2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting

•Nausea and vomiting are considered amongst the most troublesome adverse events for patients receiving antineoplastics. •The guideline covers emetic risk classification, prevention and management of treatment-induced nausea and vomiting. •The Consensus Committee consisted of 34 multidisciplinary, health care professionals and three patient advocates. •Recommendations are based on evidence-based data (level of evidence) and the authors’ collective expert opinion (grade). •All recommendations are for the first course of antineoplastic therapy; modifications may be needed in subsequent courses.

Severity and 1-month outcome of SARS-CoV-2 infection in patients with solid cancers: a Danish nationwide cohort study

BACKGROUND

Cancer patients are vulnerable to infections, are older and often have comorbidities in comparison to the general population, which increases the risk for severe outcomes related to COVID-19 diagnosis.

METHODS

This study is a prospective, nationwide study in patients with solid cancer and SARS-CoV-2 infection included between 10 March to 15 June 2020. Patient's baseline characteristics were collected. The study's primary outcome was overall survival within 30 days of verified SARS-CoV-2 infection. Secondary outcomes were hospital admission, admission to an ICU, and need for supplemental oxygen.

RESULTS

A total of 112 patients with a cancer diagnosis and verified SARS-CoV-2 infection were identified. After one month of follow up, hospitalization was required for 54% (n = 61) and 21% of the patients had died and 14 of the 23 deceased cancer patients were ≥70 years. Most patients were classified with mild COVID-19 symptoms (66%, n = 74); however, 48% (n = 23) of the ≥70-year-olds patients were classified with severe or critical COVID-19 symptoms. Among the total study population, 61% (n = 68) had comorbidities and comorbidity were more frequently observed among the deceased (91%, n = 21) and older cancer patients (≥70 years, 81%, n = 39).

CONCLUSIONS

Acknowledging the low sample size in this study, our work shows that age and comorbidities, but not recent cytotoxic therapy, are associated with adverse outcomes of SARS-CoV-2 infection for patients with solid cancer. Particularly, patients with progressive disease seem to be at greater risk of a fatal outcome from COVID-19.HighlightsAge, performance status, and comorbidities are strong predictors of adverse outcome in cancer patients with SARS-CoV-2 infection.Patients with progressive cancer disease seem to be at greater risk of a fatal outcome from COVID-19.Recent cytotoxic therapy, however, did not seem to be associated with increased risk for adverse outcomes of SARS-CoV-2 infection for patients with solid cancer.

Organized breast cancer screening not only reduces mortality from breast cancer but also significantly decreases disability-adjusted life years: analysis of the Global Burden of Disease Study and screening programme availability in 130 countries

Background

Multiple studies over the past 4 decades have shown the significant benefit of breast cancer screening (BCS) in reducing mortality rates from breast cancer (BC). However, significant debate exists about the role of BCS in this regard, with some studies also showing no benefit in terms of mortality along with issues such as overdiagnosis, health care utilisation costs, psychological distress or overtreatment. To date, no BCS study has focused on disability. Hence the aim of this study is to evaluate the relative contribution of BCS approaches to age-standardized mortality and disability-adjusted life years (DALYs) rates along with other related risk factors, from a country-level perspective.

Patients and methods

This study created a country-dataset by merging information from the Global Burden of Disease study regarding female age-standardized BC mortality, DALYs rates and other risk factors with the BCS programme availability at the national or regional level (versus no or only pilot such programme), BCS type (mammography, digital screening, breast self-examination and clinical breast examination) and other BCS-related information among 130 countries. Mixed-effect multilevel regression models were run to examine the associations of interest.

Results

The most important factor predictive of lower mortality was the more advanced type of BCS programme availability [mammography: −4.16, 95% CI −6.76 to −1.55; digital mammography/ultrasound: −3.64, 95% CI −6.59 to −0.70] when compared with self- or clinical breast examinations. High levels of low-density lipoprotein cholesterol (LDL-c) and smoking were also related to higher mortality and DALYs from BC. In terms of BC DALYs, BCS had a 21.9 to 22.3-fold increase in the magnitude of effect compared with that in terms of mortality. Data on mortality and DALYs in relation to BCS programmes were also calculated for high-, middle- and low-income countries.

Conclusions

These data further support the positive effects of BCS in relation to age-standardized BC mortality rates, and for the first time show the impact of BCS on DALYs too. Additional factors, such as diabetes, high levels of LDL-c or smoking seemed to be related to BC mortality and disability, and could be considered as additional components of possible interventions to be used alongside BCS to optimize the BCS benefit on patients.

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A key factor predictive of lower age-standardized BC mortality was breast cancer screening (BCS).

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This was the case with national-level BCS programmes as well as the availability of different types of BCS.

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LDL-c and smoking among others, were related to mortality and disability.

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BCS with mammography or digital screening was related to less age-standardized BC disability.

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These data support, for the first time, the relation of BCS on disability.

Long-term safety in patients with recurrent ovarian cancer treated with niraparib versus placebo: Results from the phase III ENGOT-OV16/NOVA trial

OBJECTIVE

Niraparib is a poly(ADP-ribose) polymerase (PARP) inhibitor approved for use in heavily pretreated patients and as maintenance treatment in patients with newly-diagnosed or recurrent ovarian cancer following a response to platinum-based chemotherapy. We present long-term safety data for niraparib from the ENGOT-OV16/NOVA trial.

METHODS

This multicenter, double-blind, randomized, controlled phase III trial evaluated the efficacy and safety of niraparib for the treatment of recurrent ovarian cancer. Patients were randomly assigned 2:1 to receive either once-daily niraparib 300 mg or placebo. Two independent cohorts were enrolled based on germline BRCA mutation status. The primary endpoint was progression-free survival, reported previously. Long-term safety data were from the most recent data cutoff (September 2017).

RESULTS

Overall, 367 patients received niraparib 300 mg once daily. Dose reductions due to TEAEs were highest in month 1 (34%) and declined every month thereafter. Incidence of any-grade and grade ≥ 3 hematologic and symptomatic TEAEs was also highest in month 1 and subsequently declined. Incidence of grade ≥ 3 thrombocytopenia decreased from 28% (month 1) to 9% and 5% (months 2 and 3, respectively), with protocol-directed dose interruptions and/or reductions. Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) were reported in 2 and 6 niraparib-treated patients, respectively, and in 1 placebo patient each. Treatment discontinuations due to TEAEs were <5% in each month and time interval measured.

CONCLUSION

These data demonstrate the importance of appropriate dose reduction according to toxicity criteria and support the safe long-term use of niraparib for maintenance treatment in patients with recurrent ovarian cancer.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01847274.

Integrated safety analysis of rolapitant with coadministered drugs from phase II/III trials: an assessment of CYP2D6 or BCRP inhibition by rolapitant

BACKGROUND

Rolapitant, a long-acting neurokinin (NK)1 receptor antagonist (RA), has demonstrated efficacy in prevention of chemotherapy-induced nausea and vomiting in patients administered moderately or highly emetogenic chemotherapy. Unlike other NK1 RAs, rolapitant does not inhibit or induce cytochrome P450 (CYP) 3A4, but it does inhibit CYP2D6 and breast cancer resistance protein (BCRP). To analyze potential drug-drug interactions between rolapitant and concomitant medications, this integrated safety analysis of four double-blind, randomized phase II or III studies of rolapitant examined adverse events (AEs) by use versus non-use of drug substrates of CYP2D6 or BCRP.

PATIENTS AND METHODS

Patients were randomized to receive either 180 mg oral rolapitant or placebo ∼1-2 h before chemotherapy in combination with a 5-hydroxytryptamine type 3 RA and dexamethasone. Data for treatment-emergent AEs (TEAEs) and treatment-emergent serious AEs (TESAEs) during cycle 1 were pooled across the four studies and summarized in the overall population and by concomitant use/non-use of CYP2D6 or BCRP substrate drugs.

RESULTS

In the integrated safety population, 828 of 1294 patients (64%) in the rolapitant group and 840 of 1301 patients (65%) in the control group experienced at least one TEAE. Frequencies of common TEAEs were similar in the rolapitant and control populations. Overall, 53% of patients received CYP2D6 substrate drugs, none of which had a narrow therapeutic index (like thioridazine or pimozide), and 63% received BCRP substrate drugs. When grouped by concomitant use versus non-use of CYP2D6 or BCRP substrate drugs, TEAEs and TESAEs occurred with similar frequency in the rolapitant and control populations.

CONCLUSIONS

The results of this study support the safety of rolapitant as part of an antiemetic triple-drug regimen in patients receiving emetogenic chemotherapy, including those administered concomitant medications that are substrates of CYP2D6 or BCRP, such as ondansetron, docetaxel, or irinotecan.

Prognostic factors in young ovarian cancer patients: An analysis of four prospective phase III intergroup trials of the AGO Study Group, GINECO and NSGO

OBJECTIVES

We evaluated in a large study meta-database of prospectively randomised phase III trials the prognostic factors for progression-free survival (PFS) and overall survival (OS) in patients < and >40 years of age with advanced epithelial ovarian cancer.

METHODS

A total of 5055 patients of the AGO, GINECO, NSGO intergroup studies AGO-OVAR 3, 5, 7 and 9 were merged to identify 294 patients <40 years and 4761 patients ≥40 years. We conducted survival analyses and Cox proportional hazard regression models and additionally analysed a very homogeneous subcohort of 405 patients with serous epithelial ovarian cancer, excellent performance status, who had received complete macroscopic upfront cytoreduction and ≥5 chemotherapy cycles.

RESULTS

For patients <40 years, the median PFS was 28.9 months and the median OS was 75.3 months, while the median PFS for patients ≥40 years was 18.1 months and the median OS was 45.7 months. Independent prognostic factors were similar in both age groups. In a multivariate analysis including prognostic factors potentially leading to confounding, young age appeared to improve PFS (hazard ratio [HR], 0.86; 95% confidence interval [CI]: 0.72-1.03) and OS (HR, 0.73; 95% CI: 0.59-0.91). The observed effect was even stronger in the subcohort of optimally treated patients with SEOC: PFS (HR, 0.34; 95% CI: 0.19-0.59) and OS (HR, 0.23; 95% CI: 0.09-0.56).

DISCUSSION

Prognostic factors were similar in both age groups. Young age appeared a strong independent protective prognostic factor for PFS and OS in the subcohort.

Alopecia as surrogate marker for chemotherapy response in patients with primary epithelial ovarian cancer: a metaanalysis of four prospective randomised phase III trials with 5114 patients

PURPOSE

Alopecia is a common side-effect of chemotherapy and affects quality of life of cancer patients. Some patients and physicians believe that alopecia could be a surrogate marker for response to chemotherapy and impact on prognosis. However, this was never been tested in a sufficiently large cohort of ovarian cancer patients.

PATIENTS AND METHODS

We analysed retrospectively the meta-databank of four prospective randomised phase-III-trials with platinum- and taxane-based 1st-line-chemotherapy in patients with advanced epithelial ovarian cancer (EOC) regarding the impact of alopecia overall outcome.

RESULTS

For 4705 (92.0%) of a total of 5114 EOC-patients alopecia was documented. They had received on median six cycle platinum-taxane chemotherapy (range 0-11) with 4186 (89.0%) having completed ⩾ 6 cycles. Worst alopecia grade was 0 in 2.4%, 1 in 2.9% and 2 in 94.7% of the patients. In a univariate analysis, including all patients, grade-0/1 alopecia was associated with significantly lower progression free survival (PFS) and overall survival (OS) compared to grade-2 alopecia. However when assessing only those patients who completed ⩾ 6 chemotherapy-cycles and hence eliminating the bias of lower total dose of treatment, alopecia failed to retain any significant impact on survival in the multivariate analysis. Merely the time point of alopecia onset was an independent prognostic factor of survival: patients who developed grade-2 alopecia up to cycle 3 had a significantly longer OS compared to patients who experienced alopecia later during therapy (hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.04-1.50).

CONCLUSIONS

Within a large EOC-patient cohort with 1st-line platinum- and taxane-based chemotherapy early onset alopecia appears to be significantly associated with a more favourable outcome in those patients who completed ⩾ 6 chemotherapy cycles. It remains to be elucidated if early onset alopecia is just a surrogate marker for higher sensitivity to chemotherapy or if other biological effects are underlying.

Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study

BACKGROUND

The incidence of non-intercepted prescription errors and the risk factors involved, including the impact of computerised order entry (CPOE) systems on such errors, are unknown. Our objective was to determine the incidence, type, severity, and related risk factors of non-intercepted prescription dose errors.

PATIENTS AND METHODS

A prospective, comparative cohort study in two clinical oncology units. One institution used a CPOE system with no connection to the electronic patient record system, while the other used paper-based prescription forms. All standard prescriptions were included and reviewed. Doses were recalculated according to the guidelines of each institution, using the patient data as documented in the patient record, the paper-based prescription form, or the CPOE system. A non-intercepted prescription dose error was defined as ≥10% difference between the administered and the recalculated dose.

RESULTS

Data were collected from 1 November 2012 to 15 January 2013. A total of 5767 prescriptions were evaluated, 2677 from the institution using CPOE and 3090 from the institution with paper-based prescription. Crude analysis showed an overall risk of a prescription dose error of 1.73 per 100 prescriptions. CPOE resulted in 1.60 and paper-based prescription forms in 1.84 errors per 100 prescriptions, i.e. odds ratio (OR) = 0.87 [95% confidence interval (CI) 0.59-1.29, P = 0.49]. Fifteen different types of errors and four potential risk factors were identified. None of the dose errors resulted in the death of the patient.

CONCLUSIONS

Non-intercepted prescribing dose errors occurred in <2% of the prescriptions. The parallel CPOE system did not significantly reduce the overall risk of dose errors, and although it reduced the risk of calculation errors, it introduced other errors. Strategies to prevent future prescription errors could usefully focus on integrated computerised systems that can aid dose calculations and reduce transcription errors between databases.

Bone health in cancer patients: ESMO Clinical Practice Guidelines

There are three distinct areas of cancer management that make bone health in cancer patients of increasing clinical importance. First, bone metastases are common in many solid tumours, notably those arising from the breast, prostate and lung, as well as multiple myeloma, and may cause major morbidity including fractures, severe pain, nerve compression and hypercalcaemia. Through optimum multidisciplinary management of patients with bone metastases, including the use of bone-targeted treatments such as potent bisphosphonates or denosumab, it has been possible to transform the course of advanced cancer for many patients resulting in a major reduction in skeletal complications, reduced bone pain and improved quality of life. Secondly, many of the treatments we use to treat cancer patients have effects on reproductive hormones, which are critical for the maintenance of normal bone remodelling. This endocrine disturbance results in accelerated bone loss and an increased risk of osteoporosis and fractures that can have a significant negative impact on the lives of the rapidly expanding number of long-term cancer survivors. Finally, the bone marrow micro-environment is also intimately involved in the metastatic processes required for cancer dissemination, and there are emerging data showing that, at least in some clinical situations, the use of bone-targeted treatments can reduce metastasis to bone and has potential impact on patient survival.

A randomized, phase III study (AGO-OVAR-9, GINECO-TCG, NSGO-OC-0102): Gemcitabine-paclitaxel-carboplatin (TCG) versus paclitaxel-carboplatin (TC) as first-line treatment of ovarian cancer (OC): Survival of FIGO stage I-IIA patients

LBA5510

Background: One option to increase the efficacy of TC in pts with first diagnosis of ovarian cancer is to add a not cross-resistant drug. Methods: We conducted a randomized, prospective, stratified, phase III study comparing therapy with TC to TC plus gemcitabine. From 7/02 to 4/04, pts with a histological verified first diagnosis of epithelial OC, FIGO IC-IV were randomized to either TC (paclitaxel [T] 175 mg/m2 3h iv d1 + carboplatin [C] AUC 5 iv d1) or TCG (TC + gemcitabine [G] 800 mg/m2 iv d1+8) for at least 6 cycles every 21 days starting within 6 weeks post-operatively. The randomization was balanced within three strata: 1) FIGO I-IIA, 2) FIGO IIB-IIIC with residual tumor ≤ 10mm, 3) FIGO IIB-IIIC with residual tumor > 10 mm or FIGO IV. Primary endpoint is overall survival. Results: We enrolled 1,742 pts and administered 5,268 cycles TC and 5,129 cycles TCG. All baseline characteristics of the patients in both arms were well balanced. Most pts received 6+ cycles (87.2% TC, 86.2% TCG). Previous interim analyses has shown that TCG was tolerable but induced more hematological toxicity and final analysis has shown that addition of gemcitabine did not improve overall survival in patients with FIGO stage IIB-IV disease. Approximately 11% of the patients (n = 175) had FIGO stage I-IIA disease (stratum I). Most patients received 6+ cycles (93.3% TC, 86.9% TCG). With a median follow-up of 53.8 (range 0 –75) months, and using the log rank test and Cox regression analysis, no relevant differences in progression free survival (first quartile about 57 months and median ≥ 75 months in both groups, HR = 0.90 [95% CI: 0.47–1.72], p = 0.7500) and a negative trend in overall survival (first quartile ≥ 75 months in both groups, HR = 2.19 [95% CI: 0.75–6.41], p = 0.1419) were seen. Conclusions: Addition of G to TC did not improve efficacy in patients with stage I-IIA ovarian cancer. This was also the case for stratum II-III patients (previously reported). The addition of G to TC in patients with first diagnosis of ovarian cancer cannot be recommended.

[Table: see text]

A randomized, phase III study (AGO-OVAR-9, GINECO-TCG, NSGO-OC-0102): Gemcitabine-paclitaxel-carboplatin versus paclitaxel-carboplatin as first-line treatment of ovarian cancer (OC): Survival of FIGO stage I-IIA patients

LBA5510

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

[Table: see text]