Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

The BIG 2.04 MRC/EORTC SUPREMO Trial: pathology quality assurance of a large phase 3 randomised international clinical trial of postmastectomy radiotherapy in intermediate-risk breast cancer

Introduction

SUPREMO is a phase 3 randomised trial evaluating radiotherapy post-mastectomy for intermediate-risk breast cancer. 1688 patients were enrolled from 16 countries between 2006 and 2013. We report the results of central pathology review carried out for quality assurance.

Patients and methods

A single recut haematoxylin and eosin (H&E) tumour section was assessed by one of two reviewing pathologists, blinded to the originally reported pathology and patient data. Tumour type, grade and lymphovascular invasion were reviewed to assess if they met the inclusion criteria. Slides from potentially ineligible patients on central review were scanned and reviewed online together by the two pathologists and a consensus reached. A subset of 25 of these cases was double-reported independently by the pathologists prior to the online assessment.

Results

The major contributors to the trial were the UK (75%) and the Netherlands (10%). There is a striking difference in lymphovascular invasion (LVi) rates (41.6 vs. 15.1% (UK); p = <0.0001) and proportions of grade 3 carcinomas (54.0 vs. 42.0% (UK); p = <0.0001) on comparing local reporting with central review. There was no difference in the locally reported frequency of LVi rates in node-positive (N+) and node-negative (N−) subgroups (40.3 vs. 38.0%; p = 0.40) but a significant difference in the reviewed frequency (16.9 vs. 9.9%; p = 0.004). Of the N− cases, 104 (25.1%) would have been ineligible by initial central review by virtue of grade and/or lymphovascular invasion status. Following online consensus review, this fell to 70 cases (16.3% of N− cases, 4.1% of all cases).

Conclusions

These data have important implications for the design, powering and interpretation of outcomes from this and future clinical trials. If critical pathology criteria are determinants for trial entry, serious consideration should be given to up-front central pathology review.

Electronic supplementary material

The online version of this article (doi:10.1007/s10549-017-4145-4) contains supplementary material, which is available to authorized users.

Abstract PD2-02: NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor.

TRIAL OBJECTIVES

To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib.

TRIAL DESIGN

Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy.

KEY ELIGIBILITY CRITERIA

Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS.

PRIMARY OUTCOME MEASURE

Objective clinical response to neoadjuvant treatment by RECIST criteria.

RESULTS

Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06).

Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%)  TOTAL133133266  

Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132

Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513)

CONCLUSION

The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%.

This work was supported by CRUK: CRUK/06/005 and Pfizer.

Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD2-02.

A Prospective Randomised Phase III Clinical Trial Testing the Role of Prophylactic Cranial Radiotherapy in Patients Treated with Trastuzumab for Metastatic Breast Cancer - Anglo Celtic VII

A high incidence of central nervous system (CNS) metastases has been reported in patients with HER2-positive tumours receiving trastuzumab therapy for metastatic breast cancer. This study tested whether prophylactic cranial irradiation (PCI) could reduce the incidence of CNS metastases in this setting. This was a prospective, randomised phase III trial. Patients were randomised 1:1 to no PCI or PCI delivered at around 6 weeks after study entry. Cognitive function was assessed prospectively. In total, 51 patients were randomised over a 3 year period; 25 received PCI and 26 did not. The cumulative incidence of CNS metastases at 2 years was 32.4% (standard error = 9.8%) on the no PCI arm and 21.0% (standard error = 8.6%) on the PCI arm; the associated hazard ratio was 0.57 (95% confidence interval 0.18-1.74; P = 0.32). There was no evidence of cognitive dysfunction in PCI patients.

Abstract S2-01: The PRIME II trial: Wide local excision and adjuvant hormonal therapy ± postoperative whole breast irradiation in women ≥ 65 years with early breast cancer managed by breast conservation

Background. Local Recurrence rates after breast conserving surgery (BCS) are falling because of increasing use of effective systemic therapy. The question of whether whole breast radiotherapy (WBRT) can be omitted in carefully defined groups of older patients receiving appropriate systemic therapy has not been addressed. PRIME II is an International phase III RCT addressing this question.

Methods. Between April 2003 and December 2009, 1326 patients were randomised to receive (n = 658) or nor receive (n = 668) radiotherapy (RT). Eligiblity criteria were ≥65 years, T1-2 (up to 3cm), N0, M0, hormone receptor positive, clear excision margins (≥ 1mm), axillary node negative women in receipt of adjuvant hormone therapy. Patients could have Grade 3 tumours or lympho-vascular invasion but not both. An accrual of 1300 was planned to detect a difference based on estimates of local recurrence of 2% in RT group and 5% in no RT arm at 5 years, with 80% power and 5% significance. The primary endpoint was ipsilateral breast tumour recurrence (IBTR). Secondary endpoints were regional recurrence, contralateral breast cancer, distant metastases and overall survival (OS). Median follow up is 5.0 years.

Results

IBTR at 5 years was 4.1% (95% CI 2.4, 5.7%) without RT, 1.3% (95% CI 0.2, 2.3%) with RT. The hazard ratio for IBTR in those IBTR receiving radiotherapy was 4.34 (1.79, 10.55) (p = 0.001).

Overall actuarial survival at 5 years was 93.8% (95% CI 91.6, 95.9%) without RT and 94.2% (95% CI 92.2, 96.3%) with RT, (p = 0.24). No significant differences in regional recurrence (1.4% no RT vs 0.5% RT), contralateral breast cancer (0.9% no RT vs 1.5% RT), nor distant metastases (1.0% vs 0.3%) were seen. Breast cancer-free survival was 94.6% (95% CI 92.7, 96.5%)for no RT and 97.3% (95% CI 95.9, 98.8%) for those receiving RT (p = 0.003): this difference was due to the greater IBTR in no RT group. The majority of deaths were not linked to breast cancer (35 no RT vs 29 RT from a total of 87 deaths), with no influence of omission of RT (p = 0.27).

Conclusions

The randomised International Trial has shown that

• Omission of RT in women ≥65 year of age with N0, ER positive breast cancer receiving endocrine therapy results in only a 4.1% 5 year IBTR

• Although RT reduces IBTR significantly, the absolute reduction in this study is very small.

• RT does not reduce the rate of regional recurrence, distant metastases or affect overall survival.

• Omission of postoperative WBRT in this population based on the 5 year rate of IBTR appears safe, especially in the presence of comorbidities.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S2-01.

Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial

The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.

Abstract P1-13-03: Mature analysis of UK Taxotere as Adjuvant Chemotherapy (TACT) trial (CRUK 01/001); effects of treatment and characterisation of patterns of breast cancer relapse

Introduction: TACT, an investigator-led study in 4162 women with node positive (N+ve) or high risk node negative (N-ve) early breast cancer (EBC), is the largest taxane trial unconfounded by treatment (trt) duration. At principal analysis, with 5 years follow-up (fup), no evidence of improved disease-free survival (DFS) was observed by switching to 4 cycles of docetaxel (D) after 4 cycles of FEC (Ellis, Lancet 2009). Results were provocative in suggesting differential effects according to ER & HER2 status. Longer fup provides opportunity to detect emergence of late trt effects overall & within phenotypic subgroups & explore patterns of recurrence, by tumor characteristics.

Patients & methods: TACT recruited women with histologically confirmed completely resected invasive EBC from 104 centers (UK (103), Belgium (1)) between 02/2001 & 07/2003. Centers chose FEC (600/60/600 mg/m2 q3wk × 8) or E-CMF (E 100mg/m2 q3wk × 4 → CMF 100mg/m2 PO d1-14 or 600mg/m2 IV d1&8/40/600 mg/m2 q4wk × 4) as their control, reflecting standard UK practice. Patients (pts) were randomized to FEC-D (FEC q3wk × 4 → D 100 mg/m2 q3wk × 4) or control. 2523 pts were from FEC centers (FEC = 1265: FEC-D = 1258) & 1639 from E-CMF centers (E-CMF = 824; FEC-D = 815). Endocrine therapy was given for 5 years. Few pts received HER2 directed therapy; 589 pts had unknown HER2 status. Median fup is now 97.5 months; this analysis updates DFS & overall survival in the ITT population. It also explores patterns of relapse by phenotypic & clinical characteristics. Analyses of trt effect are stratified by ER status due to issues of non-proportionality of hazard associated with length of fup.

Results: DFS events have been reported for 1329 pts (FEC-D=640, Control=689) giving an unadjusted hazard ratio (HR) & 95%CI (stratified by control regimen & ER status) of 0.93 (0.83, 1.03) overall; p = 0.16 in favor of FEC-D & for ER+ve/HER2-ve of 0.99 (0.84, 1.17), for ER+ve/HER2+ve) 0.97 (0.73, 1.30), for ER-ve/HER2+ve 0.74 (0.53, 1.03), & ER-ve/HER2-ve 0.93 (0.73, 1.17). 1017 patients have died (FEC-D=500, Control=517); unadjusted HR=0.98 (95%CI: 0.86, 1.10); p = 0.69 with intercurrent deaths (prior to distant relapse) reported for 80 pts (FEC-D=40, Control=40).

Annual event rates show different pattern of disease relapse by phenotypic subgroup

P4-16-05: A Randomized Phase 2 Study of a Loading Dose of Ibandronate in Patients with Bone Metastases from Breast Cancer

Bisphosphonates have proven efficacy in reducing skeletal complications in metastatic breast cancer. Potent third generation bisphosphonates are more effective but the dose limiting toxicity is usually renal. Ibandronate is a 3rd generation bisphosphonate available in oral and intravenous form which offers many clinical advantages in ease of administration and lack of renal toxicity. A dose-response effect has been observed between 2mg and 6 mg IV doses and there is a single study suggesting that higher dosing (4 mg IV daily for 3 days) is tolerable and effective. A steady state of oral ibandronate is achieved at 8 days with oral administration but time to response is not known. In trials so far, IV ibandronate 6mgs appears safe. Due to lack of renal toxicity there is potential for further escalation of IV ibandronate. The objective of this study was to establish if an IV loading dose can improve efficacy and time to biochemical response compared to oral standard therapy and to assess the safety of a higher IV dose of ibandronate.

Methods and Patients: This was an open randomised phase II study conducted on patients with bone metastases from breast cancer comparing IV ibandronate 12 mg on day 1 followed by oral ibandronate 50 mgs daily (Arm A) with standard oral therapy of 50 mgs daily from day 1 (Arm B). The primary study end-point was the percentage reduction in serum CTX from baseline by day 5 on study, secondary end- points were the percentage reduction of bone turnover markers including serum CTX from baseline end of week 8 and percentage reduction in urine NTX from baseline to day 5 on study and baseline to end of week 1–8. Bone pain was recorded by Brief Pain Inventory. Patients had metastatic breast cancer with proven bone metastases, no previous treatment with bisphosphonates or other bone directed therapy within 6 months and no change in systemic therapy within a 3 months preceding trial therapy. Sample size of 22 patients in each arm was calculated to give a 90% chance detecting a 20% difference in average percentage reduction between the IV and oral arms.

Results: Seventeen patients were randomised to each study arm. A more rapid change in bone turnover markers was demonstrated in patients recieving the 12 mg loading dose of ibandronate. There was a 15.8% greater reduction of serum CTX in Arm A compared with Arm B at day 5, p=0.005. The percentage reduction of serum PINP at day 5 was also greater in Arm A, p=0.002. Over the 8 week period of study there was no overall significant difference in bone turnover markers. All patients had pain at study entry, median baseline pain severity scores were 3 in study arm and 4 in controls. Average bone pair score remained higher in treatment arm B at the end of 8 weeks. There were no additional adverse side-effects following administration of 12 mg of IV ibandronate and no evidence of additional renal toxicity. Conclusion: A 12 mg dose of IV ibandronate can be safely administered without additional renal toxicity. A rapid reduction in bone turnover markers is demonstrated within 5 days of IV loading dose of ibandronate. Potential exists for dose escalation of ibandronate. The clinical benefit of a more rapid reduction in bone turnover markers is unknown.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-16-05.

Abstract P5-10-07: TACT2 Randomised Adjuvant Trial in Early Breast Cancer (EBC): Tolerability and Toxicity of Standard 3 Weekly Epirubicin (E) Versus Accelerated Epirubicin (aE) Followed by Capecitabine (X) or CMF in 129 UK Hospitals (CRUK/05/019)

Introduction: TACT2, a multicentre phase III trial with E-CMF as control (NEAT Poole NEJM 2006), tests 2 hypotheses in a 2x2 factorial design: A) accelerating chemotherapy (CT) offers superior benefits (CALGB9741 Citron JCO 2003); B) the oral 5FU prodrug X gives similar efficacy but preferential side-effect profile to CMF. Here, focus is on hypothesis B with results for compliance, QL & acute toxicities (physician & patient (pt) reported) during CMF vs. X

Materials &

Methods: 4391 pts (4371 women, 20 men) with node+ve/high risk node-ve invasive EBC were recruited between Dec 2005-08. Treatment was E(100mg/m2 x 4) q3wk vs q2wk aE(100mg/m2 x 4 + pegfilgrastim 6mg d2) followed by classical CMF q4wk x 4 vs X(2500mg/m2/day x 14) q3wk x 4. Detailed CTCAE toxicity was assessed in a subset (38 centres, 2086 pts receiving ≥1 cycle CMF or X). 1279/2086 also participated in substudy of pt-reported outcomes (EORTC QLQ-C30 and TACT2-specific toxicities). 826 had complete dataset (baseline, cycles 4&8). P-values are trend tests across all grades & %grade 3+ are reported. QL assessed via linear regression models adjusted for baseline, end cycle 4 score, & aE vs E. P&lt;0.01 classed as significant

QL in cycles 5-8 was better with X than CMF for global QL& fatigue (P&lt;0.001). Pts reporting clinically meaningful deterioration (&gt;10 points): global QL CMF 106/398 (27%), X 79/428 (18%); fatigue CMF 164/398 (41%), X 122/428 (29%)).

Conclusion: TACT2, the largest adjuvant EBC trial with X, confirms that X has preferential side-effect profile and global QL compared to CMF, with no evidence that prior aE compromised treatment delivery. Dose delivery data are consistent with advanced disease observations that for some pts, 2000mg/m2/day may be correct dose.

Results: 4264 (97%) pts continued on CT beyond cycle 4. 3726 completed all 8 cycles (E-CMF 951 (85%), aE-CMF 938 (86%), E-X 932 (84%), aE-X 905 (83%). For cycles 5-8, %RDI &gt; 85% was 69% after E and 68% after aE. Cycles delivered on time CMF 59%, X 63%; cycles without dose reduction CMF 75%, X 62%. 15 deaths in total within 30 days of CT: 9 on CMF, 6 on X. Worst grade toxicities which differed between CMF & X during cycles 5-8:

Cardiac effects when using trial-derived monitoring protocols for adjuvant trastuzumab: Results from a retrospective multicenter UK audit

582

Background: Guidelines for cardiac scanning in adjuvant Trastuzumab (T) trials were developed due to clinical concerns regarding cardiotoxicity, and these same guidelines are now used in clinical practice. This was a retrospective audit to assess adherence to these guidelines and characterise the nature and timescale of problems experienced with adjuvant T in clinical practice. Methods: A retrospective review of MUGA/ECHO results was conducted in patients who received adjuvant T for breast cancer. Data was compiled from five UK cancer centres: Glasgow, Manchester, Cardiff, The Royal Free hospital and Newcastle. Results: A total of 424 patients received at least one dose of adjuvant T between September 2005 and January 2008, using a HERA trial schedule. There were 262 with detailed information regarding treatment delays/withdrawals for cardiac reasons. 12% (32/262 pts) were withdrawn from adjuvant trastuzumab treatment for cardiac reasons, with another 11% (29/262 pts) experiencing at least 1 delay in treatment. Analysis of cardiac scan results for the remaining 162 pts suggested a total cardiac delay/withdrawal percentage of 14.4% (61/424 pts). There was no age effect with 15% (50/338) of <65 year olds experiencing cardiac delays/withdrawals compared to 18% (9/50) of ≥65 year olds. Preherceptin cardiac scan results did appear to be predictive of subsequent problems, with 29% (38/132 pts) who had an ejection fraction (EF) of 40–59% experiencing cardiac delays/withdrawals compared to 10% (19/183 pts) with an EF of 60–69% and 4% (4/98 pts) with an EF ≥ 70%. Pretreatment with Doxorubicin was associated with an approximate doubling of cardiac problems (6/20 pts; 30%) compared to pretreatment with Epirubicin containing chemotherapy regimens. No temporal relationship existed between timing of cardiac delays/withdrawals and stage of T treatment. Conclusions: Significant numbers of patients are experiencing delays/withdrawals during adjuvant T treatment. In routine practice the withdrawal rates are more than twice those reported in the HERA trial population. There is a clear role for a re-assessment of the trial-derived cardiac management guidelines, which should be prospectively audited.

[Table: see text]

Incidence and impact of abnormal liver function in patients receiving adjuvant chemotherapy for early breast cancer

Abstract #4112

Background: Abnormalities in liver function tests (LFTs) which complicate adjuvant polychemotherapy may prompt prescribers to institute a dose reduction or delay due to fears of altered pharmacokinetics and increased toxicity. However, inappropriate reduction in dose intensity is associated with reduced efficacy of adjuvant therapy. We wished to identify the incidence of abnormal liver function and its influence on decision-making and toxicity in patients (pts) receiving adjuvant chemotherapy for early breast cancer in the west of Scotland.&#x2028; Methods: Data including baseline characteristics, LFTs (bilirubin, AST, ALT) on day 1 of each chemotherapy cycle, hematologic and grade 3/4 non-hematologic toxicity, dose delay or dose reduction were prospectively collected for 160 female pts commencing adjuvant chemotherapy at the Beatson West of Scotland Cancer Centre between August 2005 and February 2006. Association between LFT abnormality on day 1 of each chemotherapy cycle and toxicity occurring within that cycle was determined.&#x2028; Results: The most common regimen administered was Epirubicin-CMF (n=128; epirubicin 100mg/m2 q3/52 x4; cyclophosphamide 600mg / m2, methotrexate 40mg/m2, 5-FU 600mg/m2 d1+8 q4/52 x 4) followed by AC (n=25; Doxorubicin 60mg/m2, Cyclophosphamide 600mg/m2 q3/52 x4), FEC (n=5) and CMF (n=3). Median age was 55 yrs. Febrile neutropenia or grade 3 /4 non-hematologic toxicity were recorded in 1.9% and 3.2% of cycles respectively. 8.5% of all cycles were delayed and 14% of pts (n=23) had a dose reduction. In only 1 patient was dose reduction due to abnormal LFTs. Grade 1, 2 or 3 hyperbilirubinemia occurred in 3%, 2% and 0% of pts respectively. Grade 1, 2 or 3 elevated ALT occurred in 39%, 9% and 3% of pts. Grade 1, 2 or 3 elevated AST occurred in 38%, 4%, and 1% of pts respectively. No episodes of grade 4 hyperbilirubinemia or elevated transaminases occurred. Despite receiving chemotherapy at full dose no patient with grade 2/3 elevated AST or ALT on day 1 of a chemotherapy cycle experienced either grade 3/4 non-hematologic toxicity or febrile neutropenia in that cycle.&#x2028; Discussion: Although grade 1 elevation in transaminases was common, particularly in the context of the Epirubicin-CMF regimen, grade 2 or 3 abnormalities were infrequent. The absence of grade 3/4 chemotherapy-related toxicity in pts with grade 2/3 LFT abnormality supports maintenance of full dose anthracycline-based polychemotherapy in this population.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4112.

HER2 positive early breast cancers: tumour demographics and trastuzumab therapy in the real-world

Abstract #3159

Background: Various trials have shown substantial benefits of addition of Trastuzumab (Herceptin®) to adjuvant chemotherapy in Early Breast Cancer (EBC). We analysed our breast cancer population to determine the incidence of HER2 positive Early Breast Cancers, the tumour demographics and the number of patients eligible for and receiving trastuzumab therapy in this group.&#x2028; Methods: Data for all patients diagnosed with EBC in 2006 was recorded prospectively in a database. Case notes were consulted where the HER2 positive patients, determined by a combination of IHC and FISH, had not received trastuzumab, to ascertain the reasons.&#x2028; Results: A total of 951 patients were diagnosed with Breast Cancer in 2006. 417 (43.9%) of these were screen-detected cancers.&#x2028; There were 123 (12.9%) HER2 positive newly diagnosed Breast Cancers of whom 117 were EBCs. The HER2 positivity rate in the screen detected cancers (n=417) was 9% and 17% in the symptomatic cancers (n=433).&#x2028; 1. Demographics of the HER2 positive Early Breast Cancer Population:&#x2028; The median age at diagnosis was 61 yrs (range: 30-92).&#x2028; &#x2028; 2. Fifty nine (50.4%) of the HER2 positive EBCs received trastuzumab therapy.&#x2028; &#x2028; Conclusions: The HER2 positivity rate is lower than that previously reported suggestive of changing demographics secondary to a high screen detected cancer population. A third of the HER2 positive tumours are screen detected. The percentage of ER positive, node negative and low grade tumours was higher than anticipated.&#x2028; Only 50% of HER 2 positive EBC patients received trastuzumab therapy. Of those who did not receive trastuzumab, the commonest reason was low risk status or age and co-morbidities precluded chemotherapy.&#x2028; HER 2 positivity alone confers high risk irrespective of pathological stage. Further trials are required to evaluate whether the substantial number of patients who are at present not eligible for trastuzumab therapy might also benefit.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3159.

A randomised phase II study of two different schedules of pegylated liposomal doxorubicin in metastatic breast cancer (EORTC-10993)

One hundred and sixteen women with measurable metastatic breast cancer participated in a randomised phase II study of single agent liposomal pegylated doxorubicin (Caelyx) given either as a 60 mg/m2 every 6 weeks (ARM A) or 50 mg/m2 every 4 weeks (ARM B) schedule. Patients were over 65 years of age or, if younger, had refused or been unsuitable for standard anthracyclines. The aims of the study were to evaluate toxicity and dose delivery with the two schedules and obtain further information on the response rate of liposomal pegylated doxorubicin as a single agent in anthracycline nai ve advanced breast cancer. Twenty-six patients had received prior adjuvant chemotherapy (including an anthracycline in 10). Sixteen had received non-anthracycline-based first-line chemotherapy for advanced disease. One hundred and eleven patients were evaluable for toxicity and 106 for response. The delivered dose intensity (DI) was 9.8 mg/m2 (95% CI, 7.2-10.4) with 37 (69%) achieving a DI of >90% on ARM A and 11.9 mg/m2 (95% CI, 7.5-12.8) with 37 (65%) achieving a DI of >90% on ARM B. The adverse event profiles of the two schedules were distinctly different. Mucositis was more common with the every 6 weeks regimen (35% CTC grade 3/4 in ARM A, 14% in ARM B) but palmar plantar erythrodysesthesia (PPE) was more frequent with the every 4 weeks regimen (2% CTC grade 3/4 in ARM A, 16% in ARM B). Confirmed objective partial responses by RECIST criteria were seen with both schedules; 15/51 (29%) on ARM A and 17/56 (31%) on ARM B. Liposomal pegylated doxorubicin showed significant activity in advanced breast cancer with a generally favourable side-effect profile. The high frequency of stomatitis seen with 6 weekly treatment makes this the less preferred of the two schedules tested.

Cost-effectiveness of oral ibandronate compared with intravenous (i.v.) zoledronic acid or i.v. generic pamidronate in breast cancer patients with metastatic bone disease undergoing i.v. chemotherapy

BACKGROUND

Ibandronate is the first third-generation bisphosphonate to have both oral and intravenous (i.v.) efficacy. An incremental cost-effectiveness model compared oral ibandronate with i.v. zoledronic acid and i.v. generic pamidronate in female breast cancer patients with metastatic bone disease, undergoing i.v. chemotherapy.

METHODS

A global economic model was adapted to the UK National Health Service (NHS), with primary outcomes of direct healthcare costs and quality-adjusted life years (QALYs). Efficacy, measured as relative risk reduction of skeletal-related events (SREs), was obtained from clinical trials. Resource use data for i.v. bisphosphonates and the cost of managing SREs were obtained from published studies. Hospital management and SRE treatment costs were taken from unit cost databases. Monthly drug acquisition costs were obtained from the British National Formulary. Utility scores were applied to time with/without an SRE to adjust survival for quality of life. Model design and inputs were validated through expert UK clinician review.

RESULTS

Total cost, including drug acquisition, was pound 386 less per patient with oral ibandronate vs. i.v. zoledronic acid and pound 224 less vs. i.v. generic pamidronate. Oral ibandronate gained 0.019 and 0.02 QALYs vs. i.v. zoledronic acid and i.v. pamidronate, respectively, making it the economically dominant option. At a threshold of pound 30,000 per QALY, oral ibandronate was cost-effective vs. zoledronic acid in 85% of simulations and vs. pamidronate in 79%.

CONCLUSIONS

Oral ibandronate is a cost-effective treatment for metastatic bone disease from breast cancer due to reduced SREs, bone pain, and cost savings from avoidance of resource use commonly associated with bisphosphonate infusions.

A Cancer Research (UK) randomized phase II study of idoxifene in patients with locally advanced/metastatic breast cancer resistant to tamoxifen

Idoxifene is a novel selective oestrogen receptor modulator (SERM) which had greater binding affinity for the oestrogen receptor (ER) and reduced agonist activity compared with tamoxifen in preclinical studies. In a randomized phase II trial in 56 postmenopausal patients with progressive locally advanced/metastatic breast cancer we assessed whether idoxifene showed evidence of activity compared with an increased 40 mg/day dose of tamoxifen in patients who had previously demonstrated resistance to the standard 20 mg/day dose of tamoxifen. Of 47 patients eligible for response (25 idoxifene, 22 tamoxifen), two partial responses and two disease stabilizations (SD) for >6 months were seen with idoxifene (overall clinical benefit rate 16%, 95% CI 4.5-36.1%). The median duration of clinical benefit was 9.8 months. In contrast, no objective responses were seen with the increased 40 mg/day dose of tamoxifen, although two patients had SD for 7 and 14 months (clinical benefit rate 9%, 95% CI 1.1-29.2%). Idoxifene was well tolerated and the reported possible drug-related toxicities were similar in frequency to those with tamoxifen (hot flushes 13% vs 15%, mild nausea 20% vs 15%). Endocrine and lipid analysis in both groups showed a similar significant fall in serum follicle-stimulating hormone and luteinizing hormone after 4 weeks, together with a significant rise in sex hormone binding globulin levels and 11% reduction in serum cholesterol levels. In conclusion, while idoxifene was associated with only modest evidence of clinical activity in patients with tamoxifen-resistant breast cancer, its toxicity profile and effects on endocrine/lipid parameters were similar to those of tamoxifen.

Early closure of a randomized trial: surgery and postoperative radiotherapy versus radiotherapy in the management of intra-oral tumours

Tumours of the oral cavity/oropharynx occur relatively infrequently in the UK. The management of such lesions, especially the squamous cell carcinomas, is still a little controversial. Some centres advocate radiotherapy while others adopt surgery and radiotherapy. In an attempt to resolve the question of which approach gives the better results, a multicentre randomized trial was established to compare surgery plus postoperative radiotherapy with radical radiotherapy alone. It was anticipated that 350 patients would be required to give a statistically significant result, but, after 35 patients had been entered, the trial was closed prematurely with a marked difference in overall survival in favour of the combination arm (P = 0.0006). At this analysis, carried out 23 months after trial closure, the survival difference between the two arms remains statistically significant for all causes of mortality (P = 0.001; relative death rate = 0.24; 95% CI 0.10-0.59).

Dihydropyrimidine dehydrogenase pharmacogenetics in patients with colorectal cancer

Individuals with a deficiency in the enzyme dihydropyrimidine dehydrogenase (DPD) may experience severe life-threatening toxicity when treated with 5-fluorouracil (5-FU). As routine measurement of enzyme activity is not practical in many clinical centres, we have investigated the use of DNA mutation analysis to identify cancer patients with low enzyme levels. We have identified two new mutations at codons 534 and 543 in the DPD cDNA of a patient with low enzyme activity and screened the DNA from 75 colorectal cancer patients for these mutations and the previously reported splice site mutation (Vreken et al, 1996; Wei et al, 1996). In all cases, DPD enzyme activity was also measured. The splice site mutation was detected in a patient (1 out of 72) with low enzyme activity whereas mutations at codons 534 (2 out of 75) and 543 (11 out of 23) were not associated with low enzyme activity. These studies highlight the need to combine DPD genotype and phenotype analysis to identify mutations that result in reduced enzyme activity.

Epirubicin chemotherapy and advanced breast cancer after adjuvant CMF chemotherapy

There have been conflicting reports on the effect of prior adjuvant chemotherapy on the response of advanced breast cancer to primary chemotherapy. We report a retrospective review of the outcome of chemotherapy with epirubicin 100 mg/m2 for advanced breast cancer in 39 patients who had previously received adjuvant cyclophosphamide, methotrexate and 5-fluorouracil (CMF). The response rate (complete responses plus partial responses) was 38.5%, with a median duration of response of 33 weeks. There was no significant difference in the response rate or duration of survival when these patients were compared with matched controls who had not received adjuvant chemotherapy. However, the limitations of this study were such that an adverse effect of adjuvant CMF on the response to epirubicin cannot be excluded.

A phase II, multicentre, UK study of vinorelbine in advanced breast cancer

Thirty-four evaluable patients were treated with vinorelbine, a novel, semisynthetic vinca alkaloid, as first-line chemotherapy for advanced breast cancer. They received vinorelbine 25 mg m-2 i.v. given weekly for a maximum of 16 cycles. Two patients achieved a complete remission and 15 a partial remission, giving a response rate of 17/34 (50%; 95% CI of 34-66%); median response duration was 5.8 months. The median progression-free interval was 4.4 months and median survival 9.9 months. Treatment was generally well tolerated. Fatigue was the most common side-effect. The main reason for dose adjustments was myelosuppression; 68% of patients had WHO grade 3 or 4 neutropenia and there was one death attributed to neutropenic sepsis. Nausea/vomiting and neuropathy were mild and alopecia was uncommon. This study confirms vinorelbine as a highly active, well-tolerated agent in advanced breast cancer worthy of evaluation in combination chemotherapy regimens.

Carboplatin and 5-fluorouracil in advanced and recurrent squamous carcinoma of the head and neck

Twenty-six patients with advanced squamous carcinoma of the head and neck or local recurrence after surgery and/or radiotherapy received carboplatin 300 mg/m2 intravenously on day 1 and 5-fluorouracil 1 gm/m2 by continuous intravenous infusion for 4 days. The treatment was well tolerated with little toxicity. The overall response rate was 58%.