1
|
Ledermann JA, Shapira-Frommer R, Santin AD, Lisyanskaya AS, Pignata S, Vergote I, Raspagliesi F, Sonke GS, Birrer M, Provencher DM, Sehouli J, Colombo N, González-Martín A, Oaknin A, Ottevanger PB, Rudaitis V, Kobie J, Nebozhyn M, Edmondson M, Sun Y, Cristescu R, Jelinic P, Keefe SM, Matulonis UA. Molecular determinants of clinical outcomes of pembrolizumab in recurrent ovarian cancer: Exploratory analysis of KEYNOTE-100. Gynecol Oncol 2023; 178:119-129. [PMID: 37862791 DOI: 10.1016/j.ygyno.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/15/2023] [Accepted: 09/23/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE This prespecified exploratory analysis evaluated the association of gene expression signatures, tumor mutational burden (TMB), and multiplex immunohistochemistry (mIHC) tumor microenvironment-associated cell phenotypes with clinical outcomes of pembrolizumab in advanced recurrent ovarian cancer (ROC) from the phase II KEYNOTE-100 study. METHODS Pembrolizumab-treated patients with evaluable RNA-sequencing (n = 317), whole exome sequencing (n = 293), or select mIHC (n = 125) data were evaluated. The association between outcomes (objective response rate [ORR], progression-free survival [PFS], and overall survival [OS]) and gene expression signatures (T-cell-inflamed gene expression profile [TcellinfGEP] and 10 non-TcellinfGEP signatures), TMB, and prespecified mIHC cell phenotype densities as continuous variables was evaluated using logistic (ORR) and Cox proportional hazards regression (PFS; OS). One-sided p-values were calculated at prespecified α = 0.05 for TcellinfGEP, TMB, and mIHC cell phenotypes and at α = 0.10 for non-TcellinfGEP signatures; all but TcellinfGEP and TMB were adjusted for multiplicity. RESULTS No evidence of associations between ORR and key axes of gene expression was observed. Negative associations were observed between outcomes and TcellinfGEP-adjusted glycolysis (PFS, adjusted-p = 0.019; OS, adjusted-p = 0.085) and hypoxia (PFS, adjusted-p = 0.064) signatures. TMB as a continuous variable was not associated with outcomes (p > 0.05). Positive associations were observed between densities of myeloid cell phenotypes CD11c+ and CD11c+/MHCII-/CD163-/CD68- in the tumor compartment and ORR (adjusted-p = 0.025 and 0.013, respectively). CONCLUSIONS This exploratory analysis in advanced ROC did not find evidence for associations between gene expression signatures and outcomes of pembrolizumab. mIHC analysis suggests CD11c+ and CD11c+/MHCII-/CD163-/CD68- phenotypes representing myeloid cell populations may be associated with improved outcomes with pembrolizumab in advanced ROC. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02674061.
Collapse
Affiliation(s)
- Jonathan A Ledermann
- Department of Oncology, UCL Cancer Institute, University College London, London, United Kingdom.
| | - Ronnie Shapira-Frommer
- The Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Tel HaShomer Hospital, Ramat Gan, Israel
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT, United States
| | - Alla S Lisyanskaya
- Department of Oncogynecology, St. Petersburg City Clinical Oncology Dispensary, St. Petersburg, Russia
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - Ignace Vergote
- Department of Obstetrics and Gynaecology, Division of Gynecologic Oncology, University Hospital Leuven, Leuven, Belgium
| | | | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michael Birrer
- UAMS Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, United States
| | - Diane M Provencher
- Centre Hospitalier de l'Université de Montréal (CHUM), Institut du Cancer de Montréal, Montreal, Canada
| | - Jalid Sehouli
- Gynecology with Center of Oncological Surgery, Charité-Medical University of Berlin, Berlin, Germany
| | - Nicoletta Colombo
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; European Institute of Oncology, IRCCS, Milan, Italy
| | - Antonio González-Martín
- Department of Medical Oncology and Program in Solid Tumors-Cima, Cancer Center Clínica Universidad de Navarra, Madrid, Spain
| | - Ana Oaknin
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - P B Ottevanger
- Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Vilius Rudaitis
- Clinic of Obstetrics and Gynecology, Vilnius University Institute of Clinical Medicine, Vilnius, Lithuania
| | - Julie Kobie
- Merck & Co., Inc., Rahway, NJ, United States
| | | | | | - Yuan Sun
- Merck & Co., Inc., Rahway, NJ, United States
| | | | | | | | - Ursula A Matulonis
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| |
Collapse
|
2
|
Hendrikse CSE, Theelen PMM, van der Ploeg P, Westgeest HM, Boere IA, Thijs AMJ, Ottevanger PB, van de Stolpe A, Lambrechts S, Bekkers RLM, Piek JMJ. The potential of RAS/RAF/MEK/ERK (MAPK) signaling pathway inhibitors in ovarian cancer: A systematic review and meta-analysis. Gynecol Oncol 2023; 171:83-94. [PMID: 36841040 DOI: 10.1016/j.ygyno.2023.01.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/01/2023] [Accepted: 01/30/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND The RAS/RAF/MEK/ERK (MAPK) pathway plays a role in ovarian carcinogenesis. Low-grade serous ovarian carcinoma (LGSOC) frequently harbors activating MAPK mutations. MAPK inhibitors have been used in small subsets of ovarian carcinoma (OC) patients to control tumor growth. Therefore, we performed a meta-analysis to evaluate the effectiveness of MAPK inhibitors in OC patients. We aimed to determine the clinical benefit rate (CBR), the subgroup of MAPK inhibitors with the best CBR and overall response rate (ORR), and the most common adverse events. METHODS We conducted a search in PubMed, Embase via Ovid, the Cochrane library and clinicaltrials.gov on studies evaluating the efficacy of single MAPK pathway inhibition with MAPK pathway inhibitors in OC patients. Our primary outcome included the CBR, defined by the proportion of patients with stable disease (SD), complete (CR) and partial response (PR). Secondary outcomes included the ORR (including PR and CR) and grade 3 and 4 adverse events. Meta-analysis was performed using a random-effects model. RESULTS We included nine studies with a total of 319 OC patients, for which we determined a pooled CBR of 63% (95%-CI 39-84%, I2 = 92%). Combined treatment with Raf- and MEK inhibitors in in BRAFv600 mutated LGSOC (n = 6) had the greatest efficacy with a CBR of 100% and ORR of 83%. MEK inhibitors had the best efficacy as a single agent. Subgroup analysis by tumor histology demonstrated a significantly higher CBR and ORR in patients with LGSOC, with a pooled CBR and ORR of 87% (95%-CI 81-92%, I2 = 0%) and 27% (95%-CI 10-48%, I2 = 77%) respectively. Adverse events of grade 3 or higher were reported frequently: 123 in 167 patients. CONCLUSIONS MEK inhibitors are the most promising single agents in (LGS)OC. However, dual MAPK pathway inhibition should be considered in patients with a BRAFv600 mutation, or non-mutated OC with depleted treatment options due indications of higher efficacy and tolerable toxicity profiles.
Collapse
Affiliation(s)
- C S E Hendrikse
- Department of Obstetrics and Gynecology and Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - P M M Theelen
- Department of Obstetrics and Gynecology and Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands
| | - P van der Ploeg
- Department of Obstetrics and Gynecology and Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - H M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
| | - I A Boere
- Department of Medical Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - A M J Thijs
- Department of Internal Medicine and Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - A van de Stolpe
- Drug Companion Diagnostics Company - Therapeutics (DCDC-Tx), Vught, the Netherlands
| | - S Lambrechts
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - R L M Bekkers
- Department of Obstetrics and Gynecology and Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - J M J Piek
- Department of Obstetrics and Gynecology and Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands
| |
Collapse
|
3
|
Blok LJ, Frijstein MM, Eysbouts YK, Custers J, Sweep F, Lok C, Ottevanger PB. The psychological impact of gestational trophoblastic disease: a prospective observational multicentre cohort study. BJOG 2021; 129:444-449. [PMID: 34314567 PMCID: PMC9292450 DOI: 10.1111/1471-0528.16849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the short-term psychological consequences of gestational trophoblastic disease (GTD). DESIGN A prospective observational multicentre cohort study. SETTING Nationwide in the Netherlands. POPULATION GTD patients. METHODS Online questionnaires directly after diagnosis. MAIN OUTCOME MEASURES Hospital Anxiety and Depression Scale (HADS), Distress Thermometer (DT), Impact of Event Scale (IES) and Reproductive Concerns Scale (RCS). RESULTS Sixty GTD patients were included between 2017 and 2020. Anxious feelings (47%) were more commonly expressed than depressive feelings (27%). Patients experienced moderate to severe adaptation problems in 88%. Patients who already had children were less concerned about their reproductivity than were patients without children (mean score 10.4 versus 15.0, P = 0.031), and patients with children experienced lower distress levels (IES mean score 25.7 versus 34.7, P = 0.020). In addition, patients with previous pregnancy loss scored lower for distress compared with patients without pregnancy loss (IES mean score 21.1 versus 34.2, P = 0.002). DISCUSSION We recommend that physicians monitor physical complaints and the course of psychological wellbeing over time in order to provide personalised supportive care in time for patients who have high levels of distress at baseline. CONCLUSIONS GTD patients experience increased levels of distress, anxiety and depression, suggesting the diagnosis has a substantial effect on the psychological wellbeing of patients. The impact of GTD diagnosis on intrusion and avoidance seems to be ameliorated in patients who have children or who have experienced previous pregnancy loss. TWEETABLE ABSTRACT Patients with gestational trophoblastic disease (GTD) experience short-term psychological consequences such as distress, anxiety and depression, suggesting that the diagnosis GTD has a substantial effect on the psychological wellbeing of patients. Various patient characteristics affect the impact of GTD diagnosis.
Collapse
Affiliation(s)
- L J Blok
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M M Frijstein
- Department of Gynaecologic Oncology, Centre of Gynaecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Y K Eysbouts
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jae Custers
- Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Fcgj Sweep
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Car Lok
- Department of Gynaecologic Oncology, Centre of Gynaecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
4
|
Rietveld MJA, van der Velden J, Westermann AM, van Driel WJ, Sonke GS, Witteveen PO, Ploos van Amstel FK, Massuger LFAG, Ottevanger PB. Intraperitoneal treatment for advanced ovarian cancer, the Dutch experience. What did we learn? Neth J Med 2020; 78:349-356. [PMID: 33380532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Combined administration of intravenous (iv) and intraperitoneal (ip) (iv/ip) chemotherapy is an effective adjuvant treatment option after primary debulking surgery (PDS) for advanced ovarian cancer (OC). Increased toxicityand patient burden limit its use in daily practice. OBJECTIVE To assess toxicity and survival outcomes of iv/ip chemotherapy in daily practice in the Netherlands. METHODS This retrospective cohort study included 81 women who underwent at least an optimal PDS for FIGO stage III OC followed by iv/ip chemotherapy according to the Armstrong regimen, in four hospitals in the Netherlands between January 2007 and May 2016. We collected information on surgical procedure, abdominal port implantation, toxicity, and recurrence-free and overall survival. RESULTS All participants underwent PDS, of whom 60 (74%) had their ip catheter implanted during PDS. Most frequently reported all grade toxicity was haematological n = 44 (54%). Forty-four patients (54%) completed all six cycles of iv/ip chemotherapy. The most frequent causes of discontinuation of iv/ip administration were renal dysfunction (12/37 = 32%) and catheter problems (7/37 = 19%). Median recurrence-free survival and overall survival were 24 months (range 0 - 108) and 80 months (range 4-115), respectively. Surgical outcome, completion of more than three courses of treatment and intra-abdominal localisation of recurrent disease were associated with better survival outcomes. CONCLUSION In daily practice, 54% of patients with advanced OC could complete all scheduled cycles of iv/ ip chemotherapy with acceptable morbidity and toxicity, leading to outcomes comparable with the results of published trials on iv/ip chemotherapy.
Collapse
Affiliation(s)
- M J A Rietveld
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Matulonis UA, Shapira R, Santin A, Lisyanskaya AS, Pignata S, Vergote I, Raspagliesi F, Sonke GS, Birrer M, Sehouli J, Colombo N, González-Martín A, Oaknin A, Ottevanger PB, Rudaitis V, Wu H, Keefe SM, Stein K, Ledermann JA. Final results from the KEYNOTE-100 trial of pembrolizumab in patients with advanced recurrent ovarian cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.6005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6005 Background: Pembrolizumab (pembro) showed modest clinical activity in patients (pts) with recurrent advanced ovarian cancer (AOC) after a median follow-up of 16.9 mo in an interim analysis of KEYNOTE-100 (NCT02674061). We present the protocol-specified final analysis based on a data cutoff of 18-SEP-2019. Methods: Key eligibility criteria included epithelial ovarian, fallopian tube, or primary peritoneal cancer, confirmed recurrence following front-line platinum-based therapy, ECOG PS 0-1, and provision of a tumor sample for biomarker analysis. Pts in cohort A received ≤2 prior chemotherapy lines for recurrent AOC and had a platinum-free or treatment-free interval (PFI/TFI) of ≥3 to 12 mo. Pts in cohort B received 3-5 prior chemotherapy lines and had a PFI/TFI of ≥3 mo. Pts received pembro 200 mg Q3W for 2 yr or until progression, death, or unacceptable toxicity. Tumor imaging was performed every 9 wk for 1 yr and every 12 wk thereafter. Primary study endpoint was ORR per RECIST v1.1 by independent central review in both cohorts and by tumor PD-L1 expression using the combined positive score (CPS). Secondary endpoints included DOR, DCR (CR+PR+SD≥24 wk), PFS, OS, and safety. Results: 376 pts were enrolled and treated, 285 in cohort A and 91 in cohort B. Median age (range) was 61 (25 to 89) yr, 64.4% had ECOG PS 0, and 75.3% had high grade serous disease. In cohorts A and B, ORR (95% CI) was 8.1% (5.2, 11.9) and 9.9% (4.6, 17.9) in the total population, 6.9% (2.8, 13.8) and 10.2% (3.4, 22.2) in pts with CPS ≥1, and 11.6% (3.9, 25.1) and 18.2% (5.2, 40.3) in pts with CPS ≥10. Median DOR (range) was 8.3 (3.9 to 35.4+) mo in cohort A and 23.6 (3.3+ to 32.8+) mo in cohort B. DCR (95% CI) was 22.1% (17.4, 27.4) and 22.0% (14.0, 31.9). Median PFS was 2.1 mo in both cohorts. In cohorts A and B, median OS was 18.7 mo (17.0, 22.5) and 17.6 mo (13.3, 24.4) in the total population, 20.6 mo (15.2, 23.2) and 20.7 mo (13.6, 27.4) in pts with CPS ≥1, and 21.9 mo (12.9, 26.8) and 24.0 mo (14.5, NR) in pts with CPS ≥10. 73.7% of pts had treatment-related AEs and 20.2% were grades 3-4. There were 2 treatment-related deaths (Stevens-Johnson syndrome and hypoaldosteronism). Immune-mediated AEs occurred in 23.7% of pts. Conclusions: Pembro monotherapy was associated with modest antitumor activity in pts with recurrent AOC. There appeared to be a trend toward increased ORR with higher PD-L1 expression in both cohorts. Responses were durable and typically lasted ≥6 months. Median OS was 18.7 months overall, with a trend toward a longer OS with increasing PD-L1 expression in both cohorts. No new safety signals were identified. Clinical trial information: NCT02674061.
Collapse
Affiliation(s)
| | | | | | | | - Sandro Pignata
- Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | | | | | - Gabe S. Sonke
- DGOG and Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Jalid Sehouli
- Charité-Medical University of Berlin, Berlin, Germany
| | - Nicoletta Colombo
- University of Milan-Bicocca and European Institute of Oncology, IRCCS and Mario Negri Gynecologic Oncology Group (MANGO), Milan, Italy
| | | | - Ana Oaknin
- Vall d’Hebron University Hospital, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | - Vilius Rudaitis
- Vilnius University Institute of Clinical Medicine, Vilnius, Lithuania
| | | | | | | | | |
Collapse
|
6
|
Hoeijmakers YM, Sweep F, Lok C, Ottevanger PB. Risk factors for second-line dactinomycin failure after methotrexate treatment for low-risk gestational trophoblastic neoplasia: a retrospective study. BJOG 2020; 127:1139-1145. [PMID: 32141676 PMCID: PMC7383780 DOI: 10.1111/1471-0528.16198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To find risk factors for second-line dactinomycin failure in patients with low-risk gestational trophoblastic neoplasia (GTN). DESIGN Retrospective multicentre study. SETTING Tertiary reference centre. POPULATION Patients with low-risk GTN, treated with dactinomycin after methotrexate (MTX) failure. METHODS Retrospective analysis of 45 patients with low-risk GTN treated with dactinomycin after MTX failure, registered between 2006 and 2018. MAIN OUTCOME MEASURES Treatment outcome and risk factors for second-line dactinomycin failure. RESULTS Thirty patients (66.7%) were cured and 15 patients (33.3%) required third-line therapy. Type of antecedent pregnancy and hCG levels pre-dactinomycin were risk factors for failure in univariate analysis (odds ratio [OR] 19.30, 95% CI 2.04-182.60, P = 0.01 and OR 2.77, 95% CI 1.18-6.50, P = 0.02, respectively). Level of hCG pre-dactinomycin remained a significant risk factor in multivariate analysis (OR 2.93, 95% CI 1.02-8.40, P = 0.045). Complete remission (CR) was achieved in 83.3% of patients with pre-dactinomycin hCG levels <10 ng/ml, in 75% with hCG levels between 10 and 20 ng/ml, in 66.7% with hCG levels between 20 and 30 ng/ml, and in 50% with hCG levels between 30 and 40 ng/ml. No patients with hCG levels >40 ng/ml achieved CR. Patients with dactinomycin failure were treated surgically and/or with multi-chemotherapy; all except one achieved CR. CONCLUSIONS Treatment with dactinomycin after MTX failure in patients with low-risk GTN resulted in CR in 66.7%. Chance of curative treatment with dactinomycin is strongly related to the hCG level. TWEETABLE ABSTRACT Chance of curative treatment with dactinomycin after MTX failure in GTN patients is strongly related to the level of hCG pre-dactinomycin.
Collapse
Affiliation(s)
- Y M Hoeijmakers
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Fcgj Sweep
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Car Lok
- Department of Gynaecologic Oncology, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.,Cancer Institute Amsterdam, Amsterdam, the Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
7
|
Aydemirli MD, Kapiteijn E, Ferrier KRM, Ottevanger PB, Links TP, van der Horst-Schrivers ANA, Broekman KE, Groenwold RHH, Zwaveling J. Effectiveness and toxicity of lenvatinib in refractory thyroid cancer: Dutch real-life data. Eur J Endocrinol 2020; 182:131-138. [PMID: 31751307 DOI: 10.1530/eje-19-0763] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/14/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The SELECT trial showed progression-free survival (PFS) benefit for lenvatinib for advanced radioiodine-refractory differentiated thyroid cancer (RAI-refractory or RR-DTC) patients, on which current clinical practice is based. We assessed whether the effectiveness and toxicity of lenvatinib in real-life clinical practice in the Netherlands were comparable to the pivotal SELECT trial. METHODS From three Dutch centres Electronic Health Records (EHRs) of patients treated in the lenvatinib compassionate use program or as standard of care were reviewed and checked for SELECT eligibility criteria. Baseline characteristics, safety, and efficacy measures were compared and PFS and overall survival (OS) were calculated. Furthermore, PFS was compared to estimates of PFS reported in other studies. RESULTS A total of 39 DTC patients with a median age of 62 years were analysed. Of these, 27 patients (69%) did not fulfil the SELECT eligibility criteria. The most common grade ≥3 toxicities were hypertension (n = 11, 28%), diarrhoea (n = 7, 18%), vomiting (n = 4, 10%), and gallbladder disease (n = 3, 8%). Median PFS and median OS were 9.7 (95% confidence interval (CI): 4.0-15.5) and 18.3 (95% CI: 4.9-31.7) months, respectively, response rate was 38% (95% CI: 23-54%). PFS in the Dutch real-life situation was comparable to previous real-life studies, but inferior to PFS as shown in the SELECT trial (P = 0.04). CONCLUSIONS PFS in our non-trial population was significantly shorter than in the SELECT trial population. In the interpretation of results, differences in the real-life population and the SELECT study population regarding patient characteristics should be taken into account.
Collapse
Affiliation(s)
- M D Aydemirli
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - E Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - K R M Ferrier
- Department of Pharmacology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - T P Links
- Department of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - K E Broekman
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - R H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J Zwaveling
- Department of Clinical Pharmacology and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
8
|
Matulonis UA, Shapira-Frommer R, Santin AD, Lisyanskaya AS, Pignata S, Vergote I, Raspagliesi F, Sonke GS, Birrer M, Provencher DM, Sehouli J, Colombo N, González-Martín A, Oaknin A, Ottevanger PB, Rudaitis V, Katchar K, Wu H, Keefe S, Ruman J, Ledermann JA. Antitumor activity and safety of pembrolizumab in patients with advanced recurrent ovarian cancer: results from the phase II KEYNOTE-100 study. Ann Oncol 2019; 30:1080-1087. [PMID: 31046082 DOI: 10.1093/annonc/mdz135] [Citation(s) in RCA: 404] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Advanced recurrent ovarian cancer (ROC) is the leading cause of gynecologic cancer-related death in developed countries and new treatments are needed. Previous studies of immune checkpoint blockade showed low objective response rates (ORR) in ROC with no identified predictive biomarker. PATIENTS AND METHODS This phase II study of pembrolizumab (NCT02674061) examined two patient cohorts with ROC: cohort A received one to three prior lines of treatment with a platinum-free interval (PFI) or treatment-free interval (TFI) between 3 and 12 months and cohort B received four to six prior lines with a PFI/TFI of ≥3 months. Pembrolizumab 200 mg was administered intravenously every 3 weeks until cancer progression, toxicity, or completion of 2 years. Primary end points were ORR by Response Evaluation Criteria in Solid Tumors version 1.1 per blinded independent central review by cohort and by PD-L1 expression measured as combined positive score (CPS). Secondary end points included duration of response (DOR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and safety. RESULTS Cohort A enrolled 285 patients; the first 100 served as the training set for PD-L1 biomarker analysis. Cohort B enrolled 91 patients. ORR was 7.4% for cohort A and 9.9% for cohort B. Median DOR was 8.2 months for cohort A and not reached for cohort B. DCR was 37.2% and 37.4%, respectively, in cohorts A and B. Based on the training set analysis, CPS 1 and 10 were selected for evaluation in the confirmation set. In the confirmation set, ORR was 4.1% for CPS <1, 5.7% CPS ≥1, and 10.0% for CPS ≥10. PFS was 2.1 months for both cohorts. Median OS was not reached for cohort A and was 17.6 months for cohort B. Toxicities were consistent with other single-agent pembrolizumab trials. CONCLUSIONS Single-agent pembrolizumab showed modest activity in patients with ROC. Higher PD-L1 expression was correlated with higher response. CLINICAL TRIAL NUMBER Clinicaltrials.gov, NCT02674061.
Collapse
MESH Headings
- Adenocarcinoma, Clear Cell/drug therapy
- Adenocarcinoma, Clear Cell/pathology
- Aged
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Cohort Studies
- Cystadenocarcinoma, Serous/drug therapy
- Cystadenocarcinoma, Serous/pathology
- Female
- Follow-Up Studies
- Humans
- Male
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Ovarian Neoplasms/drug therapy
- Ovarian Neoplasms/pathology
- Prognosis
- Survival Rate
Collapse
Affiliation(s)
- U A Matulonis
- Division of Gynecologic Oncology, Dana-Farber Cancer Institute, Boston, USA.
| | - R Shapira-Frommer
- Oncology Institute and Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - A D Santin
- Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, USA
| | - A S Lisyanskaya
- Department of Gynaecological Oncology, City Clinical Oncology Dispensary, Saint Petersburg, Russia
| | - S Pignata
- Department of Urogynaecological Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G Pascale", IRCCS, Naples, Italy
| | - I Vergote
- Department of Obstetrics and Gynaecology and Gynaecologic Oncology, University Hospital Leuven, Leuven, Belgium
| | - F Raspagliesi
- Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - G S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M Birrer
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, USA
| | - D M Provencher
- Hôpital Notre-Dame - Pavillon L-C Simard, Centre Hospitalier de L'Université de Montréal (CHUM), Montreal, Canada
| | - J Sehouli
- Gynecology and Obstetrics, Charité-Medical University of Berlin, Berlin, Germany
| | - N Colombo
- Department of Surgical Sciences, University of Milano-Bicocca and European Institute of Oncology, Milano, Italy
| | - A González-Martín
- Medical Oncology, Clinica Universidad de Navarra; formerly of MD Anderson International España, Madrid
| | - A Oaknin
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - P B Ottevanger
- Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - V Rudaitis
- Clinic of Obstetrics and Gynecology, Vilnius University Institute of Clinical Medicine, Vilnius, Lithuania
| | - K Katchar
- Companion Diagnostics, Merck & Co., Inc, Kenilworth, USA
| | - H Wu
- BARDS, MSD China, Beijing, China
| | - S Keefe
- Clinical Development, Merck & Co., Inc., Kenilworth, USA
| | - J Ruman
- Clinical Development, Merck & Co., Inc., Kenilworth, USA
| | - J A Ledermann
- UCL Cancer Institute and UCL Hospitals, Department of Oncology, University College London, London, UK
| |
Collapse
|
9
|
Kenter G, Greggi S, Vergote I, Katsaros D, Kobierski J, Massuger L, van Doorn HC, Landoni F, Van Der Velden J, Reed NS, Coens C, van Luijk I, Ottevanger PB, Casado A. Results from neoadjuvant chemotherapy followed by surgery compared to chemoradiation for stage Ib2-IIb cervical cancer, EORTC 55994. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.5503] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5503 Background: Conflicting evidence on the value of neoadjuvant chemotherapy followed by surgery compared to concomitant chemoradiation in Stage IB2-IIB cervical carcinoma led to this multinational multicenter trial. As the trial is approaching completion of its follow-up, preliminary results are presented. Methods: Between May 2002 and June 2014 a total of 620 patients with FIGO stage Ib2-IIb were randomized between neoadjuvant chemotherapy followed by surgery (NACTS, arm 1, N=311) with standard concomitant chemoradiotherapy (CCRT, arm 2, N=309) . In arm 1, radical hysterectomy was required within 6 weeks after completion of cisplatin-based chemotherapy with a cumulative minimum of 225mg/m2, in arm 2, radiation consisted of 45-50 Gy plus boost concurrent with weekly cisplatin chemotherapy (40 mg/m2 per week). Primary endpoint was 5-yrs overall survival (OS). Results: Median follow-up time was 8.2 years ( 95% CI = 7.8 yrs – 8.6 yrs)) and similar between both arms. A total of 191 deaths (31%) occurred. Age, stage and histological cell type were balanced in both arms. Protocol treatment was completed in 459 (74%) patients (71% for NACTS; 82% for CCRT). In arm 1 238 (76%) patients underwent surgery. Main reasons for not having surgery as per protocol, were toxicity (25/74, 34%), progressive disease (18/74, 24%) and insufficient response to NACT (12/74, 16%). Additional radiotherapy was given to 113 patients (36.3%) in arm 1; additional surgery performed in 9 patients (2.9%) in arm 2. Short term severe adverse events (≥G3) occurred more frequently in arm 1 than in arm 2 (35% vs 21%, p < 0.001). The 5 year OS was 72% in arm 1 and 76% in arm 2 (not statistically significant, difference = 4.0% (95%CI: -4% - 12%); HR 0.87, 95%CI: 0.65-0.15, p=0.332). Conclusions: These preliminary results revealed no difference in 5-year OS between NACTS and CCRT, indicating that quality of life and long term toxicity are important to decide optimal treatment. The final results will be available by April 2019, including long-term toxicity and treatment effect across prognostic factors. Clinical trial information: NCT00039338.
Collapse
Affiliation(s)
- Gemma Kenter
- Center Gynaecological Cancer Amsterdam, Amsterdam, Netherlands
| | | | - Ignace Vergote
- BGOG and University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Dionyssios Katsaros
- Dept Surgical Sciences, Gynecologic Oncology, Città della Salute, S.Anna Hospital, Torino, Italy
| | | | - Leon Massuger
- Radboud University Medical Center, Nijmegen, Netherlands
| | - H. C. van Doorn
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Daniel Den Hoed/Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Fabio Landoni
- MaNGO and Division of Gynecologic Oncology, European Institute of Oncology, Milan, Italy
| | | | | | - Corneel Coens
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Iske van Luijk
- MC Haaglanden Bronovo, Gynaecology, The Hague, Netherlands
| | | | | |
Collapse
|
10
|
Timmermans M, Sonke GS, Van de Vijver KK, Ottevanger PB, Nijman HW, van der Aa MA, Kruitwagen RFPM. Localization of distant metastases defines prognosis and treatment efficacy in patients with FIGO stage IV ovarian cancer. Int J Gynecol Cancer 2019; 29:392-397. [PMID: 30665898 DOI: 10.1136/ijgc-2018-000100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 10/10/2018] [Accepted: 12/27/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with ovarian cancer who are diagnosed with Federation of Gynecology and Obstetrics (FIGO) stage IV disease are a highly heterogeneous group with possible survival differences. The FIGO staging system was therefore updated in 2014. OBJECTIVE To evaluate the 2014 changes to FIGO stage IV ovarian cancer on overall survival. METHODS We identified all patients diagnosed with FIGO stage IV disease between January 2008 and December 2015 from the Netherlands Cancer Registry. We analyzed the prognostic effect of FIGO IVa versus IVb. In addition, patients with extra-abdominal lymph node involvement as the only site of distant disease were analyzed separately. Overall survival was analyzed by Kaplan-Meier curves and multivariable Cox regression models. RESULTS We identified 2436 FIGO IV patients, of whom 35% were diagnosed with FIGO IVa disease. Five-year overall survival of FIGO IVa and IVb patients (including those with no or limited therapy) was 8.9% and 13.0%, respectively (p=0.51). Patients with only extra-abdominal lymph node involvement had a significant better overall survival than all other FIGO IV patients (5-year overall survival 25.9%, hazard ratio 0.77 [95% CI 0.62 to 0.95]). CONCLUSION Our study shows that the FIGO IV sub-classification into FIGO IVa and IVB does not provide additional prognostic information. Patients with extra-abdominal lymph node metastases as the only site of FIGO IV disease, however, have a better prognosis than all other FIGO IV patients. These results warrant a critical appraisal of the current FIGO IV sub-classification.
Collapse
Affiliation(s)
- Maite Timmermans
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands .,Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - G S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - K K Van de Vijver
- Department of Pathology, Ghent University Hospital, Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - H W Nijman
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - M A van der Aa
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - R F P M Kruitwagen
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht, The Netherlands
| |
Collapse
|
11
|
Matulonis UA, Shapira-Frommer R, Santin A, Lisyanskaya AS, Pignata S, Vergote I, Raspagliesi F, Sonke GS, Birrer M, Provencher DM, Sehouli J, Colombo N, González-Martín A, Oaknin A, Ottevanger PB, Rudaitis V, Katchar K, Wang Z, Ruman J, Ledermann JA. Antitumor activity and safety of pembrolizumab in patients with advanced recurrent ovarian cancer: Interim results from the phase 2 KEYNOTE-100 study. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.5511] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Gabe S. Sonke
- Netherlands Cancer Institute and BOOG Study Center, Amsterdam, Netherlands
| | | | | | - Jalid Sehouli
- Charité-Medical University of Berlin, Berlin, Germany
| | - Nicoletta Colombo
- University of Milano-Bicocca and European Institute of Oncology, Milano, Italy
| | | | - Ana Oaknin
- Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | - Vilius Rudaitis
- Vilnius University Institute of Clinical Medicine, Vilnius, Lithuania
| | | | | | | | | |
Collapse
|
12
|
Hensley ML, Enserro D, Hatcher H, Ottevanger PB, Krarup-Hansen A, Blay JY, Fisher C, Moxley KM, Lele SB, Lea JS, Tewari KS, Thaker PH, Zivanovic O, O'Malley DM, Robison K, Miller DS. Adjuvant gemcitabine plus docetaxel followed by doxorubicin versus observation for uterus-limited, high-grade leiomyosarcoma: A phase III GOG study. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.5505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Martee Leigh Hensley
- Memorial Sloan Kettering Cancer Center and Weil Cornell Medical College, New York, NY
| | | | - Helen Hatcher
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | | | | | - Cyril Fisher
- The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | | | | | | | | | - Premal H. Thaker
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | | - Katina Robison
- Women and Infants Hospital in Rhode Island, Providence, RI
| | - David S. Miller
- The University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
13
|
Eysbouts YK, Ottevanger PB, Massuger LFAG, IntHout J, Short D, Harvey R, Kaur B, Sebire NJ, Sarwar N, Sweep FCGJ, Seckl MJ. Can the FIGO 2000 scoring system for gestational trophoblastic neoplasia be simplified? A new retrospective analysis from a nationwide dataset. Ann Oncol 2018; 28:1856-1861. [PMID: 28459944 DOI: 10.1093/annonc/mdx211] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Worldwide introduction of the International Fedaration of Gynaecology and Obstetrics (FIGO) 2000 scoring system has provided an effective means to stratify patients with gestational trophoblastic neoplasia to single- or multi-agent chemotherapy. However, the system is quite elaborate with an extensive set of risk factors. In this study, we re-evaluate all prognostic risk factors involved in the FIGO 2000 scoring system and examine if simplification is feasible. Patients and methods Between January 2003 and December 2012, 813 patients diagnosed with gestational trophoblastic neoplasia were identified at the Trophoblastic Disease Centre in London and scored using the FIGO 2000. Multivariable analysis and stepwise logistic regression were carried out to evaluate whether the FIGO 2000 scoring system could be simplified. Results Of the eight FIGO risk factors only pre-treatment serum human chorionic gonadotropin (hCG) levels exceeding 10 000 IU/l (OR = 5.0; 95% CI 2.5-10.4) and 100 000 IU/l (OR = 14.3; 95% CI 4.7-44.1), interval exceeding 7 months since antecedent pregnancy (OR = 4.1; 95% CI 1.0-16.2), and tumor size of over 5 cm (OR = 2.2; 95% CI 1.3-3.6) were identified as independently predictive for single-agent resistance. In addition, increased risk was apparent for antecedent term pregnancy (OR = 3.4; 95% CI 0.9-12.7) and the presence of five or more metastases (OR = 3.5; 95% CI 0.4-30.4), but patient numbers in these categories were relatively small. Stepwise logistic regression identified a simplified risk scoring model comprising age, pretreatment serum hCG, number of metastases, antecedent pregnancy, and interval but omitting tumor size, previous failed chemotherapy, and site of metastases. With this model only 1 out 725 patients was classified different from the FIGO 2000 system. Conclusion Our simplified alternative using only five of the FIGO prognostic factors appears to be an accurate system for discriminating patients requiring single as opposed to multi-agent chemotherapy. Further work is urgently needed to validate these findings.
Collapse
Affiliation(s)
| | | | | | - J IntHout
- Department of Health Evidence, Section Biostatistics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - D Short
- Department of Medical Oncology
| | | | - B Kaur
- Department of Pathology, Charing Cross and Hammersmith Campuses, Imperial College London, London, UK
| | - N J Sebire
- Department of Pathology, Charing Cross and Hammersmith Campuses, Imperial College London, London, UK
| | | | - F C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | |
Collapse
|
14
|
IJsbrandy C, Ottevanger PB, Tsekou Diogeni M, Gerritsen WR, van Harten WH, Hermens RPMG. Review: Effectiveness of implementation strategies to increase physical activity uptake during and after cancer treatment. Crit Rev Oncol Hematol 2018; 122:157-163. [PMID: 29458784 DOI: 10.1016/j.critrevonc.2017.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/11/2017] [Accepted: 09/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The purpose of this review was to assess the effectiveness of different strategies to implement physical activity during and after cancer treatment. DESIGN We searched for studies containing strategies to implement physical activity in cancer care that meet the inclusion criteria of the Cochrane EPOC group. The primary outcome was physical activity uptake. We expressed the effectiveness of the strategies as the percentage of studies with improvement. RESULTS Nine studies met the inclusion criteria. Patient groups doing physical activities via an implementation strategy had better outcomes than those receiving usual care: 83% of the studies showed improvement. Strategies showing significant improvement compared to usual care employed healthcare professionals to provide individual counselling or advice for exercise or interactive elements such as audit and feedback systems. When comparing the different strategies 1) interactive elements or 2) elements tailored to the needs of the patients had better physical activity uptake. CONCLUSIONS Implementation strategies containing individual and interactive elements, tailored to the individual needs of patients, are more successful in improving physical activity uptake.
Collapse
Affiliation(s)
- C IJsbrandy
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Science (RIHS), Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands; Department of Medical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands; Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - P B Ottevanger
- Department of Medical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
| | - M Tsekou Diogeni
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Science (RIHS), Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
| | - W R Gerritsen
- Department of Medical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
| | - W H van Harten
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Health Technology and Services Research, MB-HTSR, University of Twente, Enschede, The Netherlands.
| | - R P M G Hermens
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Science (RIHS), Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
| |
Collapse
|
15
|
Desar IME, Ottevanger PB, Benson C, van der Graaf WTA. Systemic treatment in adult uterine sarcomas. Crit Rev Oncol Hematol 2017; 122:10-20. [PMID: 29458779 DOI: 10.1016/j.critrevonc.2017.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/12/2017] [Indexed: 12/28/2022] Open
Abstract
Uterine sarcomas (US) are rare mesenchymal tumours of the uterus and are divided mainly into uterine leiomyosarcoma (uLMS), low grade endometrial stromal sarcoma (LG-ESS), high grade endometrial stromal sarcoma (HG-ESS), adenosarcomas and high grade undifferentiated sarcoma (HGUS). US are often high-grade tumours with a high local recurrence rate and metastatic risk. We here discuss the current standard of care and knowledge of systemic therapy for adult uterine sarcomas, in particular uLMS, LG-ESS, HG-ESS and HGUS, in both the adjuvant as well as the metastatic setting.
Collapse
Affiliation(s)
- I M E Desar
- Department of Medical Oncology, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - C Benson
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - W T A van der Graaf
- Department of Medical Oncology, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, Sutton, London, United Kingdom.
| |
Collapse
|
16
|
Heitz F, Harter P, Avall-Lundqvist E, Reuss A, Pautier P, Cormio G, Colombo N, Hell J, Vergote I, Poveda A, Ottevanger PB, Hanker LC, Leminen AO, Alexandre J, Canzler U, Sehouli J, Herrstedt J, Fiane B, Merger M, Du Bois A. The prognostic value of tumor residuals indicated by surgeon, by radiology or an integrated approach by surgeons' assessment and pre-chemotherapy CT-scan in patients with advanced ovarian cancer: An exploratory analysis of the AGO Study led Intergroup trial AGO-OVAR 12. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.5521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5521 Background: Post-OP TR is a strong prognostic factor in AOC; the best prognosis is observed after complete resection (TR0). TR assessment is performed at the end of the surgery and may be exposed to personal bias. Pre-Chemo CT may improve post-OP assessment, however, it may also be prone to findings by post-OP tumor re-growth, tissue repair or scarring. Methods: Pts with FIGO IIB-IV AOC recruited into the double-blind randomized frontline AGO-OVAR12 trial were scheduled for baseline CT before the 1st chemo cycle. SA and RA of TR were compared. Additionally, a measurement of TR integrating both approaches were assessed (IA). For this IA information of surgical and path reports were reviewed by two of the authors. Results: 1355 pts had complete data for all 3 assessment methods. Of 689 pts with TR0 in SA, 497 (72%) and 539 (78%) had also TR0 pre-Chemo (RA and IA), but showed TR>0 in 192 (28%) and 150 pts (22%), respectively. Pts with SA defined TR0 had a similar median PFS of 27.6 mos compared to TR0 defined by RA (27.8 mos) and IA (28.9 mos). Pts with concordant TR0 (SA/ IA and SA/ RA) had a median PFS of 28.9 mos. In contrast, pts with discordant SA TR0 - RA TR>0 or SA TR0 - IA TR>0 showed inferior median PFS of 19.2 mos (HR: 1.89, 95%CI: 1.48-2.40; p<0.0001) and 16.9 mos (HR: 2.02, 95% CI: 1.57- 2.59; p<0.0001), respectively. Pts with concordant TR>0 had an even lower median PFS of 13.5 (SA and IA) and 12.9 mos (SA and RA). PFS of the experimental therapy or placebo dependent if SA, RA or IA were used, will be presented. Conclusions: Pre-Chemo CT provides information separating the group of pts with post-OP TR0 in pts with TR0 and pts with TR> 0 pre-Chemo. The latter group showed PFS values in between those with surgically assessed post-OP TR0 and those with post-OP TR> 0, forming a third prognostic group. Detailed analysis should evaluate to what extend tumor biology, surgical bias, or imperfect imaging contribute to the discrepancies. Integrating all this may lead to better definition of prognostic groups and the need for specific treatment strategies.
Collapse
Affiliation(s)
- Florian Heitz
- Department of Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | | | | | - Alexander Reuss
- AGO and Coordinating Center for Clinical Trials, Marburg, Germany
| | - Patricia Pautier
- Medical Oncology Department, Institut Gustave Roussy, Paris, France
| | | | - Nicoletta Colombo
- University of Milano-Bicocca and Istituto Europeo di Oncologia, Milan, Italy
| | - Johanna Hell
- Klinikum Wels, Abt. Frauenheilkunde u Geburtshilfe, Austria, Wels, Austria
| | - Ignace Vergote
- BGOG and University of Leuven, Leuven Cancer Institute, Leuven, Belgium
| | | | | | | | | | - Jerome Alexandre
- Department of Medical Oncology, Cochin Hospital, Paris Descartes University, AP-HP, CARPEM, Immunomodulatory Therapies Multidisciplinary Study group (CERTIM), Paris, France
| | - Ulrich Canzler
- Department of Gynecology and Obstetrics, University of Dresden, Dresden, Germany
| | - Jalid Sehouli
- AGO and Charité Campus Virchow-Klinikum, Berlin, Germany
| | | | - Bent Fiane
- Department of Gynecology and Gynecologic Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Michael Merger
- Clinical Research, Boehringer Ingelheim Pharma, Biberach An Der Riss, Germany
| | | |
Collapse
|
17
|
Eysbouts YK, Massuger LFAG, IntHout J, Lok CAR, Sweep FCGJ, Ottevanger PB. The added value of hysterectomy in the management of gestational trophoblastic neoplasia. Gynecol Oncol 2017; 145:536-542. [PMID: 28390821 DOI: 10.1016/j.ygyno.2017.03.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/15/2017] [Accepted: 03/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite the undoubted effectiveness of chemotherapeutic treatment in gestational trophoblastic neoplasia (GTN), problems related to toxicity of chemotherapy and chemo-resistant disease have led to reconsideration of the use of hysterectomy. Aim of the present study was to evaluate indications for and outcome of hysterectomy in patients with GTN in a nation-wide cohort. METHODS Between 1977 and 2012, we identified all patients diagnosed with GTN and treated with hysterectomy from the Dutch national databases. Demographics, clinical characteristics and follow-up were recorded retrospectively. RESULTS One hundred and nine patients (16.5% of all registered patients with GTN) underwent hysterectomy as part of their management for GTN. The majority of patients was classified as low-risk disease (74.3%), post-molar GTN (73.5%) and disease confined to the uterus (65.1%). After hysterectomy, complete remission was achieved in 66.2% of patients with localized disease and in 15.8% of patients with metastatic disease. For patients with localized disease, treated with primary hysterectomy, treatment duration was significantly shorter (mean 3.2weeks and 8.0weeks respectively, p=0.01) with lower number of administered chemotherapy cycles (mean 1.5 and 5.8 respectively, p<0.01) than patients in a matched control group. CONCLUSION In selected cases, a hysterectomy may be an effective means to either reduce or eliminate tumor bulk. Primary hysterectomy should mainly be considered in older patients with localized disease and no desire to preserve fertility, whereas patients with chemotherapy-resistant disease may benefit from additional hysterectomy, especially when disease is localized. For patients with widespread metastatic disease, the benefit of hysterectomy lies in the removal of chemotherapy-resistant tumor bulk with subsequent effect on survival.
Collapse
Affiliation(s)
- Y K Eysbouts
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - L F A G Massuger
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J IntHout
- Department for Health Evidence, Section Biostatistics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C A R Lok
- Department of Gynecologic Oncology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute Amsterdam, The Netherlands
| | - F C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
18
|
Melief CJ, Gerritsen WR, Welters M, Vergote I, Kroep JR, Kenter G, Ottevanger PB, Tjalma WA, Denys H, Nijman H, van Poelgeest MIE, Reyners AK, Velu TJ, Blumenstein BA, Goffin F, Lalisang RI, Stead RB, van der Burg S. Correlation between strength of T-cell response against HPV16 and survival after vaccination with HPV16 long peptides in combination with chemotherapy for late-stage cervical cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.7_suppl.140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
140 Background: Therapeutic vaccination with HPV type 16 synthetic long peptides (HPV16-SLP) results in T cell–mediated regression of HPV16-induced premalignant lesions but fails to install effective immunity in patients with advanced HPV16-positive cervical cancer. We showed that HPV16-SLP vaccination in mice and in patients with advanced cervical cancer patients fosters robust HPV16-specific T cell responses, when combined with chemotherapy. In this study we noted that a single dose of vaccine 2 weeks into the 2nd cycle of chemotherapy was optimal, because at this time the immunosuppressive myeloid cells were down. Methods: We now completed a chemo-immunotherapy study in a larger number of patients with late stage HPV16+ cervical cancer. Three HPV16-SLP vaccine doses were given 2 weeks after the second, third, and fourth cycles of standard chemotherapy. Cohorts of 12 patients each were vaccinated with each of 4 dose levels (20, 40, 100, and 300 µg/ per peptide) of 13 overlapping HPV16 synthetic long peptides (HPV16-SLP) together covering the length of the 2 E6 and E7 proteins. Results: Robust vaccine-induced HPV16-specific T cell responses as assessed by interferon-g Elispot were observed and were sustained throughout the cycles of chemotherapy. These T cell responses were substantially increased in all patients who received HPV16-SLP . In addition, the chemotherapy augmented recall responses to microbial antigens. Such robust T cell responses were not noted in previous trials when similar patients were vaccinated without timing of vaccination during chemotherapy. A marked correlation was observed between the strength of the vaccine-induced immune response and longer-term clinical outcomes such as overall survival. No such correlation exists between the strength of the T cell response against common recall antigens and survival. In addition, a remarkably high proportion of patients survived beyond 20 months after the start of therapy. Conclusions: These results indicate that the survival advantage is specifically related to the strength of the vaccine-induced T cell response and is not due to generally better immuno-competence. Clinical trial information: NCT02128126.
Collapse
Affiliation(s)
| | | | - Marij Welters
- Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Gemma Kenter
- Amsterdam Medical Center, Amsterdam, Netherlands
| | | | | | - Hannelore Denys
- Department of Medical Oncology, Gent University Hospital, Gent, Belgium
| | - Hans Nijman
- University Medical Center Groningen, Groningen, Netherlands
| | | | | | | | | | - Frederic Goffin
- Gynecologic Oncology, CHU of Liege, Site Hopital de la Citadelle, Liege, Belgium
| | | | | | | |
Collapse
|
19
|
van der Steen MJ, de Waal YRP, Westermann A, Tops B, Leenders W, Ottevanger PB. An impressive response to pazopanib in a patient with metastatic endometrial carcinoma. Neth J Med 2016; 74:410-413. [PMID: 27905309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The incidence of endometrial carcinoma is rising and the patients with distant metastases have a poor prognosis, especially when progression of disease occurs after systemic treatment with hormonal therapy or chemotherapy. Pazopanib, a multi-targeted inhibitor of several oncogenic receptor tyrosine kinases, has been investigated in patients with chemotherapy-resistant endometrial carcinoma or patients for whom chemotherapy is contraindicated. In this report we will describe a spectacular response to pazopanib in a patient with recurrent metastatic endometrial carcinoma.
Collapse
Affiliation(s)
- M J van der Steen
- First auteur: Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands Second auteur: Gynaecological Oncology, Amsterdam Medical Centre, Amsterdam, the Netherlands
| | | | | | | | | | | |
Collapse
|
20
|
Mol L, Ottevanger PB, Koopman M, Punt CJA. The prognostic value of WHO performance status in relation to quality of life in advanced colorectal cancer patients. Eur J Cancer 2016; 66:138-43. [PMID: 27573427 DOI: 10.1016/j.ejca.2016.07.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Performance status (PS) is an established prognostic factor in patients with advanced cancer and is usually scored by the treating physician. The EORTC QLQ-C30 questionnaire as reported by cancer patients is a validated tool to assess quality of life (QoL). Subjectivity plays a role in both assessments, and data on a direct comparison are scarce. METHODS We compared the prognostic value for overall survival (OS) of the WHO PS to the baseline physical function scale of the EORTC QLQ-C30 (QLQ-C30 PF) in a prospective randomised phase 3 trial in advanced colorectal cancer (ACC), the CAIRO study. Patients were divided into two groups based on the baseline QLQ-C30 PF. QLQ-C30 PF was considered 'good' if the score was more than 66.7% and 'poor' if 66.7% or less. Results were validated in a subsequent phase 3 study in ACC, the CAIRO2 study. RESULTS The median OS for patients with a 'good' QLQ-C30 PF and a 'poor' PF in patients with WHO PS 0 was 20.3 months (n = 300) and 10.4 months (n = 44), in patients with WHO PS 1 16.8 months (n = 125) and 10.1 months (n = 63), and in patients with WHO PS 2 16.2 months (n = 11) and 9.9 months (n = 12), respectively. In a Cox regression model which included other prognostic factors, 'good' versus 'poor' QLQ-C30 PF was significantly prognostic for OS (0.57 95% confidence interval: 0.46-0.72), but not WHO PS. These results were confirmed in the CAIRO2 study. CONCLUSIONS We demonstrate in ACC patients that PF, as assessed by patients using the EORTC QLQ-C30, is superior in terms of prognostic value to WHO PS as scored by physicians. Our data support to include the results of baseline EORTC QLQ-C30 PF instead of WHO PS as a stratification parameter in oncology trials.
Collapse
Affiliation(s)
- L Mol
- Clinical Trial Department, Netherlands Comprehensive Cancer Organisation (IKNL), The Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Koopman
- Department of Medical Oncology, University Medical Centre, Utrecht, The Netherlands
| | - C J A Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, The Netherlands.
| |
Collapse
|
21
|
Hermens R, Stienen J, Krieken HV, Blijlevens N, Ottevanger PB. Improving hospital care for patients with non-Hodgkin's lymphomas. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.6593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rosella Hermens
- Radboud University Medical Center, Department IQ Healthcare, Nijmegen, Netherlands
| | - Jozette Stienen
- Radboud University Medical Center, Department IQ Healthcare, Nijmegen, Netherlands
| | - Han van Krieken
- Radboud University Medical Center, Department of Pathology, Nijmegen, Netherlands
| | - Nicole Blijlevens
- Radboud University Medical Center, Department of Hematology, Nijmegen, Netherlands
| | | |
Collapse
|
22
|
Creutzberg CL, de Boer SM, Putter H, Powell M, Mileshkin LR, Katsaros D, Bessette P, Haie-Meder C, Ledermann JA, Ottevanger PB, Khaw P, Colombo A, Fyles AW, Baron MH, Nijman HW, Nout RA, Smit VT, Verhoeven-Adema K, Kruitwagen RF, Kitchener HC. Adjuvant chemotherapy and radiation therapy (RT) versus RT alone for women with high-risk endometrial cancer: Toxicity and quality-of-life results of the randomized PORTEC-3 trial. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.5501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Stephanie M. de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, Netherlands
| | - Melanie Powell
- Department of Clinical Oncology, Barts Health NHS Trust, London, United Kingdom
| | | | - Dionyssios Katsaros
- Dept of Surgical Sciences, Gynecologic Oncology, Città della Salute and S Anna Hospital, Torino, Italy
| | | | | | | | | | - Pearly Khaw
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne Vic, Australia
| | | | | | - Marie-Helene Baron
- Department of Radiotherapy, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Hans W. Nijman
- Department of Gynaecologic Oncology, University Medical Center Groningen, Groningen, Netherlands
| | - Remi A. Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | | | | |
Collapse
|
23
|
Stienen JJC, Ottevanger PB, Wennekes L, van de Schans SAM, Dekker HM, Blijlevens NMA, van der Maazen RWM, van Krieken JHJM, Hermens RPMG. Delivering high-quality care to patients with a non-Hodgkin's lymphoma: barriers perceived by patients and physicians. Neth J Med 2014; 72:41-48. [PMID: 24457441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Despite the presence of non-Hodgkin's lymphoma (NHL) guidelines, there are still gaps between best evidence as described in guidelines and quality of care in daily practice. Little is known about factors that affect this discrepancy. We aim to identify barriers that influence the delivery of care and to explore differences between patients' and physicians' experiences, as well as between the different disciplines involved. METHODS Patients and physicians involved in NHL care were interviewed about their experiences with NHL care. The barriers identified in these interviews were quantified in a web-based survey. Differences were tested using Chi-square tests. RESULTS Barriers frequently perceived by patients concerned lack of patient information and emphatic contact (12-43%), long waiting times (19-35%) and lack of guidance and support (39%). Most barriers mentioned by physicians concerned the unavailability of the guideline (32%), lack of an up-to-date guideline (66%), lack of standardised forms for diagnostics (56-70%) and of multidisciplinary meetings (56%). Perceived barriers concerning the guideline and standardised forms significantly varied between the disciplines involved (range 14-84%, p.
Collapse
Affiliation(s)
- J J C Stienen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Ottevanger PB, Oostendorp LJM, Van Der Graaf WT, Stalmeier PFM. A randomized trial of a nurse-led decision aid to inform patients with advanced cancer about palliative chemotherapy. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.e20583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e20583 Background: There is a lack of decision aids (DAs) for patients with advanced cancer considering palliative treatment. In this randomized study, we evaluated nurse-led DAs about second-line palliative chemotherapy for patients with advanced breast (BC) or colorectal cancer (CRC). Methods: Patients with advanced BC or CRC considering second-line treatment were randomized to receive only usual care (control group) or usual care plus a DA from a nurse (intervention group) (1:2 ratio). Using the DA, a nurse offered information on adverse events, tumor response, and survival. Patients completed a baseline questionnaire and two follow-up questionnaires 1 week and 8 weeks after the treatment-related information was provided. Outcome measures were well-being, coping, knowledge, and information and decision-related outcomes. Intent-to-treat analyses were performed using Chi Square tests, independent samples t-tests, and linear mixed models to examine differences between groups over time. Results: In all,128 patients participated in the study; median age 62 years (range 32-81), 37% male, 73% CRC. Of the 83 patients assigned to the intervention group, 77 received a DA. At the first follow-up, more patients receiving a DA preferred chemotherapy (96% vs. 84%; p=0.067). Seven weeks later, 88% of patients in the intervention group and 84% of patients in the control group had started chemotherapy (p=0.746). The only statistically significant effect was the stronger treatment preference of patients in the intervention group (3.0 vs. 2.5; p=0.030). The DAs did not negatively impact anxiety, depression, cancer worries, and hopelessness. Conclusions: It is possible to offer a DA with explicit information to patients with advanced cancer without negative impact on patients' well-being. Unexpectedly, this study did not show consistent effectiveness of the DAs. Our interpretation is that most patients receiving the DA had already decided to start chemotherapy. Clinical trial information: NTR1113.
Collapse
Affiliation(s)
- P. B. Ottevanger
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Linda JM Oostendorp
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Peep FM Stalmeier
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, Netherlands
| |
Collapse
|
25
|
Lybol C, Westerdijk K, Sweep FCGJ, Ottevanger PB, Massuger LFAG, Thomas CMG. Human chorionic gonadotropin (hCG) regression normograms for patients with high-risk gestational trophoblastic neoplasia treated with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine) chemotherapy. Ann Oncol 2012; 23:2903-2906. [PMID: 22730100 DOI: 10.1093/annonc/mds199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND We present normograms for human chorionic gonadotropin (hCG) regression in patients with high-risk gestational trophoblastic neoplasia (GTN) successfully treated with multiagent chemotherapy in order to predict treatment resistance. PATIENTS AND METHODS We collected data for 46 patients with high-risk GTN treated with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine) who had hCG values available. Patients were classified as having methotrexate (MTX)-resistant disease (n = 22) or primary high-risk disease (n = 24). The 10th, 50th and 90th percentiles of the hCG before every chemotherapy course were calculated and plotted in normograms. RESULTS Half of the patients treated for MTX-resistant disease and primary high-risk disease had normal hCG levels before the third and sixth course of chemotherapy, respectively. In patients with MTX-resistant disease, the 90th percentile line fell below normal before the start of the fourth course, whereas in patients with primary high-risk disease this was not the case until the eighth course of chemotherapy. CONCLUSION Resistance to EMA/CO treatment for high-risk GTN, as illustrated by examples, could be predicted using normograms for hCG resistance. Normograms differed depending on the indication for multiagent chemotherapy due to much higher initial hCG values in patients with primary high-risk disease compared with those treated for MTX-resistant disease.
Collapse
Affiliation(s)
- C Lybol
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - K Westerdijk
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - F C G J Sweep
- Department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - P B Ottevanger
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - L F A G Massuger
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - C M G Thomas
- Department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
26
|
Lybol C, Thomas CMG, Blanken EA, Sweep FCGJ, Verheijen RH, Westermann AM, Boere IA, Reyners AKL, Massuger LFAG, van Hoesel RQGCM, Ottevanger PB. Comparing cisplatin-based combination chemotherapy with EMA/CO chemotherapy for the treatment of high risk gestational trophoblastic neoplasia. Eur J Cancer 2012; 49:860-7. [PMID: 23099004 DOI: 10.1016/j.ejca.2012.09.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/10/2012] [Accepted: 09/15/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cisplatin-based chemotherapy (etoposide 100 mg/m(2) days 1-5, methotrexate 300 mg/m(2) day 1, cyclophosphamide 600 mg/m(2) day 1, actinomycin D 0.6 mg/m(2) day 2 and cisplatin 60 mg/m(2) day 4, EMACP) was compared to EMA/CO (etoposide 100 mg/m(2) days 1-2, methotrexate 300 mg/m(2) day 1 and actinomycin D 0.5 mg i.v. bolus day 1 and 0.5 mg/m(2) day 2, alternating with cyclophosphamide 600 mg/m(2) day 8 and vincristine 1 mg/m(2) day 8) for the treatment of high-risk gestational trophoblastic neoplasia (GTN). PATIENTS AND METHODS In the Netherlands, 83 patients were treated with EMACP and 103 patients with EMA/CO. Outcome measures were remission rate, median number of courses to achieve normal human chorionic gonadotrophin (hCG) concentrations, toxicity, recurrent disease rate and disease specific survival. RESULTS Remission rates were similar (EMACP 91.6%, EMA/CO 85.4%). The median number of courses of EMA/CO to reach hCG normalisation for single-agent resistant disease and primary high-risk disease was three and five courses, respectively, compared to 1.5 (p=0.001) and three (p<0.001) courses of EMACP. Patients treated with EMACP more often developed fever, renal toxicity, nausea and diarrhoea compared to patients treated with EMA/CO. Patients treated with EMA/CO more often had anaemia, neuropathy and hepatotoxicity. CONCLUSION EMACP combination chemotherapy is an effective treatment for high-risk GTN, with a remission rate comparable to EMA/CO. However, the difference in duration of treatment is only slightly shorter with EMACP. Cisplatin-based chemotherapy in the form of EMACP in this study was not proven more effective than EMA/CO.
Collapse
Affiliation(s)
- C Lybol
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Lybol C, Centen DW, Thomas CMG, ten Kate-Booij MJ, Verheijen RHM, Sweep FCGJ, Ottevanger PB, Massuger LFAG. Fatal cases of gestational trophoblastic neoplasia over four decades in the Netherlands: a retrospective cohort study. BJOG 2012; 119:1465-72. [DOI: 10.1111/j.1471-0528.2012.03480.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
28
|
Boers-Sonderen M, Desar I, Van Der Graaf WT, Ottevanger PB, Van Herpen C. A phase Ib study of the combination of temsirolimus (T) and pegylated liposomal doxorubicin (PLD) in advanced or recurrent breast, endometrial, and ovarian cancer. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.5061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5061 Background: PLD is active in metastatic breast, endometrial and ovarian cancer. Preclinical studies suggest that mTOR inhibitors (mTORi), such as T, have an additive therapeutic effect to chemotherapy and resistance to doxorubicin can be reversed by adding an mTORi. Therefore, the combination of T and PLD is highly promising. Methods: This phase I study assessed the maximum tolerated dose (MTD), safety and activity of the combination of T and PLD in advanced or recurrent breast, endometrial or ovarian cancer. Patients (pts) who were not previously treated with PLD or T, with adequate organ function were eligible. After a two week run in period with T iv once weekly, PLD iv once every four weeks was added. In case of clinical benefit, pts were treated for a maximum of 9 cycles combination therapy. T could be continued as monotherapy afterwards. The MTD was defined as the highest dose at which ≤ 1 dose limiting toxicity (DLT) had been observed among 6 pts. FDG PET scans were performed at baseline and after 2 and 6 wks to assess the effect on tumor metabolism. Pharmacokinetic (PK) sampling was performed during cycle 1. Results: 20 pts were enrolled. On the 4th dose level with 20 mg T and 40 mg/m2 PLD 2 DLTs occurred in 6 pts: a grade 3 thrombocytopenic bleeding and a grade 3 skin toxicity. Therefore, the MTD was assessed at 15 mg T and 40 mg/m2 PLD. Adverse events (all grades/grade 3-4 in %) occurring most frequently were fatigue (84/5), nausea (84/16), mucositis (79/21), vomiting (74/16) and anorexia (74/0) Furthermore, rash and hand foot syndrome occurred both in 53% of pts, with 11% and 21% grade 3 respectively. 3 pts had a confirmed PR and 9 had SD (> 3 months). The mean progression free survival (PFS) was 4.9 months with 2 pts still on treatment. Results of FDG PET and PK data are currently being analyzed and will be presented. Conclusions: The combination of T and PLD is safe and tolerable. The MTD was assessed at PLD 40 mg/m2 once every 4 weeks and T 15 mg weekly. The activity of this combination in breast, endometrial and ovarian cancer pts is promising and warrants further studies.
Collapse
Affiliation(s)
- Marye Boers-Sonderen
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Ingrid Desar
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - P. B. Ottevanger
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Carla Van Herpen
- Department of Medical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| |
Collapse
|
29
|
Lybol C, Ottevanger PB, Thomas CMG, Sweep FCGJ, Massuger LFAG. Centralised registration of gestational trophoblastic disease and trends in incidence. Acta Oncol 2012; 51:415-6. [PMID: 22229747 DOI: 10.3109/0284186x.2011.643824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
30
|
Burg ME, Janssen JT, Ottevanger PB, Kerkhofs LG, Valster F, Stouthard JM, Onstenk W, Termorshuizen F, Verweij J. Multicenter randomized phase III trial of 3-weekly paclitaxel/platinum (PC3w) versus weekly paclitaxel/platinum (PCw) induction therapy followed by PC3w maintenance therapy in advanced epithelial ovarian cancer (EOC). J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.5538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5538 Background: Response rates (RR) up to 50% were found with PCw in platinum resistant EOC. We compared the efficacy of first-line PCw induction therapy to PC3w. Methods: 270 patients (pts) with FIGO stage II-IV, Performance status (PS) 0–2 were randomly assigned to 3 x PC3w (P 175mg/m2 with either cisplatin [Cis] 75mg/m2 or carboplatin [Car] AUC 6) or 6 x PCw (P 90mg/m2 with either Cis 70mg/m2 or Car AUC 4, day 1,8,15 and day 29,36,43) followed by up to 6 cycles PC3w in both arms. Pts were stratified for FIGO stage, PS, tumor size and center. Primary endpoints were progression free survival (PFS) and overall survival (OS). Secondary endpoints were RR and toxicity. A total of 225 events were needed to detect a 10–13% absolute difference in PFS/OS with a power of 84% (one-sided). Results: 267 pts (134 TC-3w and 133 TCw) were eligible (3 pts wrong tumor type). Pt characteristics were well balanced; median age 58 years, serous 62%, residual disease >1cm 66%, FIGO stage II 7%, III 64%, IV 29%. Median dose-intensity for PC3w was: P 58(47–58) and Cis 25(22.5–25) mg/m2/w, Car 2(1.6–2) AUC/w, for PCw: P 60(36–60) and Cis 44.7(30–44.7) mg/m2/w and for Car 2.7(1,6–2,7) AUC/w. After a median follow-up of 39 months (m) (range 0.03 - 93.3m) 206 pts (77%) had progressed and 164 pts (61%) had died. Median PFS was 18m for TC3w and 19m for TCw, 5-year PFS was 20% and 18%, respectively (logrank test: p = 0.63). Median OS was 44m for TC3w and 45m for TCw, 5-year OS was 36% and 37%, respectively (logrank test: p = 0.87). RR after induction therapy in 176 pts with measurable disease was 72% for TC3w and 74% for TCw (p = 0.68). TCw was well tolerated. Grade 3/4 toxicity for TC3w vs. TCw was respectively, platelets 1.75% vs.1.55% (ns), WBC 5.5% vs. 8.7 (p = <0.0001), granulocytes 16.7% vs. 11.7% (p = <0.001) and delay 3% vs. 9% of the cycles. TCw induced less grade 2/3 muscular and joint pain (TC3w 6.3% and 3.5% vs. TCw 0.3% and 0.8% of the cycles) and less neurotoxicity (TC3w 6% vs. 1.6% of the pts in TCw). The other toxicities were similar in frequency and severity in both arms. Conclusions: TCw was well tolerated and had less granulocytopenia, neurotoxicity, and muscular and joint pain but did not yield benefit in terms of OS, PFS or RR. No significant financial relationships to disclose.
Collapse
Affiliation(s)
- M. E. Burg
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - J. T. Janssen
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - P. B. Ottevanger
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - L. G. Kerkhofs
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - F. Valster
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - J. M. Stouthard
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - W. Onstenk
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - F. Termorshuizen
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| | - J. Verweij
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands; Franciscus Ziekenhuis Roosendaal, Roosendaal, Netherlands; University Medical Center Nijmegen, Nijmegen, Netherlands; Ziekenhuis Walcheren, Vlissingen, Netherlands; Lievensberg Ziekenhuis, Bergen op Zoom, Netherlands; Maasstad Ziekenhuis locatie Clara, Rotterdam, Netherlands
| |
Collapse
|
31
|
Ottevanger PB. [Intraperitoneal chemotherapy in ovarian carcinoma. Life prolonging in selected patients]. Ned Tijdschr Geneeskd 2009; 153:503-507. [PMID: 19402326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- P B Ottevanger
- Afd. Medische Oncologie, Universitair Medisch Centrum St Radboud, Nijmegen.
| |
Collapse
|
32
|
Wennekes L, Ottevanger PB, Raemaekers JM, Schouten HC, De Mulder PH, Grol RP, Hermens RP. Development of quality indicators for non-Hodgkin lymphoma. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.17017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
17017 Background: Indicator development to monitor quality of care for non-Hodgkin lymphoma's (NHL) is difficult because NHL represents variable disorders with different and fast changing treatment policies. This study aimed to generate a set of valid indicators for NHL, using a systematic consensus method. Methods: Recommendations from evidence-based guidelines were collected as potential indicators. A multidisciplinary panel of 14 experts rated and discussed these recommendations on the usefulness as an indicator in three rounds using the Rand-modified Delphi procedure. This procedure was innovated with a flow chart from diagnostics to follow-up that showed which recommendations were crucial for the continuation of the care process. Experts were enforced to develop indicators for diagnostics, treatment and follow-up and the organization of care. Results: From a list of 99 recommendations 10 potential indicators for diagnostics, 10 for treatment and follow-up and 8 for the organization of care were selected. All potential indicators for diagnostics and treatment were crucial according to the flow chart. Six indicators were relevant for only a few patients and were rejected. Another six were merged into two. For diagnostics 8 indicators remained including taking a biopsy, evaluation of morphology and immune phenotype, the World Health Organization- classification, staging with CT-scanning of neck, thorax and abdomen, bone marrow aspirate and crista biopsy according to Ann Arbor, blood counts and the International Prognostic Index. For treatment 3 indicators remained regarding treatment with R-CHOP in optimal dose intensity for diffuse large B-cell lymphoma and response evaluation according to Cheson. For organization of care 7 indicators remained including waiting times, multidisciplinary consultations, adequate reporting and accredited expertise and facilities. Conclusions: This study showed that relevant quality indicators can be developed for a complex malignancy like NHL. Our innovations with the flow chart made a relevant contribution to the selection method and we managed to develop indicators for each part of the care process. They are currently tested for validity and feasibility. The use of these indicators makes it possible to monitor and improve the quality of care for NHL. No significant financial relationships to disclose.
Collapse
Affiliation(s)
- L. Wennekes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| | - P. B. Ottevanger
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| | - J. M. Raemaekers
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| | - H. C. Schouten
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| | - P. H. De Mulder
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| | - R. P. Grol
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| | - R. P. Hermens
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; University Hospital Maastricht, Maastricht, The Netherlands
| |
Collapse
|
33
|
Ottevanger PB, De Mulder PHM. The quality of chemotherapy and its quality assurance. Eur J Surg Oncol 2005; 31:656-66. [PMID: 15893906 DOI: 10.1016/j.ejso.2005.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2004] [Revised: 11/11/2004] [Accepted: 02/10/2005] [Indexed: 11/27/2022] Open
Abstract
AIMS Assessment of the quality of chemotherapy care and its quality assurance in clinical trials and daily practice. METHODS Using Medline, literature was searched combining the following words: quality assurance or quality of care, combined with anti-neoplastic agents. The bibliography of each article was reviewed for additional literature. Those reports in English, French, German or Dutch focusing quality assurance or quality of care and chemotherapy were selected. RESULTS One hundred and five articles were selected by Medline and after review and adding of additional literature 53 articles remained. In clinical trials information on quality of chemotherapy is sparse. Different cooperative groups reported on suboptimal dosing, suboptimal registration of chemotherapy and several trials indicated that suboptimal dosing led to impaired outcome. Most quality assurance activities in clinical trials are concerned with audit and feedback and on-site visits. In daily practice the quality of chemotherapy is mostly impaired by the fact that it is not given although indicated and if it is given non-evidence based chemotherapy or administration schedules and reduced dose intensity decrease the quality of care. Especially, age, comorbidity and socio-economic status reduce the chance of receiving good quality of care regarding chemotherapy. Activities mostly used for quality assurance are generation of guidelines, specialisation and multidisciplinary care. CONCLUSIONS Most quality assurance activities in clinical trials and daily practice are directed to structure and process parameters. More evidence that quality of care is related to outcome should be sought. Quality assurance in daily practice should aim at guideline implementation, specialisation and multidisciplinary care and should pay attention especially to the older patients, patients with comorbidity and patients from lower socio-economic classes.
Collapse
Affiliation(s)
- P B Ottevanger
- Division Medical Oncology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | |
Collapse
|
34
|
Ottevanger PB, De Mulder PHM, Grol RPTM, van Lier H, Beex LVAM. Adherence to the guidelines of the CCCE in the treatment of node-positive breast cancer patients. Eur J Cancer 2004; 40:198-204. [PMID: 14728933 DOI: 10.1016/s0959-8049(03)00660-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Guidelines are tools to improve the quality of care in daily practice. To accomplish adherence, active implementation is needed. The effect of audit, group-oriented feedback and educational activities to increase guideline adherence were investigated in this study. Treatment according to a guideline for premenopausal node-positive breast cancer patients from 1988 to 1992 (P1) and from 1996 to 1998 (P2) was assessed using the following indicators: percentage of patients with breast-conserving surgery, secondary surgery, > or = 10 reported resected axillary lymph nodes, reported tumour differentiation grade, reported hormonal receptor status, chemotherapy received (CT), start of CT < or = 28 days after surgery, Dose Intensity (DI) > or = 85% and completion of CT < or = 1 week beyond the ideal duration of CT. Data were audited from patients' records. The first audit resulted in a quality programme with feedback focused on the delivery of chemotherapy and resected axillary lymph nodes and educational sessions. A Fisher's exact test was used to estimate significant differences between the two time periods. In P1, 323 patients and in P2, 155 patients were eligible for treatment according to the guideline. The percentage of patients with > or = 10 lymph nodes improved from 65.3 to 81.3% (P=0.0004), as did the percentage with a reported oestrogen receptor (ER) status, from 84.8 to 96.8% (P=0.00004), progesterone receptor (PR) status from 82.3% to 97.4% (P<0.000001) and with a DI > or = 85%, from 74.9 to 93.9% (P=0.000003). Adherence varied between the hospitals. In conclusion, significant improvements were observed for the indicators of resected axillary lymph nodes and DI of chemotherapy, which may be attributed to the quality programme. Repeated assessment of the adherence to the guideline is important to observe changes and interhospital variations in order to remain focused on areas for improvement.
Collapse
Affiliation(s)
- P B Ottevanger
- Department of Medicine, Division of Medical Oncology, University Medical Centre Nijmegen, Geert Grooteplein 8, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | |
Collapse
|
35
|
Abstract
From the literature that was initially searched by electronic databases using the keywords quality, quality control and quality assurance in combination with clinical trials, surgery, pathology, radiotherapy, chemotherapy and data management, a comprehensive review is given on what quality assurance means, the various methods used for quality assurance in different aspects of clinical trials and the impact of this quality assurance on outcome and every day practice.
Collapse
Affiliation(s)
- P B Ottevanger
- Department of Internal Medicine, Division of Medical Oncology, 550, University Hospital Nijmegen, Geert Grooteplein 8, PO 9101, 6500HB Nijmegen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
36
|
Ottevanger PB, De Mulder PHM, Grol RPTM, Van Lier H, Beex LVAM. Effects of quality of treatment on prognosis in primary breast cancer patients treated in daily practice. Anticancer Res 2002; 22:459-65. [PMID: 12017333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
UNLABELLED Information on treatment outcome outside clinical trials is sparse. This is the first study that relates surgical and medical quality of care in daily practice with outcome. BACKGROUND In a previous study we showed, that the quality of chemotherapy as described by a guideline and given in daily practice to premenopausal primary breast cancer patients was suboptimal with only 68% and 53% of the patients receiving chemotherapy with a dose intensity (DI) and relative dose intensity (RDI) of > or = 85%, respectively. Many invalid reasons for delay and dose reductions were identified. PATIENTS AND METHODS Premenopausal node-positive primary breast cancer patients treated from 1988 to 1992 were traced using two national registries. Relevant data were collected from their records. The following treatment-related variables were correlated with prognosis: type of surgery, number of investigated lymph nodes, radiotherapy, chemotherapy, interval between surgery and start of chemotherapy, DI, duration, delays and dose adjustments of chemotherapy and hospital size. RESULTS Twenty-four of the 254 traced patients did not receive any chemotherapy, 230 received the recommended schedule of cyclophosphamide (C), methotrexate (M) and 5-fluorouracil (F). The median time of follow-up was 6.7 (range 0.9-10.2) years. The 5-year disease-free survival (DFS) and overall survival (OS) was 61% and 77%, respectively. In an univariate analysis DI < 65% correlated with a worse DFS and OS (p=0.05 and p=0.03, respectively). The use of chemotherapy correlated with a better DFS (p=0.03) than no use. In a multivariate analysis DI between 65 and 85% resulted in a better DFS (p=0.02) than DI > or = 85% and DI < 65%. CONCLUSION The prognosis of the breast cancer patients in this population was comparable with the results of randomised trials using adjuvant CMF. The only treatment related variable of value for prognosis was DI. Unexpectedly DI between 65% and 85% resulted in the best prognosis in this population. The relevance of this observation remains unclear and warrants further investigation.
Collapse
Affiliation(s)
- P B Ottevanger
- Department of Medicine, University Medical Centre St. Radboud, Nijmegen, The Netherlands.
| | | | | | | | | |
Collapse
|
37
|
Ottevanger PB, Verhagen CA, Beex LV. Quality of adjuvant chemotherapy in primary breast cancer in a non-trial setting. A comprehensive cancer centre study. The Breast Cancer Group of the Dutch Comprehensive Cancer Centre East (IKO). Eur J Cancer 1999; 35:386-91. [PMID: 10448287 DOI: 10.1016/s0959-8049(98)00376-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The quality of adjuvant chemotherapy with cyclophosphamide, methotrexate and 5-fluorouracil (CMF) and the compliance with guidelines for this treatment were studied in 323 premenopausal patients with node positive breast cancer, who were treated in the Comprehensive Cancer Centre East of The Netherlands (IKO) from 1988 to 1992, outside the setting of a clinical trial. The interval surgery-chemotherapy, the duration of chemotherapy, dose intensity (DI) and relative dose intensity (RDI) of CMF chemotherapy and validations of dose modifications were evaluated. 295 of 323 patients (91%) received adjuvant chemotherapy. CMF chemotherapy was used in 230 patients (78% of the chemotherapy receiving patients). The median time to the start of chemotherapy was 62 (range-35-139) days after surgery. Forty-two per cent of the patients finished their CMF chemotherapy within 168 days. Two per cent of the patients did not finish the six courses of CMF chemotherapy. The mean DI and RDI of the eligible patients in all CMF using hospitals were 80.4 +/- 28.8% and 78.2 +/- 28.4%, respectively. Aberrations of recommended guideline procedures resulted more often in suboptimal treatment than haematological toxicity. Adherence to the guidelines was variable and resulted in suboptimal adjuvant chemotherapy. The median follow-up of the patients treated in hospitals that agreed to the use of CMF was 5 years. The mean RDI of CMF in the eligible patients who relapsed was 72.2 +/- 32.7%, compared with 81.4 +/- 25.2% for the patients who did not relapse (P 0.01), suggesting a possible influence of the RDI on disease free survival. However, when the patients who did not receive chemotherapy were excluded, the mean RDI of the patients who relapsed was 85.0 +/- 12.6% and of the patients who did not relapse 87.4 +/- 12.6%, which was not significantly different (P = 0.20).
Collapse
Affiliation(s)
- P B Ottevanger
- Department of Medicine, University Hospital Nijmegen, The Netherlands
| | | | | |
Collapse
|
38
|
Beex LV, Tjan-Heijnen VC, Ottevanger PB. [Chemotherapy in metastasized breast cancer]. Ned Tijdschr Geneeskd 1999; 143:59-60. [PMID: 10086103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
39
|
Ottevanger PB, Hermus AR, Smals AG, Kloppenborg PW. TSH-dependent production of T4 and T3 by metastases of a thyroid carcinoma. Acta Endocrinol (Copenh) 1992; 127:413-5. [PMID: 1471452 DOI: 10.1530/acta.0.1270413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A patient with T4 and T3 production by metastases of a follicular thyroid carcinoma leading to TSH suppression is described. During a period of three years, plasma T4, T3 and TSH levels were measured in the substitution-free periods before the successive iodine-131 retention measurements and iodine-131 therapies, when the patient was at least two weeks without thyroid hormones. From the presented data it can be derived that the production of thyroid hormones by metastases was enhanced by endogenous TSH.
Collapse
Affiliation(s)
- P B Ottevanger
- Department of Medicine, University Hospital Nijmegen Sint Radboud, The Netherlands
| | | | | | | |
Collapse
|