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Hoffmann MS, Hunter BD, Cobb PW, Varela JC, Munoz J. Overcoming Barriers to Referral for Chimeric Antigen Receptor T-Cell Therapy in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma. Transplant Cell Ther 2023:S2666-6367(23)01234-4. [PMID: 37031747 DOI: 10.1016/j.jtct.2023.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/18/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin lymphoma. Although outcomes to frontline therapy are encouraging, patients who are refractory to or relapse after first-line therapy experience inferior outcomes. A significant proportion of patients treated with additional lines of cytotoxic chemotherapy ultimately succumb to their disease as established in the SCHOLAR-1 study. CHIMERIC ANTIGEN RECEPTOR (CAR)-T CELL THERAPY CAR-T cell therapy is a novel approach to cancer management that reprograms a patient's own T cells to better target and eliminate cancer cells. It was initially approved by the US Food and Drug Administration (FDA) for patients with relapsed/refractory (r/r) DLBCL in the third line of treatment. Based on recently published randomized data, CAR-T cell therapy (axicabtagene ciloleucel and lisocabtagene maraleucel) has also been approved in the second line of treatment for patients who are primary refractory or relapse within 12 months of initiation of first-line therapy. Despite the proven efficacy in treating r/r DLBCL with cluster of differentiation (CD)19-directed CAR-T cell therapy, several barriers exist that may prevent eligible patients from receiving treatment. KEY BARRIERS TO CAR-T CELL TREATMENT Barriers to treatment include cost of therapy, patient hesitancy, required travel to academic treatment centers, nonreferrals, lack of understanding of CAR-T cell therapy, lack of caregiver support, knowledge of resources available, and timely patient selection by referring oncologists. CONCLUSION In this review, an overview of the FDA-approved CD19-directed CAR-T cell therapies (tisagenlecleucel, axicabtagene ciloleucel, and lisocabtagene maraleucel) is provided from pivotal clinical trials and supporting real-world evidence from retrospective studies. In both clinical trials and real-world settings CAR-T cell therapy has been shown to be safe and efficacious for treating patients with r/r DLBCL. However, several barriers prevent eligible patients from accessing these therapies. Barriers to referrals for CAR-T cell therapy are presented with recommendations to improve collaboration between community oncologists and physicians from CAR-T cell therapy treatment centers and subsequent long-term care of patients in community treatment centers.
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Affiliation(s)
- Marc S Hoffmann
- University of Kansas Cancer Center, Division of Hematologic Malignancies and Cellular Therapeutics, Westwood, KS
| | - Bradley D Hunter
- Blood and Marrow Transplantation, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | | | - Juan C Varela
- Blood and Marrow Transplant Program, AdventHealth Hospital, Orlando, FL; Beth Israel Deaconess Medical Center, Dana Farber/Harvard Cancer Center, Boston, MA
| | - Javier Munoz
- Department of Hematology, Mayo Clinic, Phoenix, AZ.
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Powles T, Tomczak P, Park SH, Venugopal B, Ferguson T, Symeonides SN, Hajek J, Gurney H, Chang YH, Lee JL, Sarwar N, Thiery-Vuillemin A, Gross-Goupil M, Mahave M, Haas NB, Sawrycki P, Burgents JE, Xu L, Imai K, Quinn DI, Choueiri TK, Choueiri T, Park SH, Venugopal B, Ferguson TR, Hajek J, Lin TP, Symeonides SN, Lee JL, Sawrycki P, Haas NB, Gurney HP, Mahave M, Sarwar N, Thiery-Vuillemin A, Gross-Goupil M, Chevreau C, Burke JM, Doshi G, Melichar B, Topart D, Oudard S, Kopyltsov E, Hammers HJ, Quinn DI, Alva A, Menezes JDJ, Silva AGE, Winquist EW, Hamzaj A, Procopio G, Karaszewska B, Nowakowska-Zajdel EM, Alekseev BY, Gafanov RA, Izmailov A, Semenov A, Afanasyev SG, Lipatov ON, Powles TB, Srinivas S, McDermott D, Kochuparambil ST, Davis ID, Peltola K, Sabbatini R, Chung J, Shkolnik MI, Matveev VB, Gajate Borau P, McCune S, Hutson TE, Dri A, Sales SC, Yeung C, Alcala Castro CM, Bostrom P, Laguerre B, Buttigliero C, de Giorgi U, Fomin EA, Zakharia Y, Hwang C, Singer EA, Yorio JT, Waterhouse D, Kowalyszyn RD, Alfie MS, Yanez Ruiz E, Buchler T, Kankaanranta K, Ferretti G, Kimura G, Nishimura K, Masumori N, Tamada S, Kato H, Kitamura H, Danielewicz I, Wojcik-Tomaszewska J, Sala Gonzalez N, Chiu KY, Atkins MB, Heath E, Rojas-Uribe GA, Gonzalez Fernandez ME, Feyerabend S, Pignata S, Numakura K, Cybulska Stopa B, Zukov R, Climent Duran MA, Maroto Rey PJ, Montesa Pino A, Chang CH, Vengalil S, Waddell TS, Cobb PW, Hauke R, Anderson DM, Sarantopoulos J, Gourdin T, Zhang T, Jayram G, Fein LE, Harris C, Beato PMM, Flores F, Estay A, Rubiano JA, Bedke J, Hauser S, Neisius A, Busch J, Anai S, Tsunemori H, Sawka D, Sikora-Kupis B, Arranz JA, Delgado I, Chen CH, Gunderson E, Tykodi S, Koletsky A, Chen K, Agrawal M, Kaen DL, Sade JP, Tatangelo MD, Parnis F, Barbosa FM, Faucher G, Iqbal N, Marceau D, Paradis JB, Hanna N, Acevedo A, Ibanez C, Villanueva L, Galaz PP, Durango IC, Manneh R, Kral Z, Holeckova P, Hakkarainen H, Ronkainen H, Abadie-Lacourtoisie S, Tartas S, Goebell PJ, Grimm MO, Hoefner T, Wirth M, Panic A, Schultze-Seemann W, Yokomizo A, Mizuno R, Uemura H, Eto M, Tsujihata M, Matsukawa Y, Murakami Y, Kim M, Hamberg P, Marczewska-Skrodzka M, Szczylik C, Humphreys AC, Jiang P, Kumar B, Lu G, Desai A, Karam JA, Keogh G, Fleming M, Zarba JJ, Leiva VE, Mendez GA, Harris SJ, Brown SJ, Antonio Junior JN, Costamilan RDC, Rocha RO, Muniz D, Brust L, Lalani AK, Graham J, Levesque M, Orlandi F, Kotasek R, Deville JL, Borchiellini D, Merseburger A, Rink M, Roos F, McDermott R, Oyama M, Yamamoto Y, Tomita Y, Miura Y, Ioritani N, Westgeest H, Kubiatowski T, Bal W, Girones Sarrio R, Rowe J, Prow DM, Senecal F, Hashemi-Sadraei N, Cole SW, Kendall SD, Richards DA, Schnadig ID, Gupta M. Pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for clear cell renal cell carcinoma (KEYNOTE-564): 30-month follow-up analysis of a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol 2022; 23:1133-1144. [PMID: 36055304 DOI: 10.1016/s1470-2045(22)00487-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/08/2022] [Accepted: 07/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The first interim analysis of the KEYNOTE-564 study showed improved disease-free survival with adjuvant pembrolizumab compared with placebo after surgery in patients with clear cell renal cell carcinoma at an increased risk of recurrence. The analysis reported here, with an additional 6 months of follow-up, was designed to assess longer-term efficacy and safety of pembrolizumab versus placebo, as well as additional secondary and exploratory endpoints. METHODS In the multicentre, randomised, double-blind, placebo-controlled, phase 3 KEYNOTE-564 trial, adults aged 18 years or older with clear cell renal cell carcinoma with an increased risk of recurrence were enrolled at 213 hospitals and cancer centres in North America, South America, Europe, Asia, and Australia. Eligible participants had an Eastern Cooperative Oncology Group performance status of 0 or 1, had undergone nephrectomy 12 weeks or less before randomisation, and had not received previous systemic therapy for advanced renal cell carcinoma. Participants were randomly assigned (1:1) via central permuted block randomisation (block size of four) to receive pembrolizumab 200 mg or placebo intravenously every 3 weeks for up to 17 cycles. Randomisation was stratified by metastatic disease status (M0 vs M1), and the M0 group was further stratified by ECOG performance status and geographical region. All participants and investigators involved in study treatment administration were masked to the treatment group assignment. The primary endpoint was disease-free survival by investigator assessment in the intention-to-treat population (all participants randomly assigned to a treatment). Safety was assessed in the safety population, comprising all participants who received at least one dose of pembrolizumab or placebo. As the primary endpoint was met at the first interim analysis, updated data are reported without p values. This study is ongoing, but no longer recruiting, and is registered with ClinicalTrials.gov, NCT03142334. FINDINGS Between June 30, 2017, and Sept 20, 2019, 994 participants were assigned to receive pembrolizumab (n=496) or placebo (n=498). Median follow-up, defined as the time from randomisation to data cutoff (June 14, 2021), was 30·1 months (IQR 25·7-36·7). Disease-free survival was better with pembrolizumab compared with placebo (HR 0·63 [95% CI 0·50-0·80]). Median disease-free survival was not reached in either group. The most common all-cause grade 3-4 adverse events were hypertension (in 14 [3%] of 496 participants) and increased alanine aminotransferase (in 11 [2%]) in the pembrolizumab group, and hypertension (in 13 [3%] of 498 participants) in the placebo group. Serious adverse events attributed to study treatment occurred in 59 (12%) participants in the pembrolizumab group and one (<1%) participant in the placebo group. No deaths were attributed to pembrolizumab. INTERPRETATION Updated results from KEYNOTE-564 support the use of adjuvant pembrolizumab monotherapy as a standard of care for participants with renal cell carcinoma with an increased risk of recurrence after nephrectomy. FUNDING Merck Sharp & Dohme LLC, a subsidiary of Merck & Co, Inc, Rahway, NJ, USA.
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Affiliation(s)
- Thomas Powles
- Royal Free Hospital NHS Foundation Trust, University College London, London, UK; Barts Cancer Institute, Experimental Cancer Medicine Centre, Queen Mary University of London, St Bartholomew's Hospital, London, UK.
| | - Piotr Tomczak
- Poznań University of Medical Sciences, Poznań, Poland
| | - Se Hoon Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Balaji Venugopal
- Beatson West of Scotland Cancer Centre, Glasgow, UK; Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | - Stefan N Symeonides
- Cancer Research UK Edinburgh Centre, Edinburgh, UK; Edinburgh Cancer Centre, Edinburgh, UK; Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | - Howard Gurney
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, Australia
| | | | - Jae Lyun Lee
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | | | | | | | - Piotr Sawrycki
- Wojewódzki Szpital Zespolony im L Rydygiera w Toruniu, Torun, Poland
| | | | - Lei Xu
- Merck & Co, Inc, Rahway, NJ, USA
| | | | - David I Quinn
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
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Harb WA, Origuchi M, Cobb PW, Wise-Draper T, Suginobe N, Nakamura M, Goto M, Chen A, Li J, Wade J. Abstract CT135: Preliminary safety and efficacy of DSP-7888 plus nivolumab (NIV) or pembrolizumab (PEM) in patients (pts) with advanced solid tumors (ASTs): A phase (Ph) 1b/2 open-label study. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-ct135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: DSP-7888—an investigational immunotherapeutic cancer vaccine derived from Wilms’ tumor 1 (WT1)—induced WT1-reactive T cells, the activity of which was maintained and enhanced by anti-PD-1 mAbs (preclinical; Goto, et al. ASH 2016). Results from the Ph 1b dose search cohort of a Ph 1b/2 study of DSP-7888 + immune checkpoint inhibitors (ICIs) NIV or PEM in ASTs (NCT03311334) are presented.
Methods: Pts (aged ≥18 y; ECOG PS 0-1; locally advanced/metastatic solid tumors; approved for NIV or PEM) received intradermal (ID) DSP-7888 10.5 mg once weekly (wk) (Q1W) + NIV 240 mg IV Q2W for 4 (Arm 1) or PEM 200 mg IV Q3W for 6 (Arm 2) wks (induction), then DSP-7888 + NIV (Q2W; Arm 1) or PEM (Q3W; Arm 2) (maintenance). A DSP-7888 3.5-mg dose cohort would open if dose limiting toxicities (DLTs) occured in >1 of 6 pts. Primary objectives: evaluate safety (including DLTs) and identify the recommended Ph 2 dose of DSP-7888 + NIV or PEM.
Results: At data cutoff (March 30, 2021), 13 pts (mean age 63.8 [range 38-82] y; 61.5% male; median 3 (1-5) lines of prior therapy; 84.6% prior ICIs) were enrolled and treated with DSP-7888 10.5 mg + NIV (Arm 1, n=7) or PEM (Arm 2, n=6). Treatment-emergent adverse events (TEAEs) were reported in 100% (any grade) and 76.9% (grade ≥3; most commonly injection site reactions [ISR; 30.8%]) of pts (Table). No DLTs occurred during the evaluation period (NIV, 4 wk; PEM, 6 wk), establishing 10.5 mg as the recommended dose for DSP-7888 + NIV or PEM. Serious AEs were reported in 7 (53.8%) pts (2 [15.4%] related to DSP-7888). At efficacy data cutoff (May 4, 2020), 2 (15.4%) pts with prior ICIs achieved partial response, which lasted 9.5 and 5.5+ months; 6 pts achieved stable disease (n=4 ≥8 months) and 3 had progressive disease.
Conclusions: DSP-7888 + NIV or PEM was generally tolerable at 10.5 mg ID (most common TEAE was ISR) and showed evidence of preliminary antitumor activity. An expansion cohort in ovarian cancer is enrolling.
Table. Safety and Efficacy (N=13a) DSP-7888 + NIV (n=7) DSP-7888 + PEM (n=6) Overall (N=13) Patient characteristics Prior lines of therapy, n (%) -1 0 1 (16.7) 1 (7.7) -2 2 (28.6) 1 (16.7) 3 (23.1) -≥3 5 (71.4) 4 (66.7) 9 (69.2) Prior ICI, n (%) 7 (100) 4 (66.7) 11 (84.6) Safety All patients with TEAE grade ≥3, n (%)b — — 10 (76.9) TEAEs grade ≥3 (in ≥2 patients), n (%)b -Injection site reaction — — 4 (30.8) Pts with treatment-emergent SAEs, any grade, n (%)b — — 7 (53.8) Efficacy ORR (CR+PR), n (%) [95% CI] 2 (28.6) [3.7, 71.0] 0 2 (15.4) [1.9, 45.5] Best overall response, n (%) -PRc 2 (28.6) 0 2 (16.7) -SD 3 (42.9) 3 (50.0) 6 (46.2) -PD 0 3 (50.0) 3 (23.1) -Non-CR/Non-PD 1 (14.3) 0 1 (7.7) -NE 1 (14.3) 0 1 (7.7) Disease control rate (CR+PR+SD+Non-CR/Non-PD), n (%) [95% CI] 6 (85.7) [42.1, 99.6] 3 (50.0) [11.8, 88.2] 9 (69.2) [38.6, 90.9] aTumor types included non-small cell lung cancer (n=7), urothelial cancer (n=3), gastroesophageal junction adenocarcinoma (n=1), head and neck squamous cell carcinoma (n=1), and renal cell carcinoma (n=1). For inclusion, patients either progressed on their prior treatment or were being treated with NIV or PEM, achieved at least SD, and could benefit from the addition of DSP-7888 (physician’s judgement). bRegardless of causality. cOf the patients that exhibited a PR, 1 had renal cell carcinoma and 1 had urothelial cancer. Both patients were previously treated with an ICI (NIV and atezolizumab, respectively. DOR w as 9.5 and 5.5 (+) months in the patients with renal cell carcinoma and urothelial cancer, respectively (DOR was defined as the time, in months, from the first documentation of CR or PR to the first documentation of PD or death due to any cause. Patients who were alive and progression-free as of the analysis cut-off date were censored (+) at their last date of response assessment. CI, confidence interval; CR, complete response; ICI, immune checkpoint inhibitor; DOR, duration of response; NE, not evaluable; NIV, nivolumab; ORR, overall response rate; PD, progressive disease; PEM, pembrolizumab; PR, partial response; SAE, serious adverse event; SD, stable disease; TEAE, treatment-emergent adverse event.
Citation Format: Wael A. Harb, Makoto Origuchi, Patrick W. Cobb, Trisha Wise-Draper, Natsuko Suginobe, Megumi Nakamura, Masashi Goto, Aaron Chen, Jian Li, James Wade III. Preliminary safety and efficacy of DSP-7888 plus nivolumab (NIV) or pembrolizumab (PEM) in patients (pts) with advanced solid tumors (ASTs): A phase (Ph) 1b/2 open-label study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT135.
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Affiliation(s)
- Wael A. Harb
- 1Syneos Health, Morrisville, NC, Horizon Oncology Center, Lafayette, IN
| | | | | | - Trisha Wise-Draper
- 4Department of Internal Medicine, Division of Hematology/Oncology, University of Cincinnati, Cincinnati, OH
| | | | | | - Masashi Goto
- 5Sumitomo Dainippon Pharma Co., Ltd., Osaka, Japan
| | - Aaron Chen
- 2Sumitomo Dainippon Pharma Oncology, Inc., Cambridge, MA
| | - Jian Li
- 2Sumitomo Dainippon Pharma Oncology, Inc., Cambridge, MA
| | - James Wade
- 6Cancer Care Specialists of Illinois, Decatur, IL
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Schwartzberg LS, Bhat G, Peguero J, Agajanian R, Bharadwaj J, Restrepo A, Hlalah O, Mehmi I, Chawla S, Lebel F, Cobb PW. Abstract P2-14-12: Eflapegrastim, a novel long-acting granulocyte-colony stimulating factor: Integrated safety results in patients with early-stage breast cancer treated with TC chemotherapy. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p2-14-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Eflapegrastim (E) represents the first myeloid growth factor innovation in more than 15 years. A novel, long-acting recombinant human granulocyte-colony stimulating factor (rhG-CSF), E consists of a rhG-CSF analog conjugated to a human IgG4 Fc fragment via a polyethylene glycol linker. Preclinical and Phase I and II pharmacodynamic and pharmacokinetic data showed increased potency for E versus pegfilgrastim (P). Two independent randomized Phase III trials comparing fixed dose E and P (E 3.6 mg G-CSF and P 6.0 mg G-CSF) for the management of chemotherapy-induced neutropenia (CIN) have recently been completed. Both trials met the primary endpoint of non-inferiority for E vs P in Cycle 1 duration of severe neutropenia (P<.001). Here we provide an integrated summary of the safety of E administered at a fixed dose in a pre-filled syringe.
Patients and Methods: Patients with early-stage breast cancer (ESBC) who were candidates for adjuvant or neoadjuvant chemotherapy were randomized 1:1 in two open-label Phase III trials to E 13.2 mg (3.6 mg G-CSF) or standard P (6 mg G-CSF) administered on Day 2 following TC (docetaxel/cyclophosphamide) chemotherapy on Day 1 of each of 4 cycles. Blood for CBC and serum chemistry was collected in every cycle. Safety assessments began with the first dose of TC and continued for one year after the last dose of study drug. AEs and laboratory values were graded according to NCI CTCAE version 4.03. Immunogenicity was assessed from blood samples collected on Day 1 of each cycle, at the end-of-treatment visit, and at 6- and 12-month follow-up visits.
Results: A total of 660 patients who received at least one dose of eflapegrastim (n=334) or pegfilgrastim (n=326) were included in this integrated safety analysis. The two treatment groups were well balanced for demographics and baseline disease characteristics. The mean age was 59y, ~40% were aged >65y, ~54% weighed >75kg, and ~80% were treated in the adjuvant setting. Median relative dose intensity for T and C was >99% for both groups. A similar percentage of patients in both treatment groups discontinued treatment due to AEs (4% E vs 6% P), with 2% in each group discontinuing due to AEs related to E or P. Serious AEs were similar in both groups (15% each). Incidence of AEs irrespective of causality were also similar between groups (74% E vs. 72% P). No notable differences between groups were observed in the types of study-drug-related AEs. The majority of study-drug-related AEs occurred with an incidence ≤10% for both E and P. As expected with myeloid growth factors, study-drug-related AEs occurring in >10% in either group were bone pain (E vs P: 33% vs 34%), arthralgia (15% vs 10%), back pain (14% vs 9%), myalgia (14% vs 9%), and headache (11% vs 8%). Incidence of febrile neutropenia and neutropenic complications were similar and less than 5% in each treatment group. No leukocytosis, splenic rupture, or anaphylaxis was reported in any patient receiving E or P. The overall incidence of immunogenicity was similar in both groups and there was no demonstrable impact on clinical safety or efficacy.
Conclusions: Two large, randomized Phase III trials (Total n=660) of E vs P administered once-per-cycle showed E at a lower G-CSF dose to be safe and effective for the prophylaxis of CIN in patients with ESBC receiving TC chemotherapy. E is a novel long-acting rhG-CSF with increased potency and similar toxicity to P and may provide an attractive alternative for growth factor support of patients at high risk for CIN-related complications.
Citation Format: Lee S Schwartzberg, Gajanan Bhat, Julio Peguero, Richy Agajanian, Jayaram Bharadwaj, Alvaro Restrepo, Osama Hlalah, Inderjit Mehmi, Shanta Chawla, Francois Lebel, Patrick W Cobb. Eflapegrastim, a novel long-acting granulocyte-colony stimulating factor: Integrated safety results in patients with early-stage breast cancer treated with TC chemotherapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-14-12.
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Affiliation(s)
| | | | | | | | | | | | | | - Inderjit Mehmi
- 8City of Hope Simi Valley/Thousand Oaks, Simi Valley, CA
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Parekh HD, Reese JA, Cobb PW, George JN. Bone marrow necrosis discovered in a patient with suspected thrombotic thrombocytopenic purpura. Am J Hematol 2015; 90:264-6. [PMID: 25196665 DOI: 10.1002/ajh.23840] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/26/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022]
Affiliation(s)
- Hiral D. Parekh
- Department of Medicine; College of Medicine, College of Public Health, University of Oklahoma Health Sciences Center; Oklahoma Oklahoma
| | - Jessica A. Reese
- Department of Biostatistics & Epidemiology; College of Public Health, University of Oklahoma Health Sciences Center; Oklahoma Oklahoma
| | | | - James N. George
- Department of Medicine; College of Medicine, College of Public Health, University of Oklahoma Health Sciences Center; Oklahoma Oklahoma
- Department of Biostatistics & Epidemiology; College of Public Health, University of Oklahoma Health Sciences Center; Oklahoma Oklahoma
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Doroshow JH, McCoy S, Macdonald JS, Issell BF, Patel T, Cobb PW, Yost KJ, Abbruzzese JL. Phase II trial of PN401, 5-FU, and leucovorin in unresectable or metastatic adenocarcinoma of the stomach: a Southwest Oncology Group study. Invest New Drugs 2007; 24:537-42. [PMID: 16832602 DOI: 10.1007/s10637-006-9244-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
From February, 2001 to September, 2002, the Southwest Oncology Group (SWOG) accrued 65 patients with advanced gastric adenocarcinoma to a phase II trial of weekly 5-FU, leucovorin, and the orally-administered uridine analog PN401. Of these 65 patients, 57 were assessable for survival and toxicity, which were the endpoints for the study. Treatment consisted of the administration of 1200 mg/m(2) of 5-FU, 500 mg/m(2) of leucovorin, and 6 grams of PN401 every 8 h, beginning 8 h after the completion of the 5-FU infusion, and continuing for a total of 8 doses (48 grams) during each weekly chemotherapy session. Therapy was delivered for six weeks out of every 8-week treatment cycle. The gastrointestinal toxicity of this regimen was mild with 2 patients experiencing grade 3 stomatitis, and 6 patients having grade 3 diarrhea; and the hematologic toxicity was acceptable with 6 of 57 patients found to have had grade 3 or 4 leukopenia, and 14 of 57 patients experiencing grade 3 or 4 neutropenia. There were two deaths judged possibly related to treatment; one in a patient who experienced a variety of Grade 2 gastrointestinal toxicities and died at home with an unknown cause of death; and a second patient who also died at home, and for whom treatment-related sepsis could not be ruled out. The overall median survival was 7.2 months. The ability to safely deliver twice the usual dose of 5-FU with leucovorin on a weekly schedule suggests that oral uridine analog supplementation with PN401 may enhance the therapeutic index of the fluoropyrimidines.
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Affiliation(s)
- James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, City of Hope National Medical Center, Duarte, CA, USA.
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Diab SG, Baker SD, Joshi A, Burris HA, Cobb PW, Villalona-Calero MA, Eckhardt SG, Weiss GR, Rodriguez GI, Drengler R, Kraynak M, Hammond L, Finizio M, Von Hoff DD, Rowinsky EK. A phase I and pharmacokinetic study of losoxantrone and paclitaxel in patients with advanced solid tumors. Clin Cancer Res 1999; 5:299-308. [PMID: 10037178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
A Phase I and pharmacological study was performed to evaluate the feasibility, maximum tolerated dose (MTD), dose-limiting toxicities (DLTs), and pharmacokinetics of the anthrapyrazole losoxantrone in combination with paclitaxel in adult patients with advanced solid malignancies. Losoxantrone was administered as a 10-min infusion in combination with paclitaxel on either a 24- or 3-h schedule. The starting dose level was 40 mg/m2 losoxantrone and 135 mg/m2 paclitaxel (as a 24- or 3-h i.v. infusion) without granulocyte colony-stimulating factor (G-CSF). Administration of these agents at the starting dose level and dose escalation was feasible only with G-CSF support. The following dose levels (losoxantrone/paclitaxel, in mg/m2) of losoxantrone and paclitaxel as a 3-h infusion were also evaluated: 50/135, 50/175, 50/200, 50/225, and 60/225. The sequence-dependent toxicological and pharmacological effects of losoxantrone and paclitaxel on the 24- and 3-h schedules of paclitaxel were also assessed. The MTD was defined as the dose at which >50% of the patients experienced DLT during the first two courses of therapy. DLTs, mainly myelosuppression, occurring during the first course of therapy were noted in four of six and five of eight patients treated with 40 mg/m2 losoxantrone and 135 mg/m2 paclitaxel over 24 and 3 h, respectively, without G-CSF. DLTs during the first two courses of therapy were observed in one of six patients at the 50/175 (losoxantrone/paclitaxel) mg/m2 dose level, two of four patients at the 50/200 mg/m2 dose level, one of four patients at the 50/225 mg/m2 dose level, and two of five patients at the 60/225 mg/m2 dose level. The degree of thrombocytopenia was worse, albeit not statistically significant, when 24-h paclitaxel preceded losoxantrone, with a mean percentage decrement in platelet count during course 1 of 80.7%, compared to 43.8% with the reverse sequence (P = 0.19). Losoxantrone clearance was not significantly altered by the sequence or schedule of paclitaxel. Cardiac toxicity was observed; however, it was not related to total cumulative dose of losoxantrone. An unacceptably high rate of DLTs at the first dose level of 40 mg/m2 losoxantrone and 135 mg/m2 paclitaxel administered as either a 24- or 3-h i.v. infusion precluded dose escalation without G-CSF support. The addition of G-CSF to the regimen permitted further dose escalation without reaching the MTD. Losoxantrone at 50 mg/m2 followed by paclitaxel (3-h i.v. infusion) at 175 mg/m2 with G-CSF support is recommended for further clinical trials.
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Affiliation(s)
- S G Diab
- The University of Texas Health Science Center at San Antonio, Division of Medical Oncology, 78234, USA
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Cobb PW, Degen DR, Clark GM, Chen SF, Kuhn JG, Gross JL, Kirshenbaum MR, Sun JH, Burris HA, Von Hoff DD. Activity of DMP 840, a new bis-naphthalimide, on primary human tumor colony-forming units. J Natl Cancer Inst 1994; 86:1462-5. [PMID: 8089865 DOI: 10.1093/jnci/86.19.1462] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND DMP 840 ((R,R)-2,2'-[1,2-ethanediylbis[imino(1-methyl-2,1-ethanediyl)]]- bis[5-nitro-1H-benz[de]-iso[quinoline-1,3(2H)-dione]dimethane- sulfonate; NSC-D640430) is one in a series of bis-naphthalimides that binds DNA with high affinity and has sequence specificity to multiple G and C bases. It is also a potent inhibitor of RNA synthesis. DMP 840 has been selected for clinical evaluation on the basis of a broad spectrum of activity (including cures) in human tumors in murine models. PURPOSE We evaluated DMP 840 in a human tumor clonogenic assay to estimate what plasma concentrations may be necessary for clinical cytotoxic activity and to determine what types of tumors potentially might be primary targets for initial phase II studies. METHODS A soft-agar cloning system assay was used to determine the in vitro effects of DMP 840 against cells from biopsy specimens of colorectal, breast, lung ovarian, renal cell, stomach, and bladder cancers and from other tumor types. A total of 260 human tumor specimens were exposed continuously during the assay to DMP 840; 103 were assessable (20 colonies or more on control plates and 30% or less survival for the positive control). An in vitro response was defined as at least a 50% decrease in tumor colony formation resulting from drug exposure compared with controls. RESULTS In vitro responses were seen in 10% (one of 10), 54% (55 of 101), 80% (82 of 103), and 89% (82 of 92) of specimens tested at 0.01, 0.1, 1.0, and 10.0 micrograms/mL of DMP 840, respectively. At a concentration of 0.1 microgram/mL, specific activity was seen against melanoma (80%) and against renal cell (80%), ovarian (63%), breast (54%), non-small-cell lung (42%), and colorectal cancers (33%). DMP 840 demonstrated activity in tumor specimens resistant in vitro to methotrexate (88%), doxorubicin (58%), platinum (57%), cyclophosphamide (53%), vinblastine (53%), etoposide (53%), fluorouracil (37%), and paclitaxel (36%). CONCLUSIONS At in vitro concentrations of 0.1 microgram/mL as a continuous exposure, DMP 840 has activity against a variety of human tumors, including a subgroup resistant in vitro to standard antineoplastic agents. IMPLICATIONS Further clinical development of DMP 840 is warranted.
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Affiliation(s)
- P W Cobb
- Hematology/Oncology Clinic, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200
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Burris HA, Awada A, Kuhn JG, Eckardt JR, Cobb PW, Rinaldi DA, Fields S, Smith L, Von Hoff DD. Phase I and pharmacokinetic studies of topotecan administered as a 72 or 120 h continuous infusion. Anticancer Drugs 1994; 5:394-402. [PMID: 7949242 DOI: 10.1097/00001813-199408000-00002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Topotecan (SK&F 104864-A, NSC 609699) is a water-soluble, semi-synthetic analog of camptothecin which is an inhibitor of topoisomerase I. Since topoisomerase I is cell specific for S phase, we undertook a phase I study to determine the maximum tolerated dose and toxicities of continuous infusion (CI) topotecan. This phase I trial first explored a 5 day CI every 21 day schedule. Doses of topotecan included 0.17, 0.34 and 0.68 mg/m2/day. Fourteen patients [median age 60; median performance status (PS) of 1] with refractory malignancies received 59 courses of drug. Hematologic toxicities occurred only at the highest dose level; NCI grade 3-4 granulocytopenia and thrombocytopenia occurred in 4/8 and 3/8 patients, respectively. The protocol was amended to a 3 day infusion in an effort to ameliorate toxicity and obtain greater dose intensity (DI). Doses of 0.68, 0.85, 1.05, 1.3 and 1.6 mg/m2/day were evaluated. Thirty-two patients (median age 60; median PS of 1) received a total of 115 courses. The major toxicity seen was hematologic with 9/32 and 5/32 patients demonstrating grade 3-4 granulocytopenia and thrombocytopenia, respectively. Non-hematologic toxicities were mild (grade 1-2) in the two schedules and included nausea, vomiting, fatigue and alopecia. At the maximum tolerated dose (MTD) on the 5 day schedule, patients received 0.87 mg/m2/week, whereas they received 1.08 mg/m2/week at the MTD on the 3 day schedule (24% increase in relative dose intensity). A steady-state plasma lactone concentration of 5.5 mg/ml of topotecan was achieved at the phase II recommended dose of 1.6 ng/m2/day as a 3 day continuous infusion.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H A Burris
- Brooke Army Medical Center, Division of Oncology, Fort Sam Houston, TX 78234
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Cobb PW, LeMaistre CF. Therapeutic use of immunotoxins. Semin Hematol 1992; 29:6-13. [PMID: 1509295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Much progress has been made in the therapeutic use of immunotoxins since the first clinical trials, especially in the prevention and treatment of AGVHD. This is also further discussed in this symposium by Champlin. Research in immunotoxin use has gone beyond cancer and into the treatment of immunologic disorders, such as rheumatoid arthritis and HIV infection. Before further advances can take place several problems must be overcome, including the rapid clearance of immunotoxin by the liver, the generation of anti-immunotoxin antibodies, and poor penetration by the immunotoxin in solid tumors. Other obstacles to the wide use of immunotoxins are the heterogeneity of tumor cells, the shedding of tumor antigens into the circulation, and the inability to identify neoplastic renewal cell specific antigens that are not cross-reactive with normal tissues. Despite these obstacles, the early success of immunotoxins, especially in hematologic malignancies, reinforces the feasibility of designing rational targeting reagents in cancer therapy.
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Affiliation(s)
- P W Cobb
- Hematology/Oncology Service, Brooke Army Medical Center, Fort Sam Houston, TX
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Vukelja SJ, Bonner MW, McCollough M, Cobb PW, Gaule DA, Fanucchi PJ, Keeling JH. Unusual serpentine hyperpigmentation associated with 5-fluorouracil. Case report and review of cutaneous manifestations associated with systemic 5-fluorouracil. J Am Acad Dermatol 1991; 25:905-8. [PMID: 1837033 DOI: 10.1016/0190-9622(91)70280-f] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A variety of cutaneous reactions have been reported with the use of systemic 5-fluorouracil. Our patient had serpentine hyperpigmented streaks appearing 5 days after bolus infusion of 5-fluorouracil. The patient also had other skin eruptions, that is, inflammation of actinic keratoses and folliculitis limited to the forehead; these reactions have been reported previously with 5-fluorouracil medication. We report this case and review the literature on skin manifestations associated with 5-fluorouracil therapy.
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Affiliation(s)
- S J Vukelja
- Hematology/Oncology Service, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200
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Cobb PW, Havlin KA, Kuhn JG, Craig JB, Harman GS, Luther JS, Turner JN, Weiss GR, Tweedy DA, Koeller J. Phase I evaluation of crisnatol (BWA770U mesylate) on a monthly extended infusion schedule. Sel Cancer Ther 1991; 7:85-91. [PMID: 1754731 DOI: 10.1089/sct.1991.7.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Crisnatol is an arylmethylaminopropanediol derivative that has shown promise as an antitumor agent in preclinical testing. In a phase I trial using a monthly six-hour infusion schedule the recommended dose for future phase II trials was found to be 388 mg/m2. Neurologic toxicity was dose-limiting in that trial and correlated with the attainment of a threshold plasma concentration of greater than 4.5 micrograms/ml. In this study we treated 15 patients with escalating doses of crisnatol from 450 mg/m2 to 900 mg/m2 administered at a rate of 50 mg/m2/hr over 9, 12, 15, and 18 hours. Toxicity was mild to moderate at all dose levels. However, serious central nervous system effects were noted in one patient at 900 mg/m2 over 18 hours whose plasma level was 6.5 micrograms/ml. This study has demonstrated higher total doses of crisnatol can be given if the drug is administered as a prolonged infusion in an attempt to avoid high plasma levels of the agent.
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Affiliation(s)
- P W Cobb
- Department of Medicine, University of Texas Health Science Center, San Antonio 78284-7884
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Cobb PW, Warner DM. Task substitution among skill classes of nursing personnel. Nurs Res 1973; 22:130-7. [PMID: 4487953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Cobb PW. A Contribution to the Study of Dark-adaptation. Trans Am Ophthalmol Soc 1919; 17:249-60. [PMID: 16692472 PMCID: PMC1318187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- P W Cobb
- Medical Research Laboratory, Hazelhurst Field, Mineola, Long Island, N. Y
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