Neoadjuvant endocrine therapy with or without palbociclib in low-risk patients: a phase III randomized double-blind SAFIA trial

BACKGROUND

The most prevalent subtype of breast cancer (BC) is luminal hormonal-positive breast cancer. The neoadjuvant chemotherapy regimens have side effects, emphasizing the need to identify new startegies.

OBJECTIVE

Analyze the complete pathologic response (pCR) rate and overall response in a low-risk hormone-positive subset of patients receiving neoadjuvant hormone treatment (NAHT) with or without Palbociclib (a CDK4/CDK6 inhibitor) to boost NAHT effectiveness.

MATERIALS AND METHODS

Based on the upfront 21-gene Oncotype DX or low-risk Breast Recurrence Score assay (RS™), the SAFIA trial is designed as a prospective multicenter international, double-blind neoadjuvant phase-III trial that selects operable with luminal BC patients that are HER2-negative for the induction hormonal therapy with Fulvestrant 500 mg ± Goserelin (F/G) followed by randomization of responding patients to palbociclib versus placebo. The pCR rate served as the study's main outcome, while the secondary endpoint was a clinical benefit.

RESULTS

Of the 354 patients enrolled, 253 initially responded and were randomized to either F/G fulvestrant with palbociclib or placebo. Two hundred twenty-nine were eligible for the evaluation of the pathologic response. No statistically significant changes were observed in the pCR rates for the patients treated with the F/G therapy with placebo or palbociclib (7% versus 2%, respectively) per the Chevallier classification (Class1 + Class2) (p = 0.1464) and 3% versus 10% assessed per Sataloff Classification (TA, NA/NB) (p = 0.3108). Palbociclib did not increase the rate of complete pathological response.

CONCLUSION

Neoadjuvant hormonal therapy is feasible in a selected population with a low RS score of < 31 CLINICAL TRIAL: NCT03447132.

Final result for SAFIA trial for neoadjuvant palbociclib in patients with operable luminal breast cancer responding to fulvestrant

596

Background: Luminal, human epidermal growth factor receptor 2 (HER2)-negative breast cancer (BC) encompasses the most common subtype of breast malignancies. Neoadjuvant strategies of operable BC are primarily based upon chemotherapy (CT), while neoadjuvant hormone therapy (NAHT) has not been well studied in the Middle East and North Africa (MENA) region. However, these tumors might respond poorly to neoadjuvant CT with significant side effects, emphasizing the need to identify patients who could be candidates for NAHT. Methods: The SAFIA trial is a prospective multicentre, international, double-blind, neoadjuvant phase-III trial using upfront 21-gene Oncotype DX Breast Recurrence Score assay (RS) <31) to select operable Luminal HER2-negative patients for induction hormonal therapy with Fulvestrant 500 mg +/– Goserelin (F/G) before randomizing responding patients to F/G + Palbociclib (Cyclin-Dependent Kinase 4/6 inhibitor / CDK 4/6) versus F/G + Placebo. The primary endpoint of this study was the complete pathologic response (pCR) rate. Results: A total of 354 patients were enrolled, leading to 277 patients treated with induction F/G. Of these, 253 responding patients were randomized to F/G fulvestrant with palbociclib or Placebo. Two hundred and thirty patients were evaluable for pathologic response. No statistically significant differences were identified in terms of pCR rates between F/G with palbociclib or placebo: 2% versus 7%, respectively. According to the radiologic responses post- induction F/G, the hormone sensitivity rate was 89.8%, while the clinical benefit of 8–9 months of neoadjuvant F/G was 96%. Safety in the MENA population was acceptable with a grade 3-4 neutropenia rate of 25% in the F/G plus palbociclib arm. The feasibility of performing the 21-gene breast recurrence score assay on core biopsy specimens was optimal in 96.4% of cases. Conclusions: The addition of palbociclib to neoadjuvant F/G did not show any additional benefit in terms of pathologic response, including pCR in neoadjuvant therapy of Luminal HER2-negative BC responding to induction F/G. The use of an upfront 21-gene assay appeared feasible on biopsy specimens, and the identification of tumors with RS<31 allowed to select endocrine sensitive patients, leading ultimately to a 96% clinical benefit with 8–9 months of F/G neoadjuvant therapy. Clinical trial information: NCT03447132. [Table: see text]

Prevalence and Risk Factors of Burnout Among Female Oncologists From the Middle East and North Africa

Background

Burnout (BO) is a recognized challenge among the oncology workforce. It affects both genders with a higher frequency among women. This study examined the factors contributing to the development of burnout among female oncologists from the Middle East and North Africa (MENA).

Methods

An online cross-sectional survey was distributed to oncology professionals from different countries in the MENA region. The validated Maslach Burnout Inventory (MBI) of emotional exhaustion (EE), Depersonalization (DE), and Personal Achievement (PA) plus questions about demography/work-related factors and attitudes toward oncology were included. Data were analyzed to measure BO prevalence and related factors.

Results

Between 10 February and 15 March 2020, 545 responses were submitted by female oncologists. The responses pre-dated the COVID-19 pandemic emergence in the region. BO prevalence was 71% among female professionals. Women aged <44 years represented 85% of the cohort. Sixty-two percent were married, 52% with children and one-third practiced a hobby. Two-thirds worked in medical oncology, worked for <10 years and 35% worked in academia. The majority (73%) spent >25% on administrative work daily. Nearly half of the respondents (49%) expressed a recurring thought of quitting oncology and 70% had no burnout support or education. Inability to deliver optimal care was reported as distressing for career development in 82%. Factors significantly influencing the BO risk were identified. Marital status, having children, academia and years in practice did not impact the risk of BO among female oncologists from MENA.

Conclusion

Female oncologists from the Middle East and North Africa (MENA) were found to have a high prevalence of BO. In this cohort, the majority of women oncology workers were young and in their early to mid-career stages. Burnout was linked to being younger, practicing in North African nations, having a heavy administrative load, and having persistent thoughts of quitting. Practicing a hobby and engaging in oncology communication, on the other hand, reduced the chance of BO. Burnout support and education, specifically for oncology women, is required.

Response to Induction Neoadjuvant Hormonal Therapy Using Upfront 21-Gene Breast Recurrence Score Assay-Results From the SAFIA Phase III Trial

Luminal, human epidermal growth factor receptor 2–negative breast cancer represents the most common subtype of breast malignancies. Neoadjuvant strategies of operable breast cancer are mostly based on chemotherapy, whereas it is not completely understood which patients might benefit from neoadjuvant hormone therapy (NAHT).

Prevalence and risk factors of burnout among female oncology professionals from the Middle East and North Africa (MENA)

11016

Background: Burnout (BO) is a recognized challenge among oncology workforce. It affects both genders with a higher frequency among women. This study examined the factors contributing to the development of burnout among women in oncology from the Middle East and North Africa (MENA). Methods: An online cross-sectional survey was distributed to oncology professionals from different countries in the MENA region. The validated Maslach Burnout Inventory (MBI) of emotional exhaustion (EE), Depersonalization (DE), and Personal Achievement (PA) plus questions about demography/work-related factors and attitudes toward oncology were included. Data were analyzed to measure BO prevalence and related factors. Results: Between February 10 and March 15, 2020, 545 responses were submitted by female professionals. The responses pre-dated the COVID-19 pandemic emergence in the region. BO prevalence was 71% among female professionals. Women aged < 44 years represented 85% of the cohort. Sixty-two percent were married, 52% with children and one-third practiced a hobby. Two-thirds worked in medical oncology, worked for < 10 years and 35% worked in academia. The majority (73%) spent > 25% on administrative work daily. Nearly half of the respondents (49%) expressed a recurring thought of quitting oncology and 70% had no burnout support or education. Inability to deliver optimal care was reported as distressing for career development in 82%. Factors significantly influencing the BO risk are listed in Table. Marital status, having children, academia and years in practice did not impact the risk of BO among female oncologists form MENA. Conclusions: High BO prevalence was reported among female oncology professionals from MENA. The majority of women oncology workforce were young and early- to mid-career in this cohort. Younger age, practicing in North African countries, high administrative load and the recurring thought of quitting were associated with increased risk of burnout. Whereas, practicing a hobby and enjoying oncology communication decreased the BO risk. Burnout support and education specifically for women in oncology is needed.[Table: see text]

Burnout in oncology: Magnitude, risk factors and screening among professionals from Middle East and North Africa (BOMENA study)

BACKGROUND

Burnout (BO) among oncology professionals (OP) is increasingly being recognized. Early recognition and intervention can positively affect the quality of care and patient safety. This study investigated the prevalence, work and lifestyle factors affecting BO among OPs in the Middle East and North Africa (MENA).

METHODS

An online survey was conducted among MENA OPs between 10 February and 15 March 2020, using the validated Maslach Burnout Inventory of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA), including questions regarding demography/work-related factors and attitudes towards oncology. Data were analysed to measure BO prevalence and risk factors and explore a screening question for BO.

RESULTS

Of 1054 respondents, 1017 participants (64% medical oncologists, 77% aged less than 45 years, 55% female, 74% married, 67% with children and 40% practiced a hobby) were eligible. The BO prevalence was 68% with high levels of EE and DP (35% and 57% of participants, respectively) and low PA scores (49%). BO was significantly associated with age less than 44 years, administrative work greater than 25% per day and the thought of quitting oncology (TQ). Practising a hobby, enjoying oncology communication and appreciating oncology work-life balance were associated with a reduced BO score and prevalence. North African countries reported the highest BO prevalence. Lack of BO education/support was identified among 72% of participants and TQ-predicted burnout in 77%.

CONCLUSIONS

This is the largest BO study in MENA. The BO prevalence was high and several modifiable risk factors were identified, requiring urgent action. TQ is a simple and reliable screening tool for BO.

Epidemiology of breast cancer in women based on diagnosis data from oncologists and senologists in Algeria

BACKGROUND

Breast cancer (BC) is a major health issue threatening women's life. No reliable epidemiological data on BC diagnosed by oncologists/senologists are available in Algeria.

METHODS

The BreCaReAl study, a non-interventional prospective cohort study, included adult women with confirmed BC in Algeria. Disease incidence, patients and disease characteristics, treatment patterns, and mortality rate were recorded up to 12 months of follow-up.

RESULTS

Overall, 1,437 patients were analysed: median age was 48 [41;57] years and 337 (23.5%) women had a family history of BC. BC incidence was 22.3 (95% CI: 21.5; 23.2) cases per 100,000 inhabitants over 8 months. Delayed diagnosis was reported in 400 (29.2%) patients. First line of treatments were mainly chemotherapy and surgery. Twenty-eight serious adverse events were reported including 10 (37.0%) events which led to death. Mortality rate reached 3.2% at 12 months CONCLUSION: A delayed diagnosis highlights the importance of implementing more effective screening strategies.

Incidence of lung cancer in males and females in Algeria: The lung cancer registry in Algeria (LuCaReAl)

BACKGROUND

Lung cancer is a major cause of death worldwide. However, few data on incidence, histologic types and mortality rates of lung cancer were available for Algeria.

METHODS

LuCaReAl is an ongoing descriptive, non-interventional, national, multicenter, prospective and longitudinal study conducted in Algeria, among oncologists and pulmonologists in public community and university hospitals. Median and interquartile ranges are displayed.

RESULTS

Between July 2016 and July 2017, 897 patients were included. Overall incidence of lung cancer was 3.4 [3.2;3.6] cases per 100,000 inhabitants; overall incidence by sex was 5.8 [5.4;6.2] for males and 1.0 [0.8;1.1] for females. Adenocarcinoma was the most common histologic type of cancer. Most tumors were diagnosed at Stage IV.

CONCLUSION

The first results from the LuCaReAl study in Algeria showed that most patients are diagnosed with lung cancer at an advanced stage. The ongoing follow-up will next provide data on the survival and mortality rates.

Toxicity and tolerance profile of ANTI-EGFRS in metastatic colorectal cancer RAS wild type from the east of Algeria

e16032

Background: The results of the different studies showed that the use of anti-EGFRs (Epidermal Growth Factor Receptor) in the management of mCRCs, confront the healthcare team to a new toxicity which until then, were unknown before the era of anti EGFRs. knowing that there were no Algerian patients in these studies, reason for us to do this work. Methods: Between October 2015 and October 2018, our work consists of an epidemiological, observational, descriptive, longitudinal prospective study, including all patients with metastatic colorectal cancer RAS wild type, receiving specific medical treatment with anti EGFR (Panitumumab or Cetuximab) from Medical Oncology Department of Didouche Mourad Hospital of Constantine and the Medical Oncology Department of Batna’s Anti Cancer Center, performance status 0-2, and age 18-75 years. We have completed this work whose main objective is to evaluate the toxicity of anti EGFRs in patients with mCRC RAS wild-type from the east of Algeria. Results: 60 patients received an anti EGFR (Panitumumab or Cetuximab), in our study the most common toxicity was folliculitis with an average onset time of 3.36 weeks and a frequency of 83% of grade 2 and 3. Xerosis was observed in 71% of patients. Paronychia was observed in 50% of patients, in addition to the classical toxicities observed with the different chemotherapy regimens used in mCRCs. For secondary objectives, the median progression free survival in our study was 12 months, with a 95% confidence interval [10,787-13,213]. This median progression-free survival is comparable to those reported in the major anti-EGFR trials. Conclusions: Our results suggest that the Algerian patients with metastatic colorectal cancer RAS wild-type have the same profile of toxicity comparing to the results from different international trials studying anti EGFRs.

Prediction of response to neoadjuvant hormonal therapy (NAHT) using upfront oncotype Dx recurrence score (RS): Results from the SAFIA phase III trial

594

Background: While hormonal therapy (HT) is a fundamental treatment in breast cancer therapy, neoadjuvant NAHT is not considered standard. The SAFIA trial is a prospective international neoadjuvant Phase III investigating the potential role of the addition of palbociclib (P) in patients (pts) sensitive to HT. We report the results of induction Faslodex (+/- zoladex) in pts initially selected by RS < 31, in order to assess their individual HT sensitivity before double-blind randomization HT vs HT + P followed by surgery. Materials and Methods: A total of 308 pts (stages II and IIIA Luminal A/B HER2 negative) in 24 centers and 6 countries (Middle-East/Maghreb) underwent upfront RS to select pts for induction HT. Pts with RS < 31 received induction neoadjuvant fulvestrant (500 mg i.m Day 1, 14, 28 then q.4 weeks) + goseriline (3.6 mg s.c q.4 w for pre and peri-menopausal pts) for 4 months, followed by clinical and radiological assessment of the disease response before randomization. Response was defined as no progression: Complete Response-CR/ Partial Response-PR: > 50% and Minor Response-MR: < 50% to > 0%/ No Response-NR: progression > 0%. Results: A total of 70 pts (22%) with RS > 31 were excluded, leaving 238 eligible pts for NAHT, age (25-84); pre-peri/ post menopause: 135 (57%)/103 (43%); Luminal A/B: 112 (49%)/114 (51%); Stage II/IIIA: 196 (87%) / 29 (13%). One hundred and seventy-seven pts (177) have validated responses to induction NAHT: CR: 9 pts (5%) / MR: 105 pts (59%) for major response rate: 64% / MR: 56 pts (32%) / NR: 7 pts (4%); available RS 0-10: 23 pts (16%) / RS 11-18: 67 pts (47%) / RS 19-25: 34 pts (24%) / RS 26-30: 18 pts (13%). Correlations between Response to NAHT and RS are shown in the table below (not statistically significant). Conclusions: In our population, upfront Oncotype DX RS < 31 allowed to select pts for induction NAHT without loss of chances with a no-progression rate (CR+PR = MR) of 96%. No significant correlation was found between RS and response to NAHT. Upfront RS > 31 (22%) is selecting pts candidates for neoadjuvant chemotherapy with a potential high risk of endocrine resistance. Clinical trial information: ICRG1201 .

Abstract B202: Hand-foot syndrome, the main side effect of patients with metastatic renal cell carcinoma treated with sunitinib

Background: Hand-foot syndrome (HFS) and related skin toxicities are common side effects of tyrosine kinase inhibitors such as sunitinib (SU), a multitargeted inhibitor of VEGF and PDGF receptors plus other receptor tyrosine kinases. In the treatment of naïve metastatic renal cancer carcinoma (mRCC) patients (pts), sunitinib showed superior progression-free survival (PFS) and objective response rate (ORR) over interferon-alfa, with a median PFS of 11 mo and median overall survival (OS) of 26.4 mo, establishing SU as a reference standard of care (Motzer et al, 2009). In this analysis, correlations between SU-associated HFS and efficacy endpoints were investigated in mRCC pts from January 2009 to January 2011 in the first- and second-line treatment settings. Methods: A total of 23 patients who received single-agent SU as 50 mg/d on a 4-week-on/2-week-off schedule (n=17; 73.9%) or 37.5 mg (n=6; 26%). Median PFS and OS were estimated and compared between pts with vs without HFS. Adverse events were recorded regularly. Results: Of 23 pts, 9 (39%) developed any-grade HFS, compared with 14 (60.8%) who did not. Most HFS (58%) initially occurred during the first 3 treatment cycles. Pts who developed HFS had significantly better ORR (55% vs. 32%), PFS (12 vs. 8 mo), and OS (23 vs. 11 mo) than pts who did not develop HFS.Conclusions: In mRCC pts, SU-associated HFS was significantly and independently associated with improved clinical outcomes. Overall, pts who did not develop HFS still had substantial benefit from SU. However, the presence of HFS identified a subset of pts that manifested highly favorable efficacy results with SU. This is suggesting that development of HFS may serve as a predictive biomarker of SU efficacy.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B202.

Citation Format: Assia Bensalem, Kamel Bouzid. Hand-foot syndrome, the main side effect of patients with metastatic renal cell carcinoma treated with sunitinib. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B202.

[Targeted therapy and breast cancer: state of the art]

CONTEXT

Scientific advances in molecular biology and understanding of oncogenesis have lead to anticancer molecular targeted therapies. They encompass monoclonal antibodies binding to active membrane epitopes and small molecules interfering with enzymatic reactions essential to cancer cell survival (oncogene addiction). These pathways may be optimal targets. Clinical benefits achieved using these targeted agents have been outstanding both in localized and metastatic disease.

METHOD

We conducted a survey of literature analyzing activity and safety of targeted agents approved by FDA and/or FDA for the treatment of patients with breast cancer: anti-HER2 and antiangiogenic agents.

RESULTS

Activity and main toxicities of these targeted agents are described according to signaling pathway targeted as well as stage of breast cancer.

CONCLUSIONS

Availability of these targeted therapies has indeed transformed the outcome of subgroups of breast cancer to the expense of acceptable and manageable side effects, as compared to classical cytotoxics to which they are nevertheless combined.

Docetaxel plus capecitabine in the treatment of previous anthracycline-treated patients with metastatic breast cancer

e12014

Background: Anthracyclines have been considered the challenge of the treatment of metastatic breast cancer. Docetaxel has changed this belief. We conducted a study in previously anthracyclines treated metastatic breast cancer by the regimen docetaxel 75 mg/m2 Day 1 - capecitabine 2500 mg/m2 day split-up over 2 daily doses from Day 1 to Day 14; every 21 Days. Methods: Patients were eligible if they had metastatic breast cancer after an adjuvant setting by anthracyclines. All patients had measurable disease, PS ≤ 2, adequate organ function. Results: From April 2004 to June 2006, 18 patients were enrolled in the study and were evaluated for the toxicity and preliminary responses to the treatment. 100 % of patients had metastatic breast cancer. The sites of metastases were liver in 14 ( 77.7%), lung in 5 (27.7%) and bone in 9 (50%). 11 patients (61.1%) had 1 or 2 metastatic sites, 7 (38.9%) had 3 metastatic sites. All of 18 patients were assessed for toxicity. The main toxicities were as follows: neutropenia grade 3 in 3 patients (16.6 %), anemia grade 2–3 in 2 patients (11.1%), fatigue in 2 patients (11.1%), hand-foot syndrome in 7 patients (38.9%), vomiting-nausea in 4 patients (22.2%), diarrhea in 2 patients (11.1%), liver toxicity in 3 patients (16.6%). The objective response was obtained in 8 patients (44.4%) (Complete response in 3 patients (16.6%), partial response in 5 patients (27.7%). Median response duration was 9 months (range 4 - 17). 7 Patients (38.9%) had stable disease, progression was observed in 3 (16.6%) of patients. Conclusions: In this preliminary analysis, the combination of docetaxel - capecitabine in the treatment of previously anthracyclines treated metastatic breast cancer appears to be an active schedule. It is safe and active, with a manageable toxicity profile and a good clinical activity.

No significant financial relationships to disclose.

Gemcitabine/paclitaxel compared to gemcitabine/vinorelbine in metastatic breast cancer: An interim analysis

1097

Background: New combinations and strategies have been developed over the past 10 years including new drugs such as taxanes and gemcitabine. It is not clear whether the activity of the gemcitabine-paclitaxel (GP) combination regimen would translate into better progression-free or overall survival (OS) when compared with gemcitabine-vinorelbine (GV) especially in metastatic breast cancer. This study was conducted to evaluate the overall response rate (RR) of GP Vs GV. Secondary objectives included individual responses of GP and GV, time to progression (TTP), time to treatment failure (TTF), OS, and toxicities. Methods: Patients(pts) with histological diagnosis of stage IV or recurrent breast cancer who had PS =2 and measurable disease were randomized to receive GP (Gemcitabine: 1,250mg/m2 D1 & D8- paclitaxel: 175 mg/m2 D1, D1=D28) or GV (Gemcitabine: 1,250mg/m2 D1 & D8 - vinorelbine: 25mg/m2 D1 & D8, D1=D21). Pts received anthracycline and/or capecitabine chemotherapy in adjuvant and/or metastatic setting. Results: Of 47 patients enrolled, 24 patients were randomized to GP arm and 23 to GV arm. 72% of patients were stage IV and 28% recurrent disease. To date, all patients were qualified for safety, TTF, TTP and OS analysis. Hematologic toxicities were: Neutropenia in 23% in GP Vs 17% in GV, Anemia in 12% in GP Vs 9% in GV. Non hematologic toxicities were essentially nausea and vomiting grad 2–3 in 27% in GP Vs 31% in GV. Anti-emetic agents were administrated to decrease them. The Complete Response (CR) was 27% in GP Vs 30% in GV, the Partial Response (PR) was 23% in GP Vs 17% in GV; with an Overall Response Rate (ORR) of 50% in GP Vs 47% in GV. Median TTF in weeks was 12 in GP Vs 14 in GV. Median TTP (weeks) was 14 in GP Vs 19 in GV. Median OS (weeks) was 32 in GP Vs 50 in GV. Conclusions: In our experience, schedules incriminating gemcitabine are efficient and produce clinical benefit and there activities are very interesting. The analysis of the useful of paclitaxel or vinorelbine associated to gemcitabine demonstrates that these associations are active with no significant differences in toxicities. Therefore, the questions are what regimens, for what patients to what high responses in pre-treated metastatic breast cancer.

No significant financial relationships to disclose.

Gemcitabine in metastatic breast cancer

10735

Background: Gemcitabine (GEM) has shown efficacy in metastatic breast cancer (MBC). We conducted studies with GEM-based regimens to assess the efficacy and toxicity of GEM combined with other drugs in MBC. GEM was combined with docetaxel (DXL) in pre-treated MBC with an anthracycline-based regimen and GEM was combined with doxorubicin (DXR) in chemonaive patients (pts) with MBC. The studies’ objectives were to show clinically relevant hematologic toxicity and response rates among pts treated with GEM-DXL either in combination in pre-treated pts with anthracycline regimen or GEM-DXR in chemonaive pts with MBC to assess the efficacy of GEM in MBC either in neoadjuvant or first-line treatment. Methods: For GEM-DXL: 42 pts were enrolled; GEM: 1250 mg /m2 D1 & D8, DXL: 75 mg /m2 D1, every 21 days with classical premedication for DXL. For GEM-DXR: 51 pts were enrolled; GEM: 1250 mg /m2 D1 & D 8, DXR: 25 mg/m2 D1 & D8, every 21 days. Results: See table below. In the GEM-DXR group, surgery was performed in 30 pts, and 13 (43.2%) had histologically complete response. The median TTP in this group was 13.3 months (range, 2–53). Conclusions: GEM in MBC is very efficient and produced an interesting objective response and clinical benefit. This activity is consistent in either chemonaive pts or in pts with relapsing breast cancer.

[Table: see text]

No significant financial relationships to disclose.