Effects of neratinib on health-related quality of life in women with HER2-positive early-stage breast cancer: longitudinal analyses from the randomized phase III ExteNET trial

BACKGROUND

We report longitudinal health-related quality-of-life (HRQoL) data from the international, randomized, double-blind, placebo-controlled phase III ExteNET study, which demonstrated an invasive disease-free survival benefit of extended adjuvant therapy with neratinib over placebo in human epidermal growth factor receptor-2-positive early-stage breast cancer.

PATIENTS AND METHODS

Women (N  = 2840) with early-stage HER2-positive breast cancer who had completed trastuzumab-based adjuvant therapy were randomly assigned to neratinib 240  mg/day or placebo for 12  months. HRQoL was an exploratory end point. Patients completed the Functional Assessment of Cancer Therapy-Breast (FACT-B) and EuroQol 5-Dimensions (EQ-5D) questionnaires at baseline and months 1, 3, 6, 9, and 12. Changes from baseline were compared using analysis of covariance with no imputation for missing values. Sensitivity analyses used alternative methods. Changes in HRQoL scores were regarded as clinically meaningful if they exceeded previously reported important differences (IDs).

RESULTS

Of the 2840 patients (intention-to-treat population), 2407 patients were evaluable for FACT-B (neratinib, N  = 1171; placebo, N  = 1236) and 2427 patients for EQ-5D (neratinib, N  = 1186; placebo, N  = 1241). Questionnaire completion rates exceeded 85%. Neratinib was associated with a decrease in global HRQoL scores at month 1 compared with placebo (adjusted mean differences: FACT-B total, -2.9 points; EQ-5D index, -0.02), after which between-group differences diminished at later time-points. Except for the FACT-B physical well-being (PWB) subscale at month 1; all between-group differences were less than reported IDs. The FACT-B breast cancer-specific subscale showed small improvements with neratinib at months 3-9, but all were less than IDs. Sensitivity analyses exploring missing data did not change the results.

CONCLUSIONS

Extended adjuvant neratinib was associated with a transient, reversible decrease in HRQoL during the first month of treatment, possibly linked to treatment-related diarrhea. With the exception of the PWB subscale at month 1, all neratinib-related HRQoL changes did not reach clinically meaningful thresholds. ClinicalTrials.gov: NCT00878709.

Gemcitabine plus docetaxel versus docetaxel in patients (pts) with HER2-negative locally advanced or metastatic breast cancer (MBC): A randomized phase III study

1015

Background: Gemcitabine (G), either as a single agent or in combination with taxanes, has demonstrated efficacy in MBC in phase II and III studies. We conducted a phase III study to compare time to progression (TTP) of G plus docetaxel (T) versus (vs.) T alone. The secondary endpoints included overall survival (OS), overall response rate (ORR), and toxicity. Methods: Females with HER-2-negative locally advanced or MBC and a WHO performance status ≤ 2 were randomized to GT (G 1,000mg/m2 day 1 + 8; T 75mg/m2 day 1) or T (100mg/m2 day 1) every 21 days. Pts were previously untreated, had prior anthracycline-based (neo)adjuvant chemotherapy or had received a single prior anthracycline-bsed chemotherapy regimen for MBC. Time-to-event endpoints were estimated using the Kaplan-Meier method, and the log-rank test was applied for comparisons between regimens. The planned sample size was 254 evaluable pts with α I and β of 0.05 and 0.90, respectively. Results: A total of 336 pts were randomized (170 GT; 166 T), data from one centre are yet missing and the present evaluation is based on data from 306 pts (155 GT; 151 T). The pts had a median age of 58 years in both regimens; range 36–73 years and 30–74 years, respectively. The median TTP was 7.5 months for the GT regimen vs. 6.5 months for the T regimen. The GT arm demonstrated an ORR of 44% vs. 38% in the T arm with 4 and 3 % complete responses, respectively. The OS was 13.4 vs. 13.2 months in the GT and T arm, respectively. Hematologic toxicity was common, especially grade 3–4 neutropenia (GT = 69%; T = 61%); infection was reported in 22 and 20% of the pts, respectively (none of the pts received G-CSF). The most commonly reported non-hematologic toxicities of grade 3–4 included mucositis (GT = 2%; T = 5%), diarrhea (GT = 4%; T = 7 %), fatigue (GT = 6%; T = 11%), oedema (GT = 10%; T = 3%), and peripheral neuropathy (GT = 9%; T = 28%). Conclusions: Preliminary data of GT as first- or second-line chemotherapy demonstrates a TTP advantage among HER-2-negative pts with advanced breast cancer. Updated results and proper statistical analyses will be presented.

No significant financial relationships to disclose.

Patient reported causes of fatigue in relation to adjuvant radiotherapy after breast conserving surgery

Abstract #4094

Background: Fatigue is one of the most frequent symptoms experienced by cancer patients, and it adversely affects the quality of life. Fatigue is multidimensional and associated with the malignancy itself, but also with anti-neoplastic treatment and probably with several other causes. The aim of the study was to assess the level of fatigue during and after adjuvant radiotherapy in breast cancer patients and to uncover the kind of factors believed by patients to play a role in the generation of fatigue in relation to radiotherapy.
 Methods: 70 patients (ages 33-76 years, mean 57 years) with early-stage breast cancer were included after breast conserving surgery. Patients were treated with adjuvant radiotherapy (48Gy/24 fractions/5 weeks; 20 patients received boost 10Gy/5 fractions/1 week with tumor-bed). The subjective feeling of fatigue was measured according to the 10-score visual analog scale (VAS). RTOG Acute Radiation Morbidity Scoring Criteria (0-4) were used for the estimation of the acute skin reaction.
 Results: 53% of the patients demonstrated no fatigue (VAS 0-1) before the start of adjuvant postoperative radiotherapy. Patients after adjuvant chemotherapy manifested a little higher level of fatigue; there were no differences between patients with or without anti estrogen therapy. Fatigue intensity increased gradually during radiotherapy, but about 1/3 of the patients felt no fatigue. The majority of the patients reported radiotherapy as a cause of fatigue (33 of 47 patients (70%) with fatigue VAS ≥ 2 at the end of radiotherapy). 25% of the patients believed that their fatigue was still associated with previously given adjuvant chemotherapy, but in fact, the patients after chemotherapy did not demonstrate a higher fatigue level at the end of the radiotherapy course. 5 patients (10%) associated their fatigue with the anti estrogen therapy. There was correlation between fatigue level and intensity of radiotherapy-induced skin toxicity – patients with strong acute skin reaction demonstrated a higher fatigue level. But only 8 patients (17%) indicated the skin reaction as a cause of fatigue. Fatigue level was associated with traveling time to the hospital, especially when the journey took 2 hours or more/day. 45% of the patients gave the transport time to the hospital as a reason for fatigue.
 Conclusion: Fatigue increased over the course of adjuvant radiotherapy of breast cancer patients after breast conserving surgery. Fatigue seems to be multidimensional, but most of the patients indicate radiotherapy treatment as the cause of fatigue.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4094.

Correlation between fatigue level and irradiated volume of the whole body, lung and heart in breast cancer patients receiving adjuvant radiotherapy after breast-conserving surgery

19608

Background: Fatigue - an unpleasant, persistent, subjective sense of tiredness - is one of the most common symptoms experienced by cancer patients. It is multidimensional and is associated with both - malignancy itself and the anti-neoplastic treatment. The aim of the study was to assess the level of fatigue during and after adjuvant postoperative radiotherapy in breast cancer patients and evaluate its correlation with the irradiated volume of the whole body, lung and heart. Methods: 48 patients (age 33–76 years, mean 57 years) with early breast cancer after breast-conserving surgery were treated with adjuvant radiotherapy (48Gy/24fractions/5weeks; 12 patients received boost 10Gy/5fractions/1week to the tumor-bed). The patients′ subjective feeling of fatigue intensity was measured according to 10- score visual analog scale (VAS) before the start and weekly during radiotherapy, as well as 14 days and 3 months after radiotherapy. Results: Fatigue intensity increased gradually during radiotherapy (mean fatigue-VAS before and in the last week of treatment was 1.21 and 2.31 respectively; p=0.004). 14 days after the end of radiotherapy, the fatigue intensity was still higher than before treatment (1.88 and 1.21 respectively; p=0.04), but 3 months later, fatigue was lower than at the pretreatment level (n.s.). Irradiation of the large volume of the whole body was correlated with higher fatigue level during and after radiotherapy. If 15% or more of the unilateral lung volume received 20Gy, patients reported higher fatigue level than patients receiving 20Gy for less than 15% of the unilateral lung volume. There were no statistical differences in fatigue level between patients with different percentage of the heart volume receiving irradiation. Patients with boost did not manifest higher fatigue level. Conclusions: Fatigue increased over the course of radiotherapy, but 3 months after the end of therapy it was reduced to lower than at the preliminary level. There was a positive correlation between fatigue level during and after radiotherapy and the irradiated whole body and lung volume, but not heart volume.

No significant financial relationships to disclose.

Fatigue in breast cancer patients during and after radiotherapy

18537

Background: Fatigue—an unpleasant sensation of tiredness, weakness or lack of energy—is one of the most prevalent and profound symptoms caused by malignancy itself and anti-neoplastic treatment. The aim of the study was to assess the level of fatigue during and after adjuvant postoperative radiotherapy of breast cancer patients. Methods: 125 patients with breast cancer were recruited between May 2004 and September 2005 (85 after breast-conserving surgery and 40 after mastectomy). Subjective feeling of fatigue intensity was measured according to 10-score visual analog scale (VAS) before the start and once a week during radiotherapy, 14 days and 3 months after radiotherapy (48 Gy/24 fractions/5 weeks; 25 patients received boost 10 Gy/5 fractions/1 week with tumor-bed). Results: 46% of patients demonstrated non-fatigue before the start of radiotherapy. Patients after breast-conserving surgery and chemotherapy manifested higher lever of fatigue in comparison with patients after lumpectomy but without chemotherapy and patients after mastectomy with and without chemotherapy (p = 0.01). Fatigue intensity increased gradually during radiotherapy (mean fatigue-VAS before and in the last week of treatment was 1.8, 2.75 after lumpectomy and 1.25, 2.95 after mastectomy, respectively). 14 days after the end of radiotherapy fatigue intensity was still higher than before treatment (p = 0.04), but 3 months later it was lower than the pretreatment level. However, 25% of the patients defined their fatigue as 2 or more in VAS three months after radiotherapy. 15% of patients reported non-fatigue during radiotherapy. Older patients (>60 years) estimated their fatigue in the last week of treatment on lower level than younger patients (2.22 vs 2.90, p = 0.065). Patients with boost manifested only a little higher fatigue level in comparison with other patients (2.97 vs 2.52). Conclusions: Increasing fatigue was found in 85% of breast cancer patients during adjuvant radiotherapy. Three months after the end of therapy fatigue was reduced to lover then the preliminary level. There were no significant differences between patients after breast-conserving surgery and mastectomy.

No significant financial relationships to disclose.

Pretreatment leukaemia cell drug resistance is correlated to clinical outcome in acute myeloid leukaemia

In 85 adult patients diagnosed with acute myeloid leukaemia (AML) and treated at the same institution during a 5-yr period, the clinical significance of in vitro cellular drug resistance to the anthracyclines aclarubicin (Acla) and daunorubicin (Dau) as well as the nucleoside analogue cytarabine (Ara-C) was investigated using a 4-d MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide) assay. In 59 patients of whom 40 were treated by the combination of Acla and Ara-C we found that leukaemia cell drug resistance towards Acla was higher (by a factor 2.80) in patients who failed to enter complete remission (CR) after the first cycle of induction chemotherapy as compared to patients who entered complete remission. The relationship was significant in univariate as well as multivariate analysis (p=0.02 and 0.03, respectively). By contrast, no in vitro single drug resistance values were consistently correlated to other parameters of clinical outcome (overall CR rate, overall survival (OS), or continuous complete remission (CCR)), whereas the combined Acla and Ara-C drug resistance profile (Acla/Ara-C DRP) was of prognostic significance to overall survival of all 85 patients (p=0.004) as well as to the CCR of 39 complete responders (p=0.04). These findings remained statistically significant in multivariate analyses correcting for other variables influencing clinical outcome including patient age, leukocyte count, karyotype, FAB-subtype, and presence/absence of secondary AML. We conclude that the in vitro drug resistance of leukaemia cells at time of disease presentation appears to be independent of prognostic significance to short- and long-term clinical outcome in AML.

MDR1 gene expression and drug resistance of AML cells

We investigated the cellular drug resistance to aclarubicin (Acla), cytosine arabinoside (Ara-C), daunorubicin (Dau), doxorubicin (Dox), etoposide (Etop) and mitoxantrone (Mitox) using the MTT assay at time of disease presentation in 93 cases of acute myeloid leukaemia (AML). In 31 cases we concomitantly investigated MDR1 (multiple drug resistance 1 gene) expression (semi-quantitative competitive RT-PCR) of the leukaemic cells. Drug resistance towards Dau, Dox and Etop was correlated to the MDR1 expression of the AML cells (P<0.05) with high MDR1 expression being associated with high drug resistance towards these drugs. Although the data did not allow firm conclusions to be drawn on the correlation between MDR1 expression and drug resistance towards Ara-C and Mitox, the drug resistance towards Acla clearly was not correlated to, or dependent on, the MDR1 expression level of the AML blast cells. In addition, when examining the cross-activities among the six drugs distinct patterns emerged. Thus, high to very high degrees of cross-activity were found to exist between Dau, Dox, Etop and Mitox, whereas Ara-C had moderate cross-activity with the other drugs except Acla, which showed absent to moderate cross-activity with the other drugs. We conclude that MDR1 gene expression is of significance for cellular drug resistance towards specific (MDR1-related) drugs in AML, whereas it is not of significance regarding drug resistance towards other drugs, which is the case with the anthracycline Acla. We suggest that in the place of other more or less complicated ways to circumvent MDR1-mediated drug resistance, Acla may be used to replace Dau, Dox and other MDR1-related drugs if proven as potent as the drug it is to substitute.

Relation of blast cell survival and proliferation to chemotherapy resistance in AML

We have investigated the in vitro blast cell survival (viability) and drug resistance to cytosine arabinoside (Ara-C), daunorubicin (Dau), mitoxantrone (Mitox) and aclarubicin (Acla) of fresh leukaemic blast cells from 80 patients with newly diagnosed acute myeloid leukaemia (AML) employing the semiautomated colourimetric MTT(3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide)-assay. In 15 cases we concurrently investigated the relation between in vitro blast cell survival (MTT assay) and blast cell proliferation (3H-thymidine incorporation) in the presence and absence of myeloid growth factors (GFs) G-CSF, GM-CSF and IL-3 (individually and in combination). A highly significant correlation was found between blast cell survival and blast cell proliferation (r = 0.87, P < 1 x 10(-4). Furthermore, in 40 evaluable adult patients who completed intravenous induction chemotherapy and were evaluable for response to chemotherapy we found a positive correlation between in vitro blast survival (MTT assay) and response to chemotherapy with high blast survival being associated with poor response to chemotherapy (P = 0.05). Moreover, in a multivariate analysis, high blast cell survival was significantly associated with high CD13 expression and monocytic phenotype (P = 0.0003 and P = 0.02, respectively). Furthermore, we found an inverse relationship between the baseline proliferation of the blasts and the magnitude of response to the GFs (P < 0.02), indicating that cells with low baseline proliferation were more readily stimulated by growth factors. Finally, we found a significant correlation between leukaemic cell survival and cellular drug resistance towards Dau (P = 0.001) and Mitox (P = 0.03), but not towards Ara-C (P = 0.68) and Acla (P = 0.13). We conclude that high in vitro leukaemic cell survival is associated with drug resistance in vivo and in vitro, and furthermore is correlated with high blast cell proliferation and some adverse prognostic factors previously identified in AML.

Synergistic and antagonistic effects of myeloid growth factors on in vitro cellular killing by cytotoxic drugs

The effect of stimulating acute myeloid leukemia blast cells with a combination of growth factors (G-CSF, GM-CSF, and IL-3) on cellular resistance to the antileukemia drugs Ara-C, daunorubicin, aclarubicin, and mitoxantrone was studied. For assessment of in vitro cellular drug resistance the MTT assay was employed. Stimulated cells showed enhanced sensitivity to Ara-C (p < 0.02), whereas a significant increase in cellular drug resistance to daunorubicin (p < 0.02) was observed. Variable and statistically non-significant changes in drug resistance to aclarubicin and mitoxantrone was induced by stimulation of the blast cells. We conclude on the basis of these observations that myeloid growth factors should be used with caution in combination with daunorubicin in AML treatment until further confirmatory evidence has been presented by other investigators.

Syngrafting skin among mice of similar and different ages increases the number of Langerhans cells and decreases responsiveness to 1,4-dinitrofluorobenzene

Counting on suction blister skin biopsies, the number of Langerhans cells per mm2 in BALB/c mouse epidermis was found identical in 1-, 11-, and 22-month-old animals, but consistently elevated in syngrafted skin 10 months after transplantation. This effect of grafting was independent of whether young or old skin was transferred to young or old recipients. Skin swelling induced by dinitrofluorobenzene (DNFB) sensitization was reduced in 22-month-old non-grafted mice and in grafted skin irrespective of donor and recipient age.

Synthesis, tissue distribution and cytostatic properties of two new daunorubicin derivatives of 2-thiouracil containing a guanidine bridge

In further attempts to utilize the affinity of 2-thiouracil for melanin-producing tissues in the design of drugs active against malignant melanomas, guanidine-bridged adducts of the anthraquinone drug daunorubicin (1a) with 2-thiouracil were prepared (Scheme 3). The expected adduct (4), and a by-product in its preparation (5) (Scheme 3), were inactive against murine melanoma, in vivo, and did not show affinity for melanin-producing tissues. They were efficient DNA intercalating agents, but were much less cytostatic than daunorubicin against Cloudman melanoma, and were inactive, in vitro, against human cervical carcinoma MS 751. The coupling chemistry employed may have application in current attempts to effect binding of drugs to high molecular weight targeting antigens.

Susceptibility to carcinogenic effect of irradiation. Relationship to age at time of exposure

Age at time of exposure is an important host factor influencing the subsequent cancer risk. Before completion of organogenesis, the fetus may be rather resistant, but thereafter the growing tissues of children are more susceptible than those of young adults. At greater age of adults at the time of exposure there is an increase in the subsequent absolute number of 'excess' cancer cases, but the relative risk (excess in relation to expectation) is rather constant for a given kind of radiation exposure as judged from the presently rather small number of investigations.