Duration of disease control (DDC) or time to failure of strategy (TFS) to evaluate a chemotherapy strategy in advanced colorectal cancer (ACC)

4073

Background: Progression-free survival (PFS) is not an optimal endpoint in therapeutic strategies evaluating either stop and go or alternated therapies, or a fixed sequence of two therapies. DDC (Tournigand, JCO 2006) and TFS (Allegra, JCO 2007) composite endpoints have been proposed to evaluate efficacy of these strategies in ACC. This study compared these two alternative endpoints. Methods: DDC is defined as the sum of the PFS of each sequence, except when progressive disease is observed at either reintroduction or second-therapy (DDC=PFS1+PFS2 if treatment 2 achieved stabilization or response). TFS is defined as the total PFS from the initiation of the strategy to disease progression while on all the planned agents, or disease progression during a treatment-free interval and no further therapy received within 1 month, or death (TFS=PFS 1+2). Both DDC and TFS have been calculated in three trials: OPTIMOX1 (oxaliplatin stop and go vs continuous administration, updated database, Tournigand, JCO 2006), OPTIMOX2 (oxaliplatin stop and go vs complete stop and go, updated database, Maindrault-Goebel, ASCO 2007) and C97–3 (FOLFIRI1- FOLFOX6 or reverse sequence, Tournigand 2004). Results: The median potential follow-up time was 39.8 months. There was a moderately shorter DDC than TFS in the two stop and go studies, but a much shorter DDC than TFS in the sequential therapy study. There was a significant correlation between DDC and OS (r=0.96, p=.002) but not between TFS and OS (r=0.71, p=.11) Conclusions: Two bias impacted TFS 1) the results of resuming the planned therapeutic strategy for progression after a chemotherapy-free interval of more than one month was not considered, 2) patients who were not progressive at the end of planned strategy could not be censored at that time. The shorter duration of DDC over TFS may have an advantage in terms of sample size for evaluation of therapeutic strategies. In case of drug registration, DDC does not increase in case of inactive second sequence.

[Table: see text]

No significant financial relationships to disclose.

Survival after surgery in patients with initially resectable metastasis receiving adjuvant/neoadjuvant FOLFOX therapy and in patients who had surgery after FOLFOX therapy

4118

Background: Surgery of metastases can cure approximately 20% of metastatic colorectal cancer (MCRC). About 15% of MCRC pts are resectable at presentation. Among the other pts, 10 to 30% can benefit from a salvage surgery after response to chemotherapy, improving their prognostic. We report here the results in pts resectable at presentation and in pts who underwent surgery after chemotherapy in phase 2 and 3 studies. Methods: We retrospectively analysed 167 pts who underwent R0/R1 surgery, 46 pts at presentation in a phase 2 study testing a combination of FOLFOX followed by FOLFIRI (MIROX, Taieb JCO 2005), and 121 pts who underwent a salvage surgery after FOLFOX treatment in OPTIMOX1 (Tournigand, JCO 2006) and OPTIMOX2 (Maindrault-Goebel, ASCO 2007) after updating the survival. Results: Patients’ baseline characteristics were (MIROX/OPTIMOX %): median age 56/62 yrs, PS 0 50/73, metachronous metastasis 41/21, ≥ 2 met sites 11/18, liver met 78/88, lung met 11/19, other met 17/10, two-stage surgery 9/10, second surgery after relapse 39/22, R0 resection 91/ 85. 114 among 142 evaluable patients had a response to FOLFOX (80%). Median time from randomisation to surgery was 8 mths in the OPTIMOX group. In the MIROX group, 46% had surgery of metastases before chemotherapy. Median disease-free survival from R0/R1 surgery was 18.6 months in MIROX group vs 9.4 months in OPTIMOX group (p=0.006).Median overall survival was 104.8 months in MIROX group vs 42.6 months in OPTIMOX group (p=0.02). Furthermore, initially resectable remained the strongest prognostic factor in this series. Conclusions: MCRC pts initially resectable at presentation have a better prognosis than pts who underwent a salvage surgery after FOLFOX chemotherapy.

No significant financial relationships to disclose.

Definition of oxaliplatin sensitivity in patients with advanced colorectal cancer previously treated with oxaliplatin-based therapy

4024

Background: Oxaliplatin combined with fluoropyrimidines is standard adjuvant therapy in stage III colon cancer and first-line therapy in stage IV colorectal cancer. Oxaliplatin can be reintroduced either at relapse, or after maintenance or after chemotherapy holidays. In this study we defined the sensitivity to oxaliplatin reintroduction based on the oxaliplatin-free interval. Methods: Stage IV pts entered in the OPTIMOX1 and 2 studies (FOLFOX4, FOLFOX7 followed by maintenance without oxaliplatin or chemotherapy holidays) and pts having relapsed after metastases surgery and neoadjuvant or adjuvant FOLFOX for resectable stage IV were eligible if they were rechallenged with FOLFOX. Endpoints were: survival from reintroduction according to interval between the last cycle of oxaliplatin first-line and reintroduction, survival and response at reintroduction according to first FOLFOX response and PFS. Results: 330 pts were included: male 60%, colon/rectum/both 62%/35%/2%, resectable/unresectable: 14%/86%, PS 0–1 / >1: 90%/10%, sites 1/>1: 57%/43%. 23 pts had adjuvant and 22 pts had neoadjuvant chemotherapy. 58 pts (18%) had FOLFOX reintroduction before progression. PFS/OS from reintroduction according to induction FOLFOX response were 8.7/19.5 mths if CR, 4.6/15.2 mths if PR, and 3.2/9.7 mths if SD (P=.0019/.01). PFS/OS from reintroduction according to induction FOLFOX PFS were 2.9/9.3 mths if PFS<6 mths, 4.6/14.7 mths if PFS 6–12 mths and 8.5/23.7 if PFS=12 mths. Table shows results according to intervals. There was no difference between 0–3 and 3–6 mths or 6–9 and 9–12 mths intervals. Conclusions: A prolonged interval between two FOLFOX therapies or a prolonged PFS at first-line FOLFOX predict the efficacy of oxaliplatin reintroduction. The interval between two FOLFOX therapies does not identify a completely refractory population. Resistance (PD rate) is divided by two at each 6 month intervals.

[Table: see text]

No significant financial relationships to disclose.

Chemotherapy-free intervals (CFI) in patients with metastatic colorectal cancer (MRC)

3581

Background: Median survival in patients (pts) with MRC can reach 20 months with chemotherapy and should further improve with combined targeted therapies. CFI should be considered in order to improve quality of life of long survivors. Methods: 197 pts responders or stable with chemotherapy in a single institution benefited from CFI of at least 3 months, for any reason, in a 12 year period (1992–2005). Therapy was rechallenged in case of disease progression. Duration of CFI and overall survival (OS) were analyzed according to therapy and prognostic factors. Results: In 146 pts who had a CFI after a first-line, chemotherapy was 5FU-based in 32 pts, oxaliplatin-based in 103 pts (FOLFOX alone in 64 pts, FOLFOX followed by 5FU in 39 pts), irinotecan-based in 11 pts. In 51 pts who had a CFI after a second-line, chemotherapy was 5FU-based in 6 pts, oxaliplatin-based in 30 pts, irinotecan-based in 15 pts. There was no correlation between therapy duration before CFI and CFI duration, p=.66. Median CFI duration was 29 weeks (wks) in first line and 21 wks in second line, p=.0005. Median therapy duration and CFI were 42 and 26 wks after 5FU-based chemotherapy, 12 and 27 wks after FOLFOX and 36 and 37 wks after FOLFOX followed by 5FU, p=.001 and p=.12, respectively. In first-line, CFI lasted a median of 39 wks in 15 pts in complete response, 29 wks in 61 partial responders and 27 wks in 70 stable pts, p=.33. Among patients who had a CFI after a first-line therapy, those with good prognostic factors (PS 0, normal LDH and alkaline phosphatases <3UNV) experienced a longer CFI and a longer OS than others, median 27 vs 25 wks (p=.025) and 139 vs 108 wks (p=.007), respectively. Conclusions: CFI should be considered especially in good prognosis patients and in first-line therapy. The Optimox 2 study which compares 5FU maintenance therapy and CFI after FOLFOX should further evaluate CFI.

[Table: see text]

Surgery of colorectal metastasis in the Optimox 1 study. A GERCOR Study

3522

Background: Surgery of metastasis can cure arround 20% of metastatic colorectal cancer (MCRC) patients. The Optimox 1 study achieved a response rate over 50% with FOLFOX therapy in patients (pts) with initially unresectable metastasis which allowed to perform surgery in a significant number of pts (JCO 2006). We report here the results in pts who underwent surgery of metastasis (met). Methods: From jan 2000 to june 2002, 620 previously untreated patients with unresectable metastasis were randomized between FOLFOX4 every two weeks until progression (arm A), or FOLFOX7 for 6 cycles, maintenance without oxaliplatin for 12 cycles and reintroduction of FOLFOX7 (arm B). 101 pts were resected with a curative intent, 57 in arm A and 45 in arm B. Results: Patients characteristics were (arm A/B %): metachronous metastasis 77/51, liver met 82/91, lung met 16/11, other met 7/4, PAL < 3 ULN: 98/97, normal LDH: 52/51. 8% of pts achieved a complete response, 72% a partial response, 16% a stable disease. 89 pts had a single resection, 12 had a two-stage surgery. One patient died in arm B. Eleven pts who relapsed had a second surgery. Resection was radical (R0) for 71 pts (43 in arm A and 28 in arm B), 15 were R1 (margin invasion) and 15 were R2. R0/R1 patients had a median overall survival (OS) of 51 mo in arm A and 38 mo in arm B. Median disease-free survival (DFS) since surgery was 12 mo in arm A and 9 mo in arm B, with no statistical difference. 32% of R0/R1 pts were alive with no progression at 3 years in arm A and 20% in arm B. Median time from randomization to surgery was 8 mo. No difference was found between patients resected before 8 mo (n = 50) and after (n = 37) in OS (39 vs 45 mo, p = .67) nor in DFS (11.6 vs 9.5 mo, p = .24). Neither in pts resected before and after 6 mo in OS (p = .77) and DFS (p = .44). Conclusions: FOLFOX treatment allowed 14 % of unresectable patients to be rescued by surgery. There was no additional benefit to perform surgery after 6 months of therapy compared to early surgery.

[Table: see text]

[Low bone mineral density in children with Crohn's disease]

Recent studies have reported low bone mineral density in children with Crohn's disease. The aims of this retrospective study were to quantify its frequency and to search for risk factors.

POPULATION AND METHODS

Bone mineral density of 29 children with Crohn's disease was measured by dual-energy X-ray absorptiometry. All the children were taking calcium and vitamin D, during all the follow-up.

RESULTS

Osteoporosis (Z-score < or = -2.5 S.D.) was found in 38% of the children, and osteopenia in 38% (Z-score between -1 and -2.5 S.D.). Low bone mineral density was correlated with age, suggesting it begins with puberty. Daily corticosteroid exposure was significantly higher for patients with osteoporosis. Disease severity measured with Harvey-Bradshaw index and exposure to immunosuppressive drugs were almost statistically significant. Sex, height, duration and site of disease, nutritional assistance exposure were not associated with low bone mineral density.

CONCLUSION

This study confirms the high frequency of low bone mineral density in children with Crohn's disease, mainly during puberty. Corticosteroid exposure is a risk factor, and the disease severity, a probable one (non significant). New treatment strategy has to be defined to prevent and to treat this complication.

[Vascular risk and menopause: role of hormone replacement therapy]

RATIONALE

Menopause dramatically increases cardiovascular risk in women who lack the protecting effects of estrogens. This emphasizes the importance of hormone replacement therapy (HRT) which, until recently, was considered beneficial in spite of the heterogeneous nature of clinical studies. Such a benefit was supposed to result from the favorable effects of estrogens, including lipid lowering and a complex vasodilating action including the improvement of vascular endothelial function.

RATIONALE REVISITED

The results of the HERS study have however questioned these affirmations because of the lack of clinical benefit due to HRT in secondary prevention of coronary artery disease in postmenopausal women, with an increased vascular risk during the first year of treatment. In clinical practice, it is not recommended to start HRT after a cardiac attack.

PRACTICAL ATTITUDE

In fact, the HERS study used a conjugated equine estrogen and progestin (with possible deleterious effects) and cannot be compared to French prescription habits which are based on the use of natural hormones. However, it remains to be demonstrated that some HRT regimens, in particular those using progesterone, may provide a real benefit in terms of lower cardiovascular morbidity-mortality.