Extended adjuvant aromatase inhibition after sequential endocrine therapy in postmenopausal women with breast cancer: follow-up analysis of the randomised phase 3 DATA trial

Background

The DATA study evaluated the use of two different durations of anastrozole in patients with hormone receptor-positive breast cancer who were disease-free after 2–3 years of tamoxifen. We hereby present the follow-up analysis, which was performed after all patients reached a minimum follow-up of 10 years beyond treatment divergence.

Methods

The open-label, randomised, phase 3 DATA study was performed in 79 hospitals in the Netherlands (ClinicalTrials.gov, number NCT00301457). Postmenopausal women with hormone receptor-positive breast cancer who were disease-free after 2–3 years of adjuvant tamoxifen treatment were assigned to either 3 or 6 years of anastrozole (1 mg orally once a day). Randomisation (1:1) was stratified by hormone receptor status, nodal status, HER2 status, and prior tamoxifen duration. The primary outcome was adapted disease-free survival, defined as disease-free survival from 3 years after randomisation onwards. Adapted overall survival was assessed as a secondary outcome. Analyses were performed according to the intention-to-treat design.

Findings

Between June 28, 2006, and August 10, 2009, 1912 patients were randomly assigned to 3 years (n = 955) or 6 years (n = 957) of anastrozole. Of these, 1660 patients were eligible and disease-free at 3 years after randomisation. The 10-year adapted disease-free survival was 69.2% (95% CI 55.8–72.3) in the 6-year group (n = 827) and 66.0% (95% CI 62.5–69.2) in the 3-year group (n = 833) (hazard ratio (HR) 0.86; 95% CI 0.72–1.01; p = 0.073). The 10-year adapted overall survival was 80.9% (95% CI 77.9–83.5) in the 6-year group and 79.2% (95% CI 76.2–81.9) in the 3-year group (HR 0.93; 95% CI 0.75–1.16; p = 0.53).

Interpretation

Extended aromatase inhibition beyond 5 years of sequential endocrine therapy did not improve the adapted disease-free survival and adapted overall survival of postmenopausal women with hormone receptor-positive breast cancer.

Funding

AstraZeneca.

Development of a prognostic risk model for clear cell renal cell carcinoma by systematic evaluation of DNA methylation markers

BACKGROUND

Current risk models for renal cell carcinoma (RCC) based on clinicopathological factors are sub-optimal in accurately identifying high-risk patients. Here, we perform a head-to-head comparison of previously published DNA methylation markers and propose a potential prognostic model for clear cell RCC (ccRCC).

PATIENTS AND METHODS

Promoter methylation of PCDH8, BNC1, SCUBE3, GREM1, LAD1, NEFH, RASSF1A, GATA5, SFRP1, CDO1, and NEURL was determined by nested methylation-specific PCR. To identify clinically relevant methylated regions, The Cancer Genome Atlas (TCGA) was used to guide primer design. Formalin-fixed paraffin-embedded (FFPE) tissue samples from 336 non-metastatic ccRCC patients from the prospective Netherlands Cohort Study (NLCS) were used to develop a Cox proportional hazards model using stepwise backward elimination and bootstrapping to correct for optimism. For validation purposes, FFPE ccRCC tissue of 64 patients from the University Hospitals Leuven and a series of 232 cases from The Cancer Genome Atlas (TCGA) were used.

RESULTS

Methylation of GREM1, GATA5, LAD1, NEFH, NEURL, and SFRP1 was associated with poor ccRCC-specific survival, independent of age, sex, tumor size, TNM stage or tumor grade. Moreover, the association between GREM1, NEFH, and NEURL methylation and outcome was shown to be dependent on the genomic region. A prognostic biomarker model containing GREM1, GATA5, LAD1, NEFH and NEURL methylation in combination with clinicopathological characteristics, performed better compared to the model with clinicopathological characteristics only (clinical model), in both the NLCS and the validation population with a c-statistic of 0.71 versus 0.65 and a c-statistic of 0.95 versus 0.86 consecutively. However, the biomarker model had limited added prognostic value in the TCGA series with a c-statistic of 0.76 versus 0.75 for the clinical model.

CONCLUSION

In this study we performed a head-to-head comparison of potential prognostic methylation markers for ccRCC using a novel approach to guide primers design which utilizes the optimal location for measuring DNA methylation. Using this approach, we identified five methylation markers that potentially show prognostic value in addition to currently known clinicopathological factors.

Abstract P1-08-20: Healthcare use in the last six months of life in advanced breast cancer: An analysis from the Southeast Netherlands Advanced Breast Cancer (SONABRE) registry

In advanced breast cancer (ABC), a growing number of treatment options have become available the past 10 years, increasing overall survival. Healthcare use near the end of life has increased, although specific data for ABC are limited. This study describes healthcare use during the last 6 months of life in patients diagnosed with ABC in Maastricht University Medical Center (MUMC+).

Methods: From our Southeast Netherlands Advanced Breast Cancer (SONABRE) Registry, we selected all patients from MUMC+ who were diagnosed with ABC and who also had passed away between January 1st, 2007 and October 1st, 2017. Patient, disease and treatment characteristics and data regarding health care use in the last period of life defined as ongoing chemotherapy ≤14 days before death, start of a new line of chemotherapy ≤30 days before death, and radiotherapy, hospital admission, surgery, intensive care unit (ICU) admission, mechanical ventilation, cardiopulmonary resuscitation (CPR) ≤ 6 months before death, and cause and place of death were collected by trained registration clerks. Healthcare use was described and univariate analyses were carried out for ongoing chemotherapy ≤14 days or start chemotherapy line ≤30 days before death, admission and death in the hospital using chi square and Fisher's exact test. The SONABRE Registry was approved by the Medical Research Ethics Committee of Maastricht University Medical Center.

Results: Of 203 included patients, chemotherapy was continued ≤ 14 days before death in 21%, and a new line of chemotherapy ≤ 30 days before death was started in 9% of patients. In the last 6 months of life, radiotherapy was applied in 21% of patients. Hospital admission occurred in 76% of patients, because of tumor-related symptoms in 60%, and because of toxicity in 12% of these. Surgery (4%), ICU admission (6%), mechanical ventilation (5%), and CPR (2%) occurred infrequently. Of all patients, 25% died in the hospital; 74% due to progressive disease, 12% due to complications of therapy for ABC and 14% non-breast cancer related. Ongoing chemotherapy ≤14 days before death was associated with age<65 years (p<0.001) and negative hormone receptor (HR) status (p=0.04); start of a new line of chemotherapy ≤30 days before death was associated with age<65 years (p<0.001). Hospital admission was associated with age< 65 years (p=0.008), de novo ABC (p=0.01), negative HR status (p=0.04) and chemotherapy as last line of therapy (p=0.001). Death in the hospital was associated with ongoing chemotherapy ≤14 days (p<0.001) and start of a new line of chemotherapy ≤30 days before death (p<0.001).

Conclusion: During the last 6 months of life, admission due to tumor-related symptoms occurred frequently, whereas ICU admission, mechanical ventilation and CPR occurred rarely. Death in the hospital occurred in a quarter of patients, and more frequently in those receiving chemotherapy shortly before death, which in turn was associated with younger age. Insight in real-life healthcare use may improve shared decision making and advanced care planning for patients with ABC.

Citation Format: de Boer M, Schmitz RS, Ibragimova KI, van Kleef M, Geurts SM, Tjan-Heijnen VC. Healthcare use in the last six months of life in advanced breast cancer: An analysis from the Southeast Netherlands Advanced Breast Cancer (SONABRE) registry [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-20.

Abstract PD6-03: Preserving fertility in young women undergoing chemotherapy for early breast cancer; the Maastricht experience

Purpose

This study aimed to evaluate the uptake of fertility preservation, rate of pregnancy, pregnancy outcome and breast cancer outcome after diagnosis of early breast cancer in young women who were referred to Maastricht University Medical Center, from the regional hospitals in the Southeast part of the Netherlands.

Patients and methods

We prospectively registered the demographics of patients, who visited our university hospital for counseling on fertility preservation at diagnosis of stage I-III invasive breast cancer in the years 2008-2015. At baseline, tumor and treatment characteristics were registered. During follow-up information on fullfilled childwish and disease status was collected. To compare the fertility preservation group and the non-fertility preservation group independent samples Student t-tests and Chi-square tests were conducted.

Results

In total 128 women with a median age of 32 years (19 – 43) were referred for fertility preservation counseling before start of chemotherapy, with an increase in referral in the more recent years. Thirty-nine (30.5%) women chose for fertility preservation: in 26 patients embryos were frozen, in seven oocytes, and in one both embryos and oocytes. In four patients the procedure was not succesfull. Patients who had chosen for fertility preservation more often had a male partner (87.2% vs 70.8%, P = 0.05) and had a smaller tumor size (median 19 versus 23 mm, P = 0.04) at the time of diagnosis compared to those who did not chose for fertility preservation. During a median follow-up of 30.3 months (range 0 – 96.9), 27 (21.1%) patients had tried to conceive: 14 (35.9%) women in the fertility versus 13 (14.6%) in the non-fertility preservation group. All of these had recovery of ovarian function after chemotherapy-induced ovarian failure. Only two women used the cryopreserved embryos, both succesfully and combined with preimplantation genetic diagnosis of the embryos because of germline mutations in BRCA1-gene. Eight patients in the fertility preservation group and seven patients in the non-fertility preservation group became at least once pregnant. In the fertility preservation group, eight healthy babies were born, one baby had Morbus Hirschsprung, one women is pregnant at this moment and one woman had a miscarriage. Of the eleven pregnancies in the non-fertility preservation group, nine healthy babies were born and one woman had two miscarriages. Of the referred 128 women, nine (7.0%) had breast cancer recurrence, three in the fertility preservation group versus six in the non-fertility preservation group.

Conclusion

One third of referred patients choose for fertility preservation before start of chemotherapy. In all of these patients, the ovarian function recovered. However, two couples used their cryopreserved embryos for preimplantation genetic diagnosis and both became pregnant. Since the follow-up time is relatively short, more data are mandatory to make a statement on the effectiveness of fertility preservation techniques in young breast cancers patients.

Citation Format: Vriens IJ, Butalid EM, Schepers-van der Sterren EE, van der Poel MH, Jansen-Engelen SL, van Riel A-MM, van de Wouw YJ, Vriens BE, van Haaren ER, Lemaire BM, Dercksen WW, Luiten EJ, de Boer M, de Die-Smulders CE, Derhaag JG, van Golde RJ, Tjan-Heijnen VC. Preserving fertility in young women undergoing chemotherapy for early breast cancer; the Maastricht experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD6-03.

Abstract P4-02-01: Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands

Background

The value of magnetic resonance imaging (MRI) for patients with breast cancer remains under debate. Breast MRI may contribute to the planning of local therapy, but also bears the risk of overtreatment. We analyzed the use of MRI and its impact on surgical treatment and risk of detecting contralateral breast cancer in the Netherlands.

Patients and methods

All patients who underwent primary surgery for stage I-III invasive breast cancer in the years 2011-2013 were identified through the Netherlands Cancer Registry. The following data were documented: year of diagnosis, hospital type and volume, age at diagnosis, clinical T and N stage, histological type and grade, presence of multifocality in resection specimen, hormone receptor status, HER2 status and use of MRI. We analyzed whether MRI use was related to type of surgery (primary or secondary mastectomy or breast conserving surgery), surgical margin involvement, and diagnosis of synchronous contralateral breast cancer.

Results

MRI was performed in 10,819 (29,8%) out of 36,333 patients newly diagnosed with invasive breast cancer and treated with primary surgery in the years 2011-2013 in the Netherlands. Use of MRI did not clearly increase in this period.

In the multivariate analysis, patients younger than 50 years of age compared to patients aged 70 years or older (OR 6.34, 95% CI 5.86-6.87), patients with lobular breast cancer compared to those with ductal carcinoma (OR 3.46; 95% CI 3.23-3.70) and patients with multifocal tumors compared to those without multifocality (OR 2.30, 95% CI 2.15-2.45) were more likely to undergo MRI. Hospital volume (<150 versus >150) was only marginally related to MRI use (OR 0.93; 95% CI 0.87-0.99).

Patients with invasive breast cancer undergoing MRI were more likely to undergo primary mastectomy than those without MRI (OR 1.21; 95% CI 1.15-1.28), but the subgroup with invasive lobular cancer undergoing MRI were less likely to undergo primary mastectomy (OR 0.85; 95% CI 0.75-0.98). A significantly lower risk of positive surgical margins was seen in patients with lobular breast cancer and breast conserving surgery who had undergone MRI as compared to those without MRI (OR 0.58, 95% CI 0.44-0.78) and, consequently, also a lower risk of secondary mastectomy (OR 0.60, 95% CI 0.41-0.87). Risk of positive surgical margins was not reduced by MRI use in patients with invasive ductal carcinoma (OR 0.91; 95% CI 0.77-1.07). Patients who underwent MRI were almost four times more frequently diagnosed with contralateral breast cancer, compared to those in whom MRI was not performed (OR 3.60, 95% CI 3.06-4.24).

Conclusion

Breast MRI was significantly more often used in younger patients, patients with lobular and/or multifocal breast cancer. Interestingly, MRI use was associated with less primary and secundary mastectomies in lobular invasive breast cancer, in contrast to an increased number of primary mastectomies in patients with invasive ductal cancer. MRI was further associated with an almost fourfold higher incidence of contralateral breast cancer.

Citation Format: Tjan-Heijnen VC, Lobbes MB, Vriens IJ, van Bommel AC, Nieuwenhuijzen GA, Smidt ML, Boersma LJ, van Dalen T, Smorenburg CH, Siesling S, Voogd AC. Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands. [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 P4-02-01.

Resistance to sunitinib in renal cell carcinoma: From molecular mechanisms to predictive markers and future perspectives

The introduction of agents that inhibit tumor angiogenesis by targeting vascular endothelial growth factor (VEGF) signaling has made a significant impact on the survival of patients with metastasized renal cell carcinoma (RCC). Sunitinib, a tyrosine kinase inhibitor of the VEGF receptor, has become the mainstay of treatment for these patients. Although treatment with sunitinib substantially improved patient outcome, the initial success is overshadowed by the occurrence of resistance. The mechanisms of resistance are poorly understood. Insight into the molecular mechanisms of resistance will help to better understand the biology of RCC and can ultimately aid the development of more effective therapies for patients with this infaust disease. In this review we comprehensively discuss molecular mechanisms of resistance to sunitinib and the involved biological processes, summarize potential biomarkers that predict response and resistance to treatment with sunitinib, and elaborate on future perspectives in the treatment of metastasized RCC.

P3-14-02: Sequential Versus Upfront Intensified Neoadjuvant Chemotherapy in Patients with Large Resectable or Locally Advanced Breast Cancer (INTENS), Toxicity Results from a Phase III Study of the Dutch Breast Cancer Trialists' Group (BOOG)

Background Taxanes have an established role as (neo-)adjuvant treatment of breast cancer. In the present study, we compared 4 AC - 4 T with 6 cycles of TAC in the neo-adjuvant setting (A=adriamycine, C=cyclophosphamide, T=docetaxel). Previously, we reported that AC-T resulted in a trend for improved outcome (odds ratio pCR of the breast 1.61; 95% CI 0.79−3.33). Now we report the safety data.

Methods Women presenting with breast cancer, cT2≥3cm, cT3, cT4 and/or cN+, with measurable disease and no prior treatment, age ≥18 and ≤70 years and Karnofsky Score ≥70% were eligible. Patients were randomized to AC (60/600 mg/m2 q3wk x 4 cycles) followed by T (100 mg/m2 q3wk x 4 cycles) without primary G-CSF prophylaxis, or to TAC (75/50/500 mg/m2 q3wk x 6 cycles) with primary G-CSF prophylaxis. If indicated, trastuzumab and/or endocrine therapy were given as adjuvant treatment. This present analysis focuses on the toxicity profile of the two treatment arms.

Results In total, 201 patients (n=100 AC-T, n=101 TAC) were included between February 2006 and April 2009. Baseline characteristics (AC-T/TAC) were well balanced. Patients in the AC-T arm had more frequently grade 3 / 4 toxicities as compared to the TAC arm, respectively in 57% and 28% (p=0.001). Grade 3 / 4 neutropenia without fever was more frequently reported with AC-T (35% vs. 4%; p=0.001). Grade 3 / 4 febrile neutropenia was also more frequent with AC-T (17% versus 5%; p=0.0062) and significantly increased during docetaxel treatment after AC. Notably, diarrhea was also more frequently seen in the AC-T arm (4% versus 0%, p=0.0423). Other grade 3 / 4 toxicities more frequently reported in the AC-T arm were neuropathy - sensory (5% vs. 0%; p=0.229) and pain other than muscle or bone pain (4% vs. 0%; p=0.0423). There were no grade 3 / 4 toxicities more frequently observed in the TAC arm.

Conclusion In the comparison of two taxane-anthracycline-cyclophosphamide regimens in the neo-adjuvant setting, it is observed that the sequential approach with a lower cumulative dose tends to have a slightly better efficacy outcome, but at the cost of increased grade 3 / 4 toxicity. However, considering the use of primary G-CSF prophylaxis in the TAC arm, and the fact that the incidence of febrile neutropenia was higher during taxane containing chemotherapy in the AC-T arm, the difference might (partly) disappear if primary G-CSF prophylaxis would be used in the sequential arm. Primary G-CSF prophylaxis may be considered during docetaxel if used sequentially after anthracycline-containing chemotherapy.

Support: Unrestricted grants from sanofi-aventis NL BV and Amgen BV.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-02.

P5-18-06: Taxanes and Cyclophosphamide Are Equally Effective in Breast Cancer: A Meta-Analysis of Ten Phase III Trials in Early and Advanced Disease

Background Overall taxanes did not improve survival in metastatic breast cancer trials (n=10 trials), whereas they do so in (neo-)adjuvant breast cancer trials (n=28 trials). We also noticed that in a substantial number of ‘negative’ metastatic trials, taxane-regimens were used without cyclophosphamide. To further explore this, we compared the outcome of studies in early and advanced breast cancer with a similar design, that is all studies substituting taxanes for cyclophosphamide.

Methods We identified 10 phase III taxane-based chemotherapy trials in early and advanced disease, in which taxanes were used instead of cyclophosphamide. They all compared a regimen of an anthracycline combined with a taxane versus an anthracycline combined with cyclophosphamide, i.e., AT versus AC. A pooled analysis was performed using the Review Manager software (RevMan 5) provided by the Cochrane Collaboration.

Results In total, 5 studies in advanced disease, 2 studies in neoadjuvant, and 3 studies in adjuvant disease setting were included and analyzed for their primary endpoint. In metastatic breast cancer studies, the hazard ratio of overall survival was 1.03 (95% CI 0.92 to 1.15) for taxanes as compared to cyclophosphamide. Also, studies on early breast cancer with a similar design showed no improvement for taxanes, resulting in an odds ratio for pCR of 0.91 (95% CI 0.57 to 1.43) in the neo-adjuvant setting and a hazard ratio for 5-year disease-free survival of 0.96 (95% CI 0.84 to 1.09) in the adjuvant setting.

Conclusion Re-assessment of studies of drugs both assessed in metastatic and early breast cancer provides a new tool for improved understanding. This meta-analysis shows that cyclophosphamide in breast cancer patients is equally effective as taxanes, and thus should be considered of pivotal importance in the treatment of metastatic and early breast cancer. Full appreciation of its relevance will prevent replacement of cyclophosphamide in future trials or in daily practice. Funding: Netherlands Organization for Health Research and Development (ZonMw 80–82500-98-10901)

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-06.

PD04-02: Recovery of Ovarian Function in Breast Cancer Patients with Chemotherapy-Induced Amenorrhea Receiving Anastrozole in the Dutch DATA Study

Background: In early stage hormone receptor positive breast cancer, aromatase inhibitors (AIs) are established as adjuvant therapy for postmenopausal women. In daily practice AIs are also offered to patients with chemotherapy-induced amenorrhea (CIA). The impact of AIs on estrogen (E2) levels in these patients has not extensively been studied, although this could be very relevant for the efficacy and safety of the adjuvant hormonal treatment. The Dutch phase III DATA study is assessing the impact on disease-free survival of 3 vs. 6 years of anastrozole after 2–3 years of tamoxifen (N=1900 patients in total), and has included both postmenopausal patients and patients with CIA. The current analysis reports on the hormonal data in the CIA group.

Patients and methods: We identified patients from the DATA study < 55 years of age at randomization who had received adjuvant chemotherapy and developed CIA, and excluded patients with ovariectomy or use of LHRH agonist. Patients were considered as having CIA if they were in amenorrhea since 3 months before start of chemotherapy up to 6 months after start of chemotherapy, and did not resume menses during tamoxifen therapy. Patients were eligible if postmenopausal E2 levels were confirmed within the last three months before randomization. Plasma FSH and E2 levels were serially determined at 6-month intervals.

Results: A total of 285 patients with CIA were identified in the DATA study. Median age was 50.8 years (range 35.9 - 54.9). Results on E2 and FSH levels are presented in the Table. During treatment with anastrazole, FSH levels tended to increase over time and E2 levels didn't decline. Of note, FSH increased in nearly all patients with significantly elevated (premenopausal) E2 levels, in contrast to the pattern seen in spontaneous recovery of ovarian function. During follow-up, 4 patients had vaginal bleeding, 2 of them having postmenopausal E2 levels. In 8 (2.8%) patients E2 levels became ≥ 200 pmol/l (considered premenopausal) after 12–30 months use of AI. Using a more strict cutoff value of E2 (≥ 100 pmol/l), 62 (21.8%) patients had elevated levels of E2 during AI treatment. With 70 pmol/l as cutoff value, 117 (41.0%) patients had at some point during treatment an increased E2 level. Updated and detailed analyses will be presented at the meeting.

Abstract S4-8: Promoter CpG Methylation of BRCA1 Predicts Sensitivity to PARP Inhibitors in Breast Cancer

Background: Poly(ADP)-ribose polymerase (PARP) inhibitors were shown to selectively kill BRCA1/2 mutated cancer cells due to conferring synthetic lethality, leading to first clinical trials in BRCA1 germline mutated breast and ovarian cancer with promising results. However, inherited breast and ovarian cancers are relatively rare. In sporadic breast cancer aberrant promoter methylation of BRCA1 is a more frequent event, intriguingly contributing to a common “BRCA phenotype”, as determined by high similarity of gene expression patterns between BRCA1 inherited and sporadic breast tumors. Currently, it is unknown whether BRCA1 methylated breast cancer cells are comparably sensitive to PARP inhibition like BRCA1 mutated breast cancer cells.

Methods: We screened a panel of 7 breast cancer cell lines for BRCA1/2 promoter methylation by bisulfite genomic sequencing, none of which harbored methylation in BRCA2. One cell line (UACC3199) revealed dense methylation in the BRCA1 gene promoter. Diminished BRCA1 protein expression in these cells was re-established after treatment with 1 µM of the DNA demethylating agent 5-aza-2'-deoxycytidin. For further analysis, UACC3199 cells were compared with MDA-MB-231 cells (BRCA1 wildtype) and MDA-MB-436 cells (BRCA1 homozygous mutant).

Results: In XTT assays the PARP inhibitors 3-ABA, DPQ and NU1025 revealed a similar toxicity in BRCA1 deficient UACC3199 and MDA-MB-436 cells, whereas BRCA1 proficient MDA-MB-231 cells were more resistant (IC50 values for Mda-MB-231, MDA-MB-436, and UACC3199 cells for 3-ABA: 8775 µM, 37 µM, 35 µM; for DPQ: 26 µM, 12 µM, 17 µM; for NU1025: 746 µM, 162 µM, 301 µM, respectively). Confocal immunofluorescent microscopy showed that after PARP inhibition, Y-H2AX focalization was strongly increased but not significantly different among all cell lines, indicating that the amount of DNA damage conferred by inhibition of PARP is independent of BRCA1 status. By comet assays after one week of PARP inhibition, however, we found that the amount of persistent DNA damage was significantly enhanced in both BRCA1 deficient lines, whereas it was low and similar to controls in MDA-MB-231 cells. This argues for defects in DNA damage repair in both BRCA1 deficient cell lines, most likely implicating disrupted homologous recombination integrity. Since BRCA1 mutations are associated with the triple-negative breast cancer subtype, we also determined the frequency of BRCA1 promoter methylation in non-inherited triple-negative breast cancers by methylation-specific PCR. Of the analyzed samples, a high fraction showed hypermethylation in BRCA1 (n=25/68; 37%). Conclusions: In conclusion, our results show for the first time that in addition to BRCA1 or BRCA2 mutation, also BRCA1 methylated breast cancer cell lines are considerably more sensitive to PARP inhibitors than BRCA1 wildtype cells. We therefore suggest to include BRCA1 methylation as a potential biomarker of drug sensitivity against these compounds in current and future prospective clinical trials of breast and ovarian cancer. Further in vitro experiments on the effects of PARP inhibition in BRCA1 methylated breast cancer cells are underway.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S4-8.

2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours

Chemotherapy-induced neutropenia is a major risk factor for infection-related morbidity and mortality and also a significant dose-limiting toxicity in cancer treatment. Patients developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently receive dose reductions and/or delays to their chemotherapy. This may impact the success of treatment, particularly when treatment intent is either curative or to prolong survival. In Europe, prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs), such as filgrastim (including approved biosimilars), lenograstim or pegfilgrastim is available to reduce the risk of chemotherapy-induced neutropenia. However, the use of G-CSF prophylactic treatment varies widely in clinical practice, both in the timing of therapy and in the patients to whom it is offered. The need for generally applicable, European-focused guidelines led to the formation of a European Guidelines Working Party by the European Organisation for Research and Treatment of Cancer (EORTC) and the publication in 2006 of guidelines for the use of G-CSF in adult cancer patients at risk of chemotherapy-induced FN. A new systematic literature review has been undertaken to ensure that recommendations are current and provide guidance on clinical practice in Europe. We recommend that patient-related adverse risk factors, such as elderly age (≥65 years) and neutrophil count be evaluated in the overall assessment of FN risk before administering each cycle of chemotherapy. It is important that after a previous episode of FN, patients receive prophylactic administration of G-CSF in subsequent cycles. We provide an expanded list of common chemotherapy regimens considered to have a high (≥20%) or intermediate (10-20%) risk of FN. Prophylactic G-CSF continues to be recommended in patients receiving a chemotherapy regimen with high risk of FN. When using a chemotherapy regimen associated with FN in 10-20% of patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN. In situations where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis may be used to maintain chemotherapy. Clinical evidence shows that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications where indicated. Filgrastim biosimilars are also approved for use in Europe. While other forms of G-CSF, including biosimilars, are administered by a course of daily injections, pegfilgrastim allows once-per-cycle administration. Choice of formulation remains a matter for individual clinical judgement. Evidence from multiple low level studies derived from audit data and clinical practice suggests that some patients receive suboptimal daily G-CSFs; the use of pegfilgrastim may avoid this problem.

Modeling the Cost Effectiveness of Secondary Febrile Neutropenia Prophylaxis During Standard-Dose Chemotherapy

Purpose

Current guidelines (ie, by the American Society of Clinical Oncology and the European Organisation for Research and Treatment of Cancer) do not recommend secondary infection prophylaxis, whereas, in contrast, caregivers prefer secondary prophylaxis to chemotherapy dose reduction after an episode of febrile neutropenia (FN). Because granulocyte colony-stimulating factor (G-CSF) is expensive, this study investigates the economic consequences of secondary prophylactic use of different prophylactic strategies (antibiotics, antibiotics plus G-CSF, and a combined sequential approach) in a population at risk of FN, using a Markov model.

Methods

The input for the model is mainly based on the clinical outcome and patient-based cost data set (adopting the health care payer's perspective for the Netherlands) derived from a randomized study on primary prophylaxis in small-cell lung cancer (SCLC) patients; establishing mean cost of an episode FN of €3,290 and prophylaxis of €79 (antibiotics) ± €1,616 (G-CSF) per cycle. The economic analysis was analyzed probabilistically using first- and second-order Monte Carlo simulation. The incremental cost-effectiveness ratio (ICER) was defined as cost per FN-free cycle.

Results

Secondary prophylaxis with antibiotics was the least expensive strategy (mean, €4,496/patient). The strategy antibiotics plus G-CSF was most expensive (mean, € 8,998/patient). Comparison of these two strategies resulted in an unacceptably high ICER (€343,110 per FN-free cycle) in the Dutch context. In scenarios using higher FN-related costs (as found in the United States), the strategies are less distinct in their monetary effects, but still favor antibiotics.

Conclusion

This model-based economic analysis demonstrates that in the Netherlands and most likely also in the United States, if secondary prophylaxis is preferred, the strategy with antibiotics is recommended.

EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphomas and solid tumours

Chemotherapy-induced neutropenia is not only a major risk factor for infection-related morbidity and mortality, but is also a significant dose-limiting toxicity in cancer treatment. Patients developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently receive dose reductions and/or delays to their chemotherapy. This may impact on the success of treatment, particularly when treatment intent is either curative or to prolong survival. The incidence of severe or FN can be reduced by prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs), such as filgrastim, lenograstim or pegfilgrastim. However, the use of G-CSF prophylactic treatment varies widely in clinical practice, both in the timing of therapy and in the patients to whom it is offered. While several academic groups have produced evidence-based clinical practice guidelines in an effort to standardise and optimise the management of FN, there remains a need for generally applicable, European-focused guidelines. To this end, we undertook a systematic literature review and formulated recommendations for the use of G-CSF in adult cancer patients at risk of chemotherapy-induced FN. We recommend that patient-related adverse risk factors such as elderly age (>or=65 years), be evaluated in the overall assessment of FN risk prior to administering each cycle of chemotherapy. In addition, when using a chemotherapy regimen associated with FN in >20% patients, prophylactic G-CSF is recommended. When using a chemotherapy regimen associated with FN in 10-20% patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN. In situations where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis may be used to maintain chemotherapy. Finally, studies have shown that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications, where indicated.

Micro-metastases in axillary lymph nodes: an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure

BACKGROUND

Sentinel lymph node (SN) biopsy will increasingly replace axillary lymph node dissection (ALND) for staging in breast cancer. For daily practice, examination of the SN by serial sectioning (SS) and/or immunohistochemistry (IHC) is being promoted. Use of these techniques may result into stage migration due to the increased detection of micro-metastases. The consequence may be overshooting of patients with adjuvant therapy, as the prognostic relevance of (small) micro-metastases and isolated tumor cells is unclear.

METHODS

The prognostic impact of micro-metastases is determined by reviewing ALND studies with a follow up of at least 5 years, including more than 100 patients, before the SN era. Furthermore, studies in which conventionally haematoxylin-eosin (H&E) negative SNs are investigated for occult metastases by SS and/or IHC are reviewed.

RESULTS

In only one of eight studies, occult metastases were an independent risk factor for reduced survival. The outcome is dependent on the size of the nodal metastasis. IHC and SS as used in the SN procedure indeed induce a shift from pNO to pN1a (according to TNM).

CONCLUSION

By the thorough pathologic examination of the SN, isolated tumor cells and micro-metastases are more frequently detected. We propose to classify small micro-metastases (<0.5 mm) in a separate pN1a(min) category (min for minimal) to prevent stage migration. As the prognostic relevance of isolated tumor cells and (small) micrometastases has not been proven, the value of adjuvant therapy can be questioned for patients with otherwise good prognostic factors.

Reduction of chemotherapy-induced febrile leucopenia by prophylactic use of ciprofloxacin and roxithromycin in small-cell lung cancer patients: an EORTC double-blind placebo-controlled phase III study

BACKGROUND

CDE (cyclophosphamide, doxorubicin, etoposide) is one of the standard chemotherapy regimens in the treatment of small-cell lung cancer (SCLC), with myelosuppression as dose-limiting toxicity. In this trial the impact of prophylactic antibiotics on incidence of febrile leucopenia (FL) during chemotherapy for SCLC was evaluated.

PATIENTS AND METHODS

Patients with chemo-naïve SCLC were randomized to standard-dose CDE (C 1,000 mg/m2 day 1, D 45 mg/m2 day 1, E 100 mg/m2 days 1-3. i.v., q 3 weeks, x5) or to intensified CDE chemotherapy (125% dose, q 2 weeks, x4, with filgrastim 5 microg/kg/day days 4-13) to assess the impact on survival (n = 240 patients). Patients were also randomized to prophylactic antibiotics (ciprofloxacin 750 mg plus roxithromycin 150 mg, bid. days 4-13) or to placebo in a 2 x 2 factorial design (first 163 patients). This manuscript focuses on the antibiotics question.

RESULTS

The incidence of FL during the first cycle was 25% of patients in the placebo and 11% in the antibiotics arm (P = 0.010; 1-sided), with an overall incidence through all cycles of 43% vs. 24% respectively (P = 0.007; 1-sided). There were less Gram-positive (12 vs. 4), Gram-negative (20 vs. 5) and clinically documented (38 vs. 15) infections in the antibiotics arm. The use of therapeutic antibiotics was reduced (P = 0.013; 1-sided), with less hospitalizations due to FL (31 vs. 17 patients, P = 0.013: 1-sided). However, the overall number of days of hospitalization was not reduced (P = 0.05; 1-sided). The number of infectious deaths was nil in the antibiotics vs. five (6%) in the placebo arm (P = 0.022; 2-sided).

CONCLUSIONS

Prophylactic ciprofloxacin plus roxithromycin during CDE chemotherapy reduced the incidence of FL, the number of infections, the use of therapeutic antibiotics and hospitalizations due to FL by approximately 50%, with reduced number of infectious deaths. For patients with similar risk for FL, the prophylactic use of antibiotics should be considered.

Treatment and survival of patients with non-small cell lung cancer Stage IIIA diagnosed in 1989-1994: a study in the region of the Comprehensive Cancer Centre East, The Netherlands

The purpose of this study was to gain insight into the treatment policy and survival of patients with non-small cell lung cancer (NSCLC) clinical stage IIIA in daily practice. We selected 212 patients, who had been diagnosed between 1989 and 1994 and registered by the Cancer Registry, Comprehensive Cancer Centre East (CCCE). Diagnostic tests comprised chest X-ray and bronchoscopy in all cases but one, computed tomography in 89%, mediastinoscopy in 55% and conventional tomography of the chest in 16%. NSCLC had been verified histologically in 88% and cytologically in 12%. The initial treatment for the primary tumor had been surgery alone in 13% of the patients, surgery plus radiotherapy in 8%, radiotherapy alone in 56%, chemotherapy in 1% (three patients, one in addition to surgery); 22% received none of these treatments. Median survival of the 212 patients was 9.4 months (95% confidence interval 8.3-11.0 months). Overall survival rates after 1, 2 and 3 years were 41, 17 and 8%, respectively. Three-year survival of the patients who had undergone surgery, surgery plus radiotherapy, radiotherapy alone and no treatment was 18, 19, 6 and 4%, respectively. Treatment was an independent prognostic factor (multivariate Cox's proportional hazards analysis adjusted for sub-stage, age, number of co-morbid diseases and hospital). In the same model, the Hazard rate ratio for one hospital relative to the five others was 1.9 (95% confidence interval 1.2-2.8). Surgery (whether or not in combination with radiotherapy) independently gave the best results. In conclusion, policies varied between hospitals, although the variation in overall survival was small except at one hospital. New regional management guidelines are in preparation. Physicians will be encouraged to follow these guidelines, both with regard to diagnostic tests and to treatment policies, as our study showed that differences in policy might lead to differences in survival.

Enhanced myelotoxicity due to granulocyte colony-stimulating factor administration until 48 hours before the next chemotherapy course in patients with small-cell lung carcinoma

PURPOSE

To evaluate the impact of granulocyte colony-stimulating factor (G-CSF) priming on peripheral-blood cell counts during standard-dose chemotherapy.

PATIENTS AND METHODS

Twelve patients with relapsed small-cell lung carcinoma (SCLC) were treated with two chemotherapy courses. Six patients received G-CSF priming only before the first course (group A) and the other six patients only before the second course (group B). Each patient served as his own control. Patients were treated with cyclophosphamide, epirubicin, and etoposide (CEE), or with vincristine, ifosfamide, mesna, and carboplatin (VIMP) every 4 weeks. G-CSF was administered subcutaneously 5 microg/kg/d for 6 days until 48 hours before the first or second chemotherapy course.

RESULTS

Priming caused a lowering of the WBC nadir, with a median value of 0.95 x 10(9)/L (P = .004), and of absolute neutrophil nadir, with a median value of 0.48 x 10(9)/L (P = .03). There was a trend for a lower platelet (PLT) nadir after G-CSF priming (P = .09). G-CSF priming resulted in a prolonged duration of WBC count less than 3.0 x 10(9)/L of +4.25 days (P = .04), and of WBC count less than 1.0 x 10(9)/L of +0.50 days (P = .03). The duration of neutropenia less than 0.5 x 10(9)/L seemed longer in primed courses (+3.75 days, P = .18). The duration of PLT counts less than 100 x 10(9)/L was prolonged by 1.5 days (P = .04). Hemoglobin (Hgb) levels were not influenced by G-CSF priming.

CONCLUSION

G-CSF administration until 48 hours before the next chemotherapy course increases chemotherapy-associated leukocytopenia and thrombocytopenia. This may be of special concern when G-CSF is administered during dose-densified chemotherapy.

Preclinical Cushing's syndrome in patients with an adrenal incidentaloma

BACKGROUND

Autonomous (hyper-)secretion of cortisol without classical stigmata of Cushing's syndrome occurs in 10-15% of patients with incidentally detected adrenal tumors (incidentalomas).

METHODS

We present the clinical and biochemical data of four such patients. Two patients had hypertension and one both hypertension and non-insulin-dependent diabetes mellitus, but none showed classical stigmata of Cushing's syndrome.

RESULTS

All patients showed insufficient suppression of plasma cortisol during a 1 mg dexamethasone screening test. Plasma ACTH levels were suppressed in all patients. However, in three out of four patients the diurnal rhythm of plasma cortisol was intact and these three patients also showed a response of plasma cortisol after administration of corticotropin-releasing hormone. All patients underwent unilateral adrenalectomy. A carcinoma was found in one patient and an adenoma in the remaining three. Postoperatively, blood pressure had normalized in 2 out of 3 hypertensive patients, whereas non-insulin-dependent diabetes mellitus had disappeared in 1 patient. Postoperative endocrine evaluation showed no abnormalities anymore.

CONCLUSIONS

We conclude that dexamethasone testing may reveal autonomous (hyper-)secretion of cortisol in adrenal incidentalomas. Adrenalectomy should be considered, especially when hypertension and/or non-insulin-dependent diabetes mellitus are present. One should be alert to the development of adrenal insufficiency after unilateral adrenalectomy.

Coincidence of seminoma and sarcoidosis: a myth or fact?

A patient with a stage II seminoma of the testis was treated with a routine orchidectomy and irradiation. One and a half years later enlarged mediastinal lymph nodes were noted. Additional staging showed no other abnormalities and a mediastinoscopy was performed. The initial histologic examination confirmed the clinically suspected diagnosis of sarcoidosis. However, additional immunohistochemical analysis unexpectedly demonstrated that there was also a microscopic relapse of the testis tumor. The literature concerning the co-incidence of non-caseating granulomas and testis tumors is reviewed. It is not clear, whether the granulomas indicate the presence of genuine idiopathic sarcoidosis or whether they reflect a sarcoid-like reaction against tumor antigens. The immunopathogenesis of sarcoid formation and its possible biologic significance in obtaining a spontaneous tumor remission is discussed.

Dose intensification of chemotherapy and the role of granulocyte colony stimulating factor and granulocyte macrophage colony stimulating factor in small cell lung cancer

The natural history of small cell lung cancer (SCLC) is characterized by early dissemination. Despite the high responsiveness to chemotherapy, the disease remains ultimately fatal in the majority of patients. One of the strategies to improve final outcome is the administration of intensified chemotherapy, either by dose escalation or by chemotherapy given at shortened intervals. By now, in only one randomized study, in which cyclophosphamide and cisplatin dosage was escalated by 30% in the first course only, a survival advantage was demonstrated in limited disease patients. The different ways of achieving intensification of chemotherapy are highlighted. The addition of growth factors in current dose-escalated or accelerated schedules seems to result in a relative dose intensity of no more than 150% when compared to optimally delivered conventional regimens. Whether such a moderate degree of dose intensification will improve survival rates has to be awaited from phase III trials.

Cutaneous infection due to Mycobacterium abscessus. A case report

Erythematous nodular and ulcerating skin lesions occurred in a 56-year-old woman treated with chemotherapy and glucocorticosteroids for metastatic breast cancer. Subsequent culture yielded Mycobacterium abscessus, a facultative pathogen which exists as a saprophyte in the environment and rarely produces clinical disease in humans. This organism is usually relatively resistant to antituberculous as well as a number of other antimicrobial agents. On the basis of in vitro susceptibility results, treatment with clarithromycin and clofazimine was installed and resolution of the lesions initiated. This report emphasizes once again that one should investigate any new or unusual skin lesions in immunocompromised patients by histology and culture of biopsies, including cultures for acidfast organisms.

Treatment in germ cell tumours: state of the art

Although the majority of patients with disseminated germ cell tumours can be cured with cisplatin-based chemotherapy, mortality is still up to 20%. Several prognostic factors have been identified to differentiate between patients with a good, intermediate or poor prognosis. In this review we discuss the recent chemotherapy trials, which were designed to reduce toxicity in good-prognosis patients and to improve efficacy in intermediate- and poor-prognosis patients. In good-prognosis patients it is obvious that the omission of bleomycin and the replacement of cisplatin by carboplatin has no place in first-line standard treatment. The reduction of four standard courses of bleomycin, etoposide and cisplatin (BEP) to three is shown possible in one study, but a confirmatory study is currently ongoing in the EORTC. In intermediate- and poor-prognosis patients, the use of new agents or alternating regimens (with or without shortened intervals) did, by now, not improve final outcome. The role of high-dose chemotherapy remains to be determined. Against this background, four courses of standard-dose BEP should still be considered treatment of first choice in the majority of patients with disseminated germ cell tumours. Furthermore, the policy in clinical stage I disease has been reviewed. In clinical stage I seminoma patients the policy is to apply adjuvant radiotherapy, while the strategy in patients with non-seminomatous tumours (surveillance, retroperitoneal lymph node dissection or adjuvant chemotherapy in high-risk patients) depends highly on the local situation, such as the operating skills of the urologist, and on the possibilities for tight follow-up. Of patients with true resistance for up-front BEP chemotherapy 90% will normally die. In patients who achieve a complete response on first-line chemotherapy, but relapse thereafter 30% will have no evidence of disease with second-line chemotherapy (VIP). In this group of patients results with high-dose chemotherapy seem promising, but its value should preferentially be determined in either a randomized fashion or by long-term follow-up from a large group of patients according to a similar protocol. The use of post-chemotherapy surgery is an essential part of management for metastatic non-seminomatous germ cell tumours, while the majority of residual masses in pure seminoma will disappear spontaneously, and frequent follow-up is recommended instead of surgical intervention.

A patient with postpartum primary hypothyroidism and acquired von Willebrand's disease

Patients with hypothyroidism often complain about easy bruising. We describe a patient with a postpartum acquired bleeding tendency. Hypothyroidism was suspected and confirmed biochemically. After substitution therapy with levothyroxine the bleeding tendency recovered completely. The coagulation disorder appeared to be based on an acquired von Willebrand's disease, secondary to the hypothyroidism. In patients with von Willebrand's disease underlying diseases have to be excluded.