68 and 49 months, respectively. Here we present the results of a large, phase I-II study, of adjuvant ovarian suppression in ER+ and in ER- patients, after a median follow-up of 123 months (range 93-223). Two hundred patients were enrolled between 06-1997 and 06-2007. The primary end point of the study was to find the best dose and schedule of a luteinizing hormone releasing hormone (LH-RH) analogue given to prevent ovarian failure in premenopausal patients treated with adjuvant chemotherapy. Secondary end points were disease free survival (DFS) and overall survival (OS). Methods: One week before chemotherapy, a LH-RH analogue was administered, 3.75 mg every 28 days for 1 year to the first cohort of 64 patients. The same monthly dose was given, for 2 years, to the second cohort of 36 patients. Because we had observed a decrease of 31% in the recurrence rate for the longer administration of LH-RH analogue, the 11.25 mg dose every 84 days, for 5 years, was chosen for the remaining 100 patients. The treatment consisted of: a- LH-RH analogue; b- Breast conserving (74%) and radical surgery (26%); c- Tailored systemic therapy concurrent with radiation therapy; d- Aromatase inhibitor in ER+ patients. Results: The median age was 43 years (range 26-45), the mean number of positive axillary nodes was 3.2 (range 1-25), including 20 patients with &gt;10 positive nodes. 71% of patients were ER+ and/or progesterone receptor positive (PGR+), 29% were ER - and PGR-, 21% of patients were c-ErbB-2 positive. The median KI-67 was 30% (range 15% -100%). Ovarian failure rate was 10% in patients younger than 40 years and 44% in patients older than 40 years. The 15-year DFS and OS rate were 64% and 73%, respectively. 15-year DFS rate of ER+ and ER- patients were 74% and 44% respectively (P&lt;0.005), while the 15-year OS rate were 74% and 75%, respectively (P&gt;0.005). The usual pattern of toxicity of chemotherapy was observed. Hot flashes and G1 osteopenia occurring after LH-RH analogue administration were temporary and receded after the cessation of therapy. Conclusions: LH-RH administration, concurrent with chemotherapy is tolerable and useful. Five full term pregnancies were observed. The long-term recurrence and survival rate for ER+ and ER-patients were similar, with different patterns: ER+ patients had disease recurrences even after 13 years, while ER- patients had late new primaries, but no recurrence after 5 years.

Citation Format: Francesco Recchia, Giampiero Candeloro, Massimo Bratta, Michele Rosselli, Silvio Rea. Adjuvant ovarian suppression in high risk premenopausal breast cancer: ten-year follow-up of a phase I-II study. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT109.

Abstract P5-15-06: 10-year follow-up of adjuvant ovarian suppression in high risk premenopausal breast cancer

Background: A large randomized study has shown the value of temporary ovarian suppression during the administration of chemotherapy in the treatment of high risk estrogen receptor positive (ER+) breast cancer (BC) (Pagani et al. N Engl J Med 2014). In another study ovarian suppression added to chemotherapy appeared to protect ovarian function (Moore et al. N Engl J Med 2014) and improve the expected outcome of estrogen receptor negative (ER-) BC. Nevertheless, both these studies have a median follow-up time limited to 68 months and 49 months, respectively. Here we present the data of a large non randomized phase II study of adjuvant ovarian suppression in ER+ and ER- breast cancer with a median follow-up of 120 months (range 90-220 months). The primary end point was the ovarian function preservation rate, secondary end points were disease-free survival (DFS) and overall survival (OS). Methods: Between 06-1997 and 06-2007, 200 premenopausal, high risk early BC patients entered the study. All patients received the LH-RH analogue before starting chemotherapy. Breast conserving and radical surgery were performed in 74% and 26% of patients, respectively. Systemic therapy was tailored to the biological characteristics of each patient, and followed by radiation therapy and hormonal therapy in ER+ tumors. Results: The median patient's age was 43 years (range 26-45). The mean number of positive axillary nodes was 3.2 (range 1-25). Seventy-one % of patients were ER+ and/or progesterone receptor positive (PGR+), 29% were ER - and PGR-. The median KI-67 was 30% (range 15% -100%). Twenty-one % of patients were c-ErbB-2 positive. After a median follow up of 120 months (range 90-220), normal menses returned in 90% of patients younger than 40 years and in 56% of patients older than 40 years. The 10 and 15-year DFS rate were 85.5% and 71%, respectively, while the 10 and 15-year OS rate were 91%, and 71%, respectively. The standard pattern of toxicity of chemotherapy was observed. Hot flashes and G1 osteopenia occurring after LH-RH analogue administration were temporary and subsided after the cessation of therapy. Conclusions: LH-RH administration, concurrent with chemotherapy is tolerable and effective. Five full term pregnancies were documented. A favourable impact on the expected DFS and OS was observed. ER- patients had late new primaries, but no recurrence after 5 years, while ER+ patients had disease recurrence even after 13 years.

Citation Format: Recchia F, Candeloro G, Rosselli M, Bratta M, Rea S. 10-year follow-up of adjuvant ovarian suppression in high risk premenopausal breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-15-06.

Adjuvant Ovarian Suppression, High-dose Chemotherapy and Immunotherapy for Premenopausal Patients with High-risk Breast Cancer

BACKGROUND

Premenopausal patients with breast cancer and more than 10 positive axillary nodes (BC>10) have a poor prognosis: In these patients the best adjuvant therapy (CT) has not yet been established.

PATIENTS AND METHODS

Forty-two BC>10 received, in sequence, the following adjuvant treatments: luteinizing hormone releasing hormone (LH-RH) analog for 5 years; anthracycline-based induction chemotherapy; radiation therapy; platinum-based high-dose CT, with autologous bone marrow transplantation; immunotherapy with interleukin 2 (IL2) and 13-cis retinoic acid (RA); anastrazole given 5 years to estrogen receptor-positive patients. Primary endpoints of the study were disease-free survival (DFS) and overall (OS) survival. A secondary endpoint was toxicity.

RESULTS

The median age of patients was 41 years, and the mean number of positive axillary nodes was 14. Estrogen and progesterone receptors were positive in 57% and 29% of patients respectively, while 14% of patients had triple-negative disease. With a median follow-up of 120 months for patients remaining alive at the end of study, median DFS and OS, had not yet been reached. The 20-year DFS and OS rates were 63.8%, and 81.6%, respectively. One to two years after the end of the therapy, three patients had had four full-term pregnancies.

CONCLUSION

Treatment with LH-RH analog, high-dose CT, peripheral blood progenitor cells and IL2 with RA for patients with BC>10 is feasible, has moderate toxicity, while preserving ovarian function, seems to improve the expected DFS and OS for these high-risk patients.

LH-RH analogues in the treatment of young women with early breast cancer: long-term follow-up of a phase II study

To prevent premature ovarian failure (POF), high-risk, premenopausal women with early breast cancer were given a luteinizing-hormone releasing hormone (LH-RH) analogue during adjuvant chemotherapy. After an adriamycin-based regimen, patients received radiation therapy concomitant with cyclophosphamide, methotrexate and 5-fluorouracil. An aromatase inhibitor was given to patients positive for the estrogen receptor (ER+). The median age was 43 years (range, 26-45). Among 200 consecutive patients, 46% had no axillary node, and 54% had a mean of 5.4 positive nodes (range, 1-25); 56% were ER+, 44% were estrogen receptor negative (ER-), 13% were triple negative, and 20 had tumors positive for the oncogene, c-erb-B2 (identified with fluorescent in situ hybridization). After a median follow-up of 105 months (range, 65-180), no patient under 40 years old exhibited POF, while 44% of patients over 40 years old exhibited POF. Eight pregnancies were recorded: 7 at term and 1 voluntary interruption. The 10-year disease-free survival and overall survival rates were 85 and 91%, respectively. These data showed that, in premenopausal patients with early breast cancer, the addition of an LH-RH analogue to adjuvant chemotherapy was well tolerated, prevented POF, and was associated with excellent disease-free survival and overall survival rates.

Immunotherapy in patients with less than complete response to chemotherapy

BACKGROUND

Patients with metastatic solid tumors (MST) with less than a complete response to chemotherapy (L-CR), a depressed immune system and elevated serum vascular endothelial growth factor (VEGF) lack defined treatment options. The primary endpoint evaluated in this study was whether interleukin-2 (IL-2) and 13-cisretinoic acid (RA) treatment reduced VEGF and improved immune function in such patients. Secondary endpoints were objective response, relapse-free survival (RFS), and overall survival (OS).

PATIENTS AND METHODS

One hundred consecutive MST patients with L-CR and a mean serum VEGF of 421.0 pg/mm3 were enrolled. Patients self-administered subcutaneous IL-2 1.8 x 10(6) IU/day, and oral RA 0.5 mg/kg/day x 5 days/week for 2 cycles of 3 weeks/month for 1 year and continued until progression.

RESULTS

After a median follow-up of 78 months, a statistically significant VEGF decrease and improvements in lymphocyte, NK, and CD4+/CD8+ ratio were observed. Twenty-four patients were converted to a CR; their 5-year RFS and OS rates were each 96%. No WHO grade 3 or 4 toxicities were observed.

CONCLUSION

Administration of IL-2/RA to this patient population produced a significant decrease in VEGF, improvement of prognostically relevant immunological parameters, and durable response in 25% of patients.

Maintenance immunotherapy in metastatic breast cancer

Maintenance chemotherapy provides only a modest survival advantage in metastatic breast cancer (MBC). We have previously shown that a maintenance immunotherapy (MI) regimen based on low-dose interleukin-2 (IL-2) and 13-cis retinoic acid (RA) improved the lymphocyte and natural killer cell (NK) counts, and CD4+/CD8+ ratio in patients with a clinical benefit from chemotherapy. With the aim of improving progression-free survival (PFS), 100 consecutive MBC patients with a clinical benefit from chemotherapy were treated with an MI. Patients with MBC were eligible if they had no evidence of progression after 6-8 courses of epirubicin-paclitaxel induction chemotherapy. Treatment consisted of low-dose IL-2 and oral RA given until progression. The primary endpoint was progression-free survival (PFS); secondary endpoints were toxicity, overall survival (OS), and changes in immunological parameters. From 04/1997 to 04/2002, 100 patients with MBC were enrolled. After a median follow-up of 49 months, median PFS and OS were 37.1 and 57.5 months, respectively. No WHO grade 3 or 4 toxicity was observed; grade 2 cutaneous toxicity and autoimmune reactions occurred in 19 and 16% of patients, respectively. A sustained improvement in lymphocytes, NKs, and in the CD4+/CD8+ ratio was observed, with respect to baseline values. In conclusion, MI with IL-2 and RA in MBC patients who do not progress after 6-8 courses of chemotherapy is well-tolerated, improves lymphocyte, NK, CD4+/CD8+ ratio, and appears to delay disease recurrence. A randomized trial is warranted.