Abstract P6-21-11: Final results from IMPROVE: A randomized, controlled, open-label, cross-over phase IV study to determine the patients' preference for either combined endocrine therapy (exemestane plus everolimus) or immunochemotherapy (capecitabine plus bevacizumab) as first line treatment for advanced HR+/HER2- breast cancer

For patients (pts) with advanced HR+/HER2- breast cancer various treatment options exist. Endocrine therapy or chemotherapy are the recommended 1st-line treatment options according to international guidelines. With comparable efficacy, it is of utmost importance to identify the treatment that has the least negative impact on the pts' quality of life (QoL). Randomized studies to determine the pts' preference (pref) for equi-effective treatment concepts, are lacking. IMPROVE compared both therapeutic concepts by assessing the pts' pref for either a combined antihormonal approach (everolimus /exemestane (E/E)) or chemotherapy (capecitabine /bevacizumab (C/B)).

In total, 77 pts were recruited from 10/14 until 04/17 at 26 sites in GER. Upon diagnosis of locally advanced, inoperable or metastatic disease, pts were randomized to receive 1st-line C/B until disease progression followed by 2nd-line E/E (Arm A) or vice versa (Arm B). Primary objective was the patient-reported pref for either treatment protocol 12 weeks after switching therapy. Key secondary endpoints include PFS, OS, safety and QoL. Descriptive statistics were used to to analyse data, PFS and OS were calculated by using the Kaplan-Meier method.

Baseline characteristics were well balanced with a slightly shorter disease-free interval after primary diagnosis and more prior treatments in Arm B.In Arm A [95% CI], 39% [13.9-68.4] vs 23% [5.0-53.8] of pts preferred E/E compared to C/B, 23% [5.0-53.8] were undecided. In Arm B, 56% [30.8-78.5] vs 11% [1.4-34.7] preferred C/B, 22% [6.4-47.6] undecided. Overall, 42% [24.5-60.9] vs 23% [9.6-41.1] of pts preferred C/B, 23% [9.6-41.1] were undecided.

Physicians' pref had a tendency for C/B treatment (Arm A, 62% [31.6-86.1] vs 39% [13.9-68.4] for C/B. Arm B, 56% [30.8-78.5] vs 28% [9.7-53.5] for C/B, no pref 17% [3.6-41.4]).

Median 1st-line PFS [months, 95% CI] was 11.1 [7.8-18.0] for C/B (Arm A) vs 3.5 [2.7-5.5] for E/E (Arm B). Median 2nd-line PFS was 3.7 [2.4-7.8] for E/E (Arm A) vs 3.6 [2.3-5.5] for C/B (Arm B). Median OS [months, 95% CI] was 28.8 [19.7-NA] (Arm A) and 24.7 [13.9-28.8] (Arm B). 73.0% and 52.6% (1st and 2nd line, C/B) vs 54.1% and 52.9% (1st and 2nd line, E/E) of pts developed grade 3/4 AEs. Most common grade 3/4 AEs (%) were hand-foot syndrome (18.9), fatigue (17.6), hypertension (13.5) for C/B and anaemia (23.5), fatigue, dyspnoea, cough (each 17.6) for E/E (either line). No treatment-related deaths occurred. Patient-reported QoL (EORTC-QLQC30) and treatment satisfaction were not significantly different between arms in either treatment phase.

In the IMPROVE study, pts had no pref for either endocrine therapy or immunochemotherapy. Overall, there was a tendency in favour of the chemotherapeutic approach (C/B), which was in line with the therapy pref reported by the physicians. C/B was found to have slightly better efficacy results but at the cost of a higher frequency of grade 3/4 AEs, bearing in mind the difference in duration of therapy between the two regimens. Patient-reported QoL, however, was similar in both arms.

Citation Format: Kurbacher CM, Söling U, Hahn A, Chiabudini M, Maintz C, Rieger L, Falkenstein J, Runkel E, Potthoff K, Decker T. Final results from IMPROVE: A randomized, controlled, open-label, cross-over phase IV study to determine the patients' preference for either combined endocrine therapy (exemestane plus everolimus) or immunochemotherapy (capecitabine plus bevacizumab) as first line treatment for advanced HR+/HER2- breast cancer [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 P6-21-11.

Bleeding, thrombosis, and anticoagulation in myeloproliferative neoplasms (MPN): analysis from the German SAL-MPN-registry

BACKGROUND

Patients with Ph-negative myeloproliferative neoplasms (MPN), such as polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), are at increased risk for thrombosis/thromboembolism and major bleeding. Due to the morbidity and mortality of these events, antiplatelet and/or anticoagulant agents are commonly employed as primary and/or secondary prophylaxis. On the other hand, disease-related bleeding complications (i.e., from esophageal varices) are common in patients with MPN. This analysis was performed to define the frequency of such events, identify risk factors, and assess antiplatelet/anticoagulant therapy in a cohort of patients with MPN.

METHODS

The MPN registry of the Study Alliance Leukemia is a non-interventional prospective study including adult patients with an MPN according to WHO criteria (2008). For statistical analysis, descriptive methods and tests for significant differences as well as contingency tables were used to identify the odds of potential risk factors for vascular events.

RESULTS

MPN subgroups significantly differed in sex distribution, age at diagnosis, blood counts, LDH levels, JAK2V617F positivity, and spleen size (length). While most thromboembolic events occurred around the time of MPN diagnosis, one third of these events occurred after that date. Splanchnic vein thrombosis was most frequent in post-PV-MF and MPN-U patients. The chance of developing a thromboembolic event was significantly elevated if patients suffered from post-PV-MF (OR 3.43; 95% CI = 1.39-8.48) and splenomegaly (OR 1.76; 95% CI = 1.15-2.71). Significant odds for major bleeding were previous thromboembolic events (OR = 2.71; 95% CI = 1.36-5.40), splenomegaly (OR = 2.22; 95% CI 1.01-4.89), and the administration of heparin (OR = 5.64; 95% CI = 1.84-17.34). Major bleeding episodes were significantly less frequent in ET patients compared to other MPN subgroups.

CONCLUSIONS

Together, this report on an unselected "real-world" cohort of German MPN patients reveals important data on the prevalence, diagnosis, and treatment of thromboembolic and major bleeding complications of MPN.

Subcutaneous Administration of Monoclonal Antibodies in Oncology

Treatment with monoclonal antibodies (mabs) has become an established component of oncological therapy. The monoclonal antibodies available for this purpose are mainly administered intravenously in individually adapted doses according to body weight over longer treatment times. For other chronic diseases such as, for example, diabetes mellitus, the subcutaneous administration of drugs is an established therapy option. For the subcutaneous administration of larger volumes as needed for mab solutions the extracellular matrix of the subcutaneous tissue represents a problem. The co-formulation with recombinant human hyaluronidase makes the relatively pain-free administration of larger fluid volumes and thus the subcutaneous administration of monoclonal antibodies possible, as illustrated by the development of a subcutaneous formulation of trastuzumab. This constitutes a less invasive, time-optimised and flexible form of administration for patients with HER2-positive breast cancer that, with its fixed dosing possibilities, contributes to therapeutic safety. The example of trastuzumab shows that the subcutaneous administration of monoclonal antibodies can simplify oncological long-term therapy not only for the patients but also for the medical personnel.

[Gastrointestinal stromal tumors: a broad clinical spectrum from incidental -discovery to acute gastrointestinal bleeding]

Three cases of gastrointestinal stromal tumors (GIST) are reported as typical examples of the broad clinical spectrum in which these rare tumors can be detected. The first case describes an 82-year-old patient with a hemorrhagic shock due to upper gastrointestinal bleeding from a GIST of the stomach. GIST most frequently present with either gastrointestinal bleeding, abdominal pain or a detectable mass on physical examination or by ultrasound imaging. Clinically asymptomatic tumor growth also occurs as demonstrated by the second case of a 44-year-old -woman with an incidental finding of GIST during surgery of the esophagus. The cases are used to discuss the consequences for therapy and prognosis resulting from the heterogeneity of this tumor entity; the relevant immunohistochemical markers used to distinguish between various tumor subtypes of gastrointestinal mesenchymal tumors (GIMT) are listed. Since gastrointestinal stromal tumors (GIST) represent the most common subgroup of GIMT, we focus on the clinicopathological prognostic factors of GIST. The third case of a 40-year-old patient with a malignant GIST recurrence after surgery and exhibiting secondary resistance after one year of successful therapy with the receptor tyrosine kinase inhibitor imatinib (Gleevec), antagonizing pathogenetically relevant constitutive c-KIT activation, illustrates the potential and limitations of the only effective drug treatment for advanced GIST.

[Thrombolytic therapy in acute cerebral infarction--a time study when organizing a new therapeutic option]

Cerebral thrombolysis is a therapeutic option for patients with acute cerebral infarction, but its use can be limited by delayed hospital admission. The aim of this study was to examine this delay, to improve admission routines and thus increase the number of potential candidates for treatment. In the first part of the study, time from first symptoms until hospital admission (time from first symptoms to contact with the primary health care system, and from contact to admission) was registered for 100 patients with acute stroke. Time spent to cerebral CT scan, and within the hospital was also registered. Measures to shorten admission time were then instituted, including information to the public and to primary health care professionals. An identical study was then performed on another 124 patients. Referral procedures were significantly improved, whereas time taken for patients to contact the primary health care system remained unchanged. Direct contact by emergency telephone secured the fastest admissions. The number of patients admitted within two hours after stroke onset increased from 17% to 26%. Four patients (3%) were treated with thrombolysis. Our study indicates that improved admission routines reduce admission delay. More public information is necessary to change patient behaviour.

Depression and social functioning in general hospital in-patients

Impairment of social functioning is often associated with depression and contributes to an unfavorable course of the disease. Although it must be suspected that both social maladaptation and depression could obstruct recovery from somatic diseases, little attention has been paid to their interaction in general hospital patients. To assess social integration in depressive and psychiatrically healthy general hospital in-patients, 250 patients were studied with the Composite International Diagnostic Interview (CIDI), a structured clinical interview, and the Social Interview Schedule (SIS). From clinical interviews, it was established that 16.4% of the patients suffered from depressive disorders (ICD-10). When these patients were compared with patients without psychiatric disorder, only a tendency to social dysfunctioning with regard to social management and satisfaction with social situations was observed. But when the depressive sample was divided into three diagnostic groups (depressive episode, dysthymia, depressive adjustment disorder), significant social impairments were found in the dysthymia subsample. Family and other interpersonal problems were most prominent. When depression preceded somatic illness, a higher level of impairment was observed. The majority of dysthymia patients suffered from long-term somatic diseases, often cancer, which were preceded by depression. The results of this study single out a small group of patients who seem to be at an extensive risk of chronic psychiatric and somatic illnesses and should therefore be a focus of consultation/liaison (C/L) interventions.

Oral idarubicin, dexamethasone and vincristine (VID) in the treatment of multiple myeloma

In order to replace the central venous line necessary for continuous infusion of vincristine and doxorubicin with high-dose dexamethasone (VAD) and to avoid hospitalization, we evaluated the efficacy and toxicity of oral idarubicin, vincristine and dexamethasone (VID) in patients with multiple myeloma. Vincristine (1.6 mg/m2, max 2 mg) was given as a bolus injection on day 1. Idarubicin was given in capsules 10 mg/m2/day for days 1-4 with an intraindividual dose escalation, 40 mg dexamethasone were given on days 1-4, 9-12, 17-20. Treatment cycles were repeated every 28 days. At this interim analysis, 53 patients have been entered into the ongoing trial; 46 patients are evaluable for toxicity. The median age was 60 years (interquartile range, 52-65). 46% were primary or secondary refractory, 20% had previously been treated with VAD and 30% had previously untreated disease, 4% had two or more relapses. Four patients died within 2 months from entry and were considered as early deaths (8.7%). 45% of the 42 patients evaluable for efficacy achieved a partial remission and 26% a minor remission. The median reduction of the M-component was 43% (interquartile range, 25-64%). VID is an effective and convenient alternative to VAD even in relapsed or refractory patients.