Real-world evidence of the management and prognosis of young women (⩽40 years) with de novo metastatic breast cancer

Background:

Breast cancer (BC) in young women merits a specific approach given the associated fertility, genetic and psychosocial issues. De novo metastatic breast cancer (MBC) in young women is an even more serious condition, with limited data available.

Methods:

We evaluated management of women aged ⩽40 years with de novo MBC in a real-life national multicentre cohort of 22,463 patients treated between 2008 and 2016 (NCT0327531). Our primary objective was to compare overall survival (OS) in young women versus women aged 41–69 years. The secondary objectives were to compare first-line progression-free survival (PFS1) and to describe treatment patterns.

Results:

Of the 4524 women included, 598 (13%) were ⩽40 years. Median age at MBC diagnosis was 36 years (range = 20–40). Compared with women aged 41–69 years, young women had more grade III tumours (49% versus 35.7%, p < 0.0001), human epidermal growth factor receptor 2 amplified (HER2+) disease (34.6% versus 26.4%, p < 0.0001) and HR–/HER2– disease known as “triple negative breast cancer” (TNBC) (17.1% versus 12.7%, p < 0.0001). BRCA testing was performed for 260 young women, with a BRCA1/2 mutation in 44 (17% of those tested) In young HR+/HER2– patients, chemotherapy (CT) was given as the frontline treatment more frequently compared with older ones (89.6% versus 68.8%, respectively, p < 0.0001). After median follow-up of 49.7 months (95% confidence interval, CI = 48.0–51.7), the median OS of young women was 58.5 months, 20.7 months and not attained in HR+/HER2–, TNBC and HER2+ subgroups, respectively. After adjustment for histological subtype, tumour grade, and number and type of metastasis, young women had significantly better OS compared with older ones, except for the TNBC subgroup, for which the outcome was similar. PFS1 was statistically different only in the TNBC subgroup, with 7.8 months for young women and 6.3 months for older women ( p = 0.0015).

Conclusion:

De novo MBC affects a significant proportion of young women. A subgroup of these patients achieves long OS and merits multidisciplinary care.

Factors associated with non-completion of radiation therapy (RT) or radiochemotherapy (RTCT) in head and neck squamous cell carcinoma (HNSCC): A prospective study

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Background: Although numerous factors have been reported to increase RT/RTCT toxicity, identification of patients with high risk of toxicities is lacking. Methods: The monocentric NutriNeck study (NCT02900963) recruited all HNSCC patients between 2014 and 2018 treated by RT or RTCT. Patients fed by enteral nutrition before RT initiation were excluded. All clinical and biological, planned RT or RTCT parameters were collected at baseline. A daily monitoring of the weight and a weekly evaluation of clinical, biological and food intake during RT/RTCT were performed. A nutritional intervention by enteral feeding was systematically proposed in case of 2 kg weight loss under treatment. Complete treatment was defined as full planned RT doses without more than 3 days interruption, and full planned doses of cisplatin and cetuximab if indicated. Primary endpoint assessed factors associated with non-completion of the planned treatment. Secondary endpoint assessed factors associated with use of enteral nutrition during treatment. A p value < 0.01 was considered significant. Results: Among the 249 HNSCC patients included, 118 (47%) were treated by RT and 131 (53%) by RTCT. 63 patients (25%) did not complete treatment: 3/118 (2.5%) in the RT group compared to 60/131 (45.8%) the RTCT group, p < 0.0001. Median weight lost during treatment (7 vs 3.8 kg, p < 0.0001) and grade 3 toxicities (53 vs 33%, p = 0.006) were more frequent in patients with incomplete RT/RTCT. Nutritional intervention was performed in 111 patients: 28 (23.7%) with RT and 83 (62.6%) with RTCT (p < 0.0001). Week 4 was associated with the higher rate of enteral nutrition initiation in both RT and RTCT groups. Among RTCT group, weight loss during treatment (OR 1.2 for each kg, p < 0.0001) and use of enteral feeding (OR 2.7, p = 0.005) were associated with incomplete treatment in multivariate analysis. Of note, 48 patients refused enteral nutrition while indicated, they had comparable grade 3 toxicities and weight loss during treatment compared to the 111 patients who accepted enteral nutrition. Conclusions: Incomplete treatment is overwhelmingly associated with RTCT rather than RT. Baseline clinical, biological features or treatment volume/dose are not associated with incomplete treatment. Enteral nutrition initiated during treatment is poorly efficient.

Hypertension, proteinuria, and overall survival in elderly cancer patients treated with bevacizumab

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Background: MARS is a multicentric, non-interventional, prospective study which first reported the high prevalence of both baseline and de novo hypertension (HTN) and proteinuria (Pu) in several sub group of cancer patients [Gligorov J et al. SABCS 2013; Ray-Coquard I et al. ASCO GI 2014; Ray-Coquard I et al. ASCO GU 2014; Goldwasser F et al. ECC 2013; Launay-Vacher V et al. ASCO 2013]. In this sub-group analysis, we focused on elderly cancer (EC) patients treated by bevacizumab. Methods: MARS included 1,124 patients, all naïve of any previous anti-VEGF treatment. A First Renal Assessment was performed at baseline before the anti-VEGF was started with periodic follow-up for 1 year. Elderly was defined as age ≥65 years at inclusion. Univariate (UA) and multivariate analyses (MA) tested the associations of HTN and Pu, at baseline or de novo, with overall survival (OS) (pre-planned) in EC patients. Results: 845 patients treated with bevacizumab were included. Among them 226 were EC patients (colorectal 81, breast 78, ovarian 26, lung 22). At inclusion, HTA was statistically higher in EC patients (table), mean aMDRD was 79.6 ml/min/1.73m2 and 15.1% had aMDRD<60. De novo HTA; de novo Pu and Scr increase were not statistically more frequent in EC patients than in non-EC patients. In addition, renal function decreased by -4.1 ml/min/1.73m²/year and 16.2% had aMDRD<60 at the end of follow-up. Baseline and de novoHTN and Pu were not associated with reduced OS in EC patients in both UA and MA analyses. Conclusions: There were no differences in term of renovascular safety in EC patients treated by bevacizumab. Furthermore, HTN and Pu were not associated with OS in EC patients treated by bevacizumab. Therefore, renovascular events should not be contraindicated at the initiation of the treatment or when the patient is already on treatment. [Table: see text]

Results of the MARS study on the management of antiangiogenics’ renovascular safety in renal cell carcinoma

394

Background: MARS is a prospective multicentric study conducted to assess the renovascular tolerance of anti-VEGF drugs (AVD) in the clinical setting in France, in a number of different tumor types. Methods: Patients (pts) from 8 centres were included when they were 1) naïve of any AVD and 2) about to start treatment with an AVD, from 2009 to 2012, with a follow-up (f/u) of 1 year. Data collected included: gender, age, serum creatinine (SCr), HTN, hematuria (Hu) and dipstick Pu, at baseline and at each visit during f/u. This sub-group analysis presents the results for renal cell carcinoma (RCC) pts receiving sunitinib. Results: 1,124 pts were included. 137 had RCC and 112 received sunitinib. Median age: 61.0 years. Visceral, bone and cerebral metastasis frequencies were 71.4, 42.0 and 12.5%, respectively. All except 3 pts, had at least one kind of metastasis. At inclusion, HTN prevalence was 43.8%. Baseline renal assessment retrieved: Pu 15.6%, Hu 8.1%, mean aMDRD 69.4 ml/min/1.73m2. The incidence of de novo Pu and HTN during f/u was 75.0 and 21.4% (Table). All pts with Pu at inclusion improved or remained stable. Among pts with de novo Pu, 75.8% afterwards improved/normalized. Mean aMDRD was 72.2 at the end of f/u. 0.7% had grade 3 SCr increase (no grade 4). No thrombotic micro-angiopathy (TMA) was reported. Conclusions: These results on the renovascular safety of AVD in RCC patients showed that 1) TMA is rare, 2) Pu develops in 75.0% of the pts, 3) 21.4% developed HTN, Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred. [Table: see text]

Results of the MARS study on the management of antiangiogenics’ renovascular safety in colorectal cancer

466

Background: MARS is a prospective multicentric study conducted to assess the renovascular tolerance of anti-VEGF drugs (AVD) in the clinical setting in France, in a number of different tumor types. Methods: Patients (pts) from 8 centers were included when they were 1) naive of any AVD and 2) about to start treatment with an AVD, from 2009 to 2012, with a follow-up (f/u) of 1 year. Data collected included: gender, age, serum creatinine (SCr), HTN, hematuria (Hu) and dipstick Pu, at baseline and at each visit during f/u. This subgroup analysis presents the results for colorectal cancer (CRC) pts receiving bevacizumab (BVZ). Results: 1,124 pts were included. 200 had CRC and all but 5 received BVZ. Median age: 63.2 years. Visceral, bone, and cerebral metastasis frequencies were 91.3, 10.8, and 0.5%, respectively. All pts presented metastasis. At inclusion, HTN prevalence was 26.2%. Baseline renal assessment retrieved: Pu 30.6%, Hu 10.1%, mean aMDRD 91.1 ml/min/1.73m2. The incidence of de novo Pu and HTN during f/u was 78.2 and 16.1% (Table). 75.6% of pts with Pu at inclusion improved or remained stable. Among pts with de novo Pu, 60.8% afterward improved/normalized. No grade 4 Pu has been reported (at inclusion or during f/u). Renal function decreased with a mean aMDRD of 90.3 at the end of f/u. 5.9% had grade 2 SCr increase (no grade 3-4). No thrombotic micro-angiopathy (TMA) was reported. Conclusions: These results on the renovascular safety of BVZ in CC patients showed that 1) TMA is rare, 2) Pu develops in 78.2% of the pts (no grade 4), 3) 16.1% developed HTN. Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred. [Table: see text]

Results of the MARS study on the management of antiangiogenics’ renovascular safety in ovarian cancer

5567

Background: Anti-VEGF drugs (AVD) are widely used in cancer patients (pts). Hypertension (HTN) and proteinuria (Pu) are class-side-effects of AVD, related to the inhibition of the VEGF pathway. The MARS study has been conducted to assess the renovascular tolerance of these drugs in the clinical setting. Methods: This multicentric, prospective, observational study evaluated the renovascular safety of AVD in pts naive from any AVD, conducted in 7 centres in France, from 2009 to 2012, with a follow-up (f/u) of 1 year. Data collected included: gender, age, serum creatinine (SCr), HTN, hematuria (Hu) and dipstick Pu, at baseline and at each visit. Results: 1,124 pts were included. 79 pts had ovarian cancer (OC) and all received bevacizumab. Median age at inclusion was 61 years. Visceral, bone and cerebral metastasis frequencies were 74.1, 52.7 and 6.0%, respectively. HTN prevalence was 16.5%. Baseline renal assessment retrieved: Pu 36.0%, Hu 21.3%, mean aMDRD 83.0 ml/min/1.73m2 and 5 pts with aMDRD<60. The incidence of de novo Pu and HTA during f/u was 56.8 and 21.2% (Table). 88.9 % of pts with Pu at inclusion improved or remained stable. Among pts with de novo Pu, 64.0% afterwards improved/normalized. No Grade 4 Pu has been reported (at inclusion or during f/u). Renal function remained stable with a mean aMDRD of 83.2 at the end of f/u. 6.0% had grade 2 SCr increase (no grade 3-4). No thrombotic micro-angiopathy (TMA) was reported. Conclusions: These results on the renovascular safety of bevacizumab in OC patients showed that 1) TMA is rare, 2) Pu develops in 56.8% of the pts, however with only 1 Grade 3/4, 3) 21.2% developed HTN, and 4) aMDRD was stable. Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred. [Table: see text]

Results of the MARS study on the management of antiangiogenics’ renovascular safety in breast cancer

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Background: Anti-VEGF drugs (AVD) are widely used in cancer patients (pts). Hypertension (HTN) and proteinuria (Pu) are class-side-effects of AVD, related to the inhibition of the VEGF pathway. The MARS study has been conducted to assess the renovascular tolerance of these drugs in the clinical setting. Methods: This multicentric, prospective, observational study evaluated the renovascular safety of AVD in pts naive from any AVD, conducted in 7 centres in France, from 2009 to 2012, with a follow-up (f/u) of 1 year. Data collected included: gender, age, serum creatinine (SCr), diabetes, HTN, hematuria (Hu) and dipstick Pu, at baseline and at each visit. Results: 1,124 pts were included; 402 breast cancer (BC) pts received bevacizumab. Median age at inclusion was 55 years. Visceral, bone and cerebral metastasis frequencies were 74.7, 5.1 and 2.5%, respectively. HTN prevalences: 12.4%. Baseline renal assessment retrieved: Pu 23.9%, Hu 16.2%, mean aMDRD 96.4 ml/min/1.73m2 and 14 pts with aMDRD<60. The incidence of de novo Pu and HTN during f/u was 61.7 and 16.8% (Table). 69.7 % of pts with Pu at inclusion improved or remained stable. Among pts with de novo Pu, 75.7% afterwards improved/normalized. No grade 4 Pu has been reported. Renal function remained stable with a mean aMDRD of 96.2 at the end of f/u. 7.4% had grade 2-3 SCr increase (no grade 3-4). No thrombotic micro-angiopathy (TMA) was reported. Conclusions: These results on the renovascular safety of bevacizumab in BC patients showed that 1) TMA is rare, 2) Grade 3 Pu developed in 4.6% of pts, with no grade 4, 3) less than 17% developed HTN, and 4) aMDRD was stable. Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred. [Table: see text]

Management of antiangiogenics’ renovascular safety in ovarian cancer subgroup and intermediate results of the MARS study

5067

Background: Anti-VEGF drugs (AVD) are widely used in cancer patients (pts). Hypertension (HTN) and proteinuria (Pu) are class-side-effects of AVD, related to the inhibition of the VEGF pathway. The MARS study has been conducted to assess the renovascular tolerance of these drugs in the clinical setting. Methods: Hypertension (HTN) and proteinuria (Pu) are class-side-effects of anti-VEGF drugs (AVD), related to the inhibition of the VEGF pathway. The MARS study has been conducted to assess the renovascular tolerance of these drugs in the clinical setting. Results: Among 77 OC pts been included, 38 completed the study to date (1-year follow-up (f/u)). Median age at inclusion (introduction of the AVD) was 62 years. Diabetes and HTN prevalences were 5.2% and 7.9%, respectively. Baseline renal assessment retrieved: Pu 13.2%, Hu 7.9%, mean aMDRD 80.9 ml/min/1.73m2 and 3 pts with aMDRD<60. The incidence of de novo Pu during f/u was 36.4% (Table). All pts with Pu at inclusion improved, except one. Among pts with de novo Pu, 58.3% afterwards improved/normalized. No Grade 3/4 Pu has been reported (at inclusion or during f/u) and no Hu. 17.1% developed HTN. In addition, a mean renal function decrease of -2.7 ml/min/1.73m2/year was observed and 4 pts had aMDRD<60 at the end of f/u. 36.4% had grade 1 SCr increase (median increase of 15.9%) No thrombotic micro-angiopathy (TMA) has been reported. Conclusions: The results of the MARS subgroup of OC pts shows that 1) TMA remains rare, 2) Pu develops in 36.4% of the pts, however with no Grade 3/4, 3) less than 20% developed HTN, and 4) renal function was not especially impaired. Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM et Al. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred. [Table: see text]

Management of antiangiogenics’ renovascular safety in breast cancer subgroup and intermediate results of the MARS study

1095

Background: Hypertension (HTN) and proteinuria (Pu) are class-side-effects of anti-VEGF drugs (AVD), related to the inhibition of the VEGF pathway. The MARS study has been conducted to assess the renovascular tolerance of AVD in the clinical setting. Methods: The MARS study is a multicentric prospective observational study of the renovascular safety of AVD in AVD-naive pts. 7 centres from 2009 to 2011. Data collected included: gender, age, serum creatinine (SCr), diabetes, HTN, hematuria (Hu) and Pu. This sub-group analysis presents the intermediate results for the 1st 155 pts with breast cancer (BC) receiving bevacizumab who completed the 1-year follow-up (f/u) (out of 337 BC pts in total). Results: Median age at inclusion: 62 years. Bone, visceral and cerebral metastasis frequencies were 74.2, 51.6 and 5.2%, respectively. Diabetes and HTN prevalences were 3.9% and 10.3%, respectively. Baseline renal assessment retrieved: Pu 14.2%, Hu 8.4%, aMDRD 98.2 ml/min/1.73m2 and 2 pts with aMDRD<60. The incidence of de novo Pu during f/u was 15% (Table). 59.1% of pts with Pu at inclusion improved. Among pts with de novo Pu, 40.0% afterwards improved/normalized. No grade 3/4 Pu has been reported and no hematuria. 12.9% developed HTN. Moreover, renal function decreased by -3.2 ml/min/1.73m2/year and 4 pts had aMDRD<60 at the end of f/u. 32.2% increased their SCr: 27.1% grade 1, 4.5% grade 2, and 0.6% grade 3. All pts with grade 2-3 returned to normal or grade 1. No thrombotic micro-angiopathy (TMA) has been reported. Conclusions: These results show that 1) TMA remains rare, 2) Pu developed in 15% of pts, with no grade 3/4, 3) less than 13% developed HTN and 4) renal function was only slightly impaired with transient elevations in SCr. Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred. [Table: see text]