Progress in breast cancer-can we do better?

Breast cancer remains the most common malignancy diagnosed in women in North America. [...]

A randomized phase II study of weekly paclitaxel with or without pelareorep in patients with metastatic breast cancer: final analysis of Canadian Cancer Trials Group IND.213

BACKGROUND

Pelareorep, a serotype 3 reovirus, has demonstrated preclinical and early clinical activity in breast cancer and synergistic cytotoxic activity with microtubule targeting agents. This multicentre, randomized, phase II trial was undertaken to evaluate the efficacy and safety of adding pelareorep to paclitaxel for patients with metastatic breast cancer (mBC).

METHODS

Following a safety run-in of 7 patients, 74 women with previously treated mBC were randomized either to paclitaxel 80 mg/m² intravenously on days 1, 8, and 15 every 4 weeks plus pelareorep 3 × 10¹⁰ TCID₅₀ intravenously on days 1, 2, 8, 9, 15, and 16 every 4 weeks (Arm A) or to paclitaxel alone (Arm B). Primary endpoint was progression-free survival (PFS). Secondary endpoints were objective response rate, overall survival (OS), circulating tumour cell counts, safety, and exploratory correlative analyses. All comparisons used a two-sided test at an alpha level of 20%. Survival analyses were adjusted for prior paclitaxel.

RESULTS

Final analysis was performed after a median follow-up of 29.5 months. Pelareorep was well tolerated. Patients in Arm A had more favourable baseline prognostic variables. Median adjusted PFS (Arm A vs B) was 3.78 mo vs 3.38 mo (HR 1.04, 80% CI 0.76-1.43, P = 0.87). There was no difference in response rate between arms (P = 0.87). Median OS (Arm A vs B) was 17.4 mo vs 10.4 mo (HR 0.65, 80% CI 0.46-0.91, P = 0.1).

CONCLUSIONS

This first, phase II, randomized study of pelareorep and paclitaxel in previously treated mBC did not show a difference in PFS (the primary endpoint) or RR. However, there was a significantly longer OS for the combination. Further exploration of this regimen in mBC may be of interest.

Systemic targeted therapy for her2-positive early female breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline

BACKGROUND

This systematic review addresses the question "What is the optimal targeted therapy for female patients with early-stage human epidermal growth factor receptor 2 (her2)-positive breast cancer?"

METHODS

The medline and embase databases were searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major guideline organizations were also searched.

RESULTS

Sixty publications relevant to the targeted therapy portion of the systematic review were identified. In four major trials (hera, National Surgical Adjuvant Breast and Bowel Project B-31, North Central Cancer Treatment Group N9831, and Breast Cancer International Research Group 006), adjuvant trastuzumab for 1 year was superior in disease-free survival (dfs) and overall survival (os) to no trastuzumab; trastuzumab showed no benefit in one trial (pacs 04). A shorter duration of trastuzumab (less than 1 year compared with 1 year) was evaluated, with mixed results for dfs: one trial showed superiority (finher), one trial could not demonstrate noninferiority (phare), another trial showed equivalent results (E 2198), and one trial is still ongoing (persephone). Longer trastuzumab duration (hera: 2 years vs. 1 year) showed no improvement in dfs or os and a higher rate of cardiac events. Newer her2-targeted agents (lapatinib, pertuzumab, T-DM1, neratinib) have been or are still being evaluated in both adjuvant and neoadjuvant trials, either by direct comparison with trastuzumab alone or combined with trastuzumab. In the neoadjuvant setting (neoaltto, GeparQuinto, Neosphere), trastuzumab alone or in combination with another anti-her2 agent (lapatinib, pertuzumab) was compared with either lapatinib or pertuzumab alone and showed superior or equivalent rates of pathologic complete response. In the adjuvant setting, lapatinib alone or in combination with trastuzumab, compared with trastuzumab alone (altto) or with placebo (teach), was not superior in dfs. The results of the completed aphinity trial, evaluating the role of dual her2 blockade with trastuzumab and pertuzumab, are highly anticipated. Ongoing trials are evaluating trastuzumab as a single agent without adjuvant chemotherapy (respect) and in patients with low her2 expression (National Surgical Adjuvant Breast and Bowel Project B-47).

CONCLUSIONS

Taking into consideration disease characteristics and patient preference, 1 year of trastuzumab should be offered to all patients with her2-positive breast cancer who are receiving adjuvant chemotherapy. Cardiac function should be regularly assessed in this patient population.

Adjuvant chemotherapy for early female breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline

BACKGROUND

The Program in Evidence-Based Care (pebc) of Cancer Care Ontario recently created an evidence-based consensus guideline on the systemic treatment of early breast cancer. The evidence for the guideline was compiled using a systematic review to answer the question "What is the optimal systemic therapy for patients with early-stage, operable breast cancer, when patient and disease factors are considered?" The question was addressed in three parts: cytotoxic chemotherapy, endocrine treatment, and human epidermal growth factor receptor 2 (her2)-directed therapy.

METHODS

For the systematic review, the medline and embase databases were searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major oncology guideline organizations were also searched. The basic search terms were "breast cancer" and "systemic therapy" (chemotherapy, endocrine therapy, targeted agents, ovarian suppression), and results were limited to randomized controlled trials (rcts), guidelines, systematic reviews, and meta-analyses.

RESULTS

Several hundred documents that met the inclusion criteria were retrieved. The Early Breast Cancer Trialists' Collaborative Group meta-analyses encompassed many of the rcts found. Several additional studies that met the inclusion criteria were retained, as were other guidelines and systematic reviews. Chemotherapy was reviewed mainly in three classes: anti-metabolite-based regimens (for example, cyclophosphamide-methotrexate-5-fluorouracil), anthracyclines, and taxane-based regimens. In general, single-agent chemotherapy is not recommended for the adjuvant treatment of breast cancer in any patient population. Anthracycline-taxane-based polychemotherapy regimens are, overall, considered superior to earlier-generation regimens and have the most significant impact on patient survival outcomes. Regimens with varying anthracycline and taxane doses and schedules are options; in general, paclitaxel given every 3 weeks is inferior. Evidence does not support the use of bevacizumab in the adjuvant setting; other systemic therapy agents such as metformin and vaccines remain investigatory. Adjuvant bisphosphonates for menopausal women will be discussed in later work.

CONCLUSIONS

The results of this systematic review constitute a comprehensive compilation of the high-level evidence that is the basis for the 2014 pebc guideline on systemic therapy for early breast cancer. Use of cytotoxic chemotherapy is presented here; the results addressing endocrine therapy and her2-targeted treatment, and the final clinical practice recommendations, are published separately in this supplement.

Ottawa Cardiac Oncology Program wins 2013 Cancer Quality Council of Ontario Innovation Award

The Ottawa Cardiac Oncology Program (ocop) has won the 2013 Innovation award from the Cancer Quality Council of Ontario [...]

NCIC CTG IND.181: phase I study of AT9283 given as a weekly 24 hour infusion in advanced malignancies

PURPOSE

AT9283 is a potent inhibitor of the mitotic regulators, Aurora-kinases A and B, and has shown anti-tumor activity in patients with solid and haematological malignancies. This phase I study assessed safety, tolerability, pharmacokinetic and pharmacodynamic properties of AT9283.

PATIENTS AND METHODS

Patients with advanced, incurable solid tumors or non-Hodgkin's lymphoma received AT9283 as a continuous 24-hour infusion on days 1, 8 of a 21-day cycle. A 3 + 3 dose escalation design was used with a starting dose of 1.5 mg/m(2)/day. Pharmacokinetic samples were collected from all patients on cycle one, and pharmacodynamic samples were collected from 4 patients at the recommended phase II dose (RP2D).

RESULTS

35 patients were evaluable for toxicity and 32 were evaluable for response. AT9283 was well tolerated, with main toxicities being reversible dose-related fatigue, gastrointestinal disturbance, anemia, lymphocytopenia and neutropenia. The dose limiting toxicities were febrile neutropenia (two patients) and neutropenia with grade 3 infection (1 patient) at 47 mg/m(2)/day (established as the maximum tolerated dose). The RP2D was 40 mg/m(2)/day. Pharmacokinetic analyses showed AT9283 appeared to follow linear kinetics, with a mean elimination half-life of 8.2 h. Pharmacodynamic analyses showed no consistent or significant changes, but trends suggested evidence of AT9283 inhibition and anti-proliferative activity. One patient had partial response and four patients experienced RECIST stable disease (median 2.6 months).

CONCLUSION

In this study, AT9283 was well tolerated. The RP2D is 40 mg/m(2)/day on days 1, 8 of a 21-day cycle. Ongoing AT9283 trials will assess efficacy and safety in solid and haematological cancers.

Abstract P1-15-06: The impact of musculoskeletal toxicity on adherence to endocrine therapy in women with early stage breast cancer– observations in a non-trial setting

Background: Aromatase inhibitor (AI) use is standard of care in the treatment of postmenopausal (PM) women with early stage breast cancer (EBC). Approximately 35% of patients (pts) discontinue their initially prescribed AI due to toxicity, the most commonly reported reason being musculoskeletal toxicity (MSKT). We report on the discontinuation rates of AI therapy based on MSKT in PM women with EBC treated at a tertiary care cancer centre.

Methods: PM women with hormone receptor positive EBC treated with endocrine therapy (ET) that included an AI (upfront or after tamoxifen) at The Ottawa Hospital Cancer Center between 01/99 and 02/06. Data included: demographics, type of ET, duration of treatment, incidence of patient-reported MSKT and treatment of MSKT. Comparisons between ETs were analyzed using Chi-square and Fischer's t-tests.

Results: A total of 626 pts, median 59 years (r: 30–92), median follow-up 98 months, with stage: I (196 pts; 31%), II (341 pts; 54%) or III (89 pts; 14%s) EBC. Treatment strategies included: AI(s) only (251 pts; 40%); tamoxifen (TAM) followed by AI(s) (323 pts; 51.6%); AI(s) followed by TAM (16 pts; 2.6%); TAM-AI(s)-TAM (24 pts; 3.8%) and unknown (12 pts). Patient-reported MSKT was experienced by significantly more women treated with AIs than TAM (64% vs 36%, p < 0.0001). Women on exemestane experienced significantly less MSKT (47%) compared to anastrozole (64%; p = 0.011) or letrozole (68% p = 0.003). Mean time to appearance of patient-reported MSKT was 20 months (23 for anastrozole; 9 for exemestane; 21 for letrozole; 23 for TAM). Longer duration of AI use did not significantly correlate with higher risk of MSKT (p = 0.65).

Significantly more pts discontinued ET due to MSKT from AIs (106/469; 22%) than TAM (21/141; 14%) (P < 0.0001); and more pts stopped letrozole due to MSKT (40/149; 27%) than the other two AIs (P < 0.0001). Treatment strategies for MSKT (n = 359 cases) included: discontinuation of AI (55; 15%), switching AI (19; 5%), treatment with medication (e.g. NSAIDs, Acetaminophen, Cox 2 inhibitors, narcotics) (75; 21%), physiotherapy and medication (2; 0.6%), and no treatment (208; 58%). Treatment strategies for MSKT did not differ significantly between ETs. Women taking anastrozole received more acetaminophen and codeine (p = 0.02 vs TAM; 0.041 vs exemestane; 0.015 vs letrozole) compared to other AI's. MSKT treatment increased adherence from 43–46% with TAM (p = 0.76); 60–72% with anastrozole (p = 0.17); 33–80% with exemestane (p < 0.0001); but did not affect adherence with letrozole (52%; p = 1.0).

Conclusions: This large cohort study reports similar MSKT rates with AI therapy as reported in the literature. AIs have higher incidence of self-reported MSKTs (64%) compared to TAM (36%). Patients discontinued treatment due to MSKT significantly more with AI (22%) than TAM (14%) but adherence to AI therapy increased when treated for MSKT. These encouraging results reflect the real life experience of women exposed to ET.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-15-06.

Real-world experience with adjuvant fec-d chemotherapy in four Ontario regional cancer centres

BACKGROUND

The efficacy of adjuvant chemotherapy with fec-d (5-fluorouracil-epirubicin-cyclophosphamide followed by docetaxel) is superior to that with fec-100 alone in women with early-stage breast cancer. As the use of fec-d increased in clinical practice, health care providers anecdotally noted higher-than-expected toxicity rates and frequent early treatment discontinuations because of toxicity. In the present study, we compared the rates of serious adverse events in patients who received adjuvant fec-d chemotherapy in routine clinical practice with the rates reported in the pacs-01 trial.

METHODS

We retrospectively reviewed all patients prescribed adjuvant fec-d for early-stage breast cancer at 4 regional cancer centres in Ontario. Information was collected from electronic and paper charts by a physician investigator from each centre. Data were analyzed using chi-square tests, independent samples t-tests, one-way analysis of variance, and univariate regression.

RESULTS

The 671 electronic and paper patient records reviewed showed a median patient age of 52.2 years, 229 patients (34.1%) with N0 disease, 508 patients (75.7%) with estrogen or progesterone receptor-positive disease (or both), and 113 patients (26%) with her2/neu-overexpressing breast cancer. Febrile neutropenia occurred in 152 patients (22.7%), most frequently at cycle 4, coincident with the initiation of docetaxel [78/152 (51.3%)]. Primary prophylaxis with hematopoietic growth factor support was used in 235 patients (35%), and the rate of febrile neutropenia was significantly lower in those who received prophylaxis than in those who did not [15/235 (6.4%) vs. 137/436 (31.4%); p < 0.001; risk ratio: 0.20].

CONCLUSIONS

In routine clinical practice, treatment with fec-d is associated with a higher-than-expected rate of febrile neutropenia, in light of which, primary prophylaxis with growth factor should be considered, per international guidelines. Adoption based on clinical trial reports of new therapies into mainstream practice must be done carefully and with scrutiny.

Use and delivery of granulocyte colony-stimulating factor in breast cancer patients receiving neoadjuvant or adjuvant chemotherapy-single-centre experience

BACKGROUND

Use of granulocyte colony-stimulating factor (g-csf) as primary prophylaxis against chemotherapy-induced neutropenia has significant cost implications. We examined use of g-csf for early-stage breast cancer patients at our centre. The study also examined the pattern of nurse-led patient teaching with respect to drug self-administration.

METHODS

Patients who received g-csf between November 2009 and October 2010 were identified from pharmacy records. After consent had been obtained, electronic charts were examined to extract data on chemotherapy and use of g-csf. Patients were contacted by telephone to obtain information on the utilization of home-care nursing visits for g-csf administration.

RESULTS

The study analyzed 36 patients. Median age was 58 years (range: 31-78 years). Of the 36 patients, 30 (83%) had received adjuvant treatment, and 6 (17%), neoadjuvant treatment. Most patients (71%) received 10 days (range: 7-10 days) of filgrastim. Of the 36 patients, 29 (81%) received g-csf as primary prophylaxis. In 90% of those patients, primary prophylaxis commenced with the taxane component of treatment. Of the 36 patients, 7 (19%) received g-csf after neutropenia, including 2 who had febrile neutropenia. In 96% of the patients, injections were received at home with the help of a nurse; those patients were subsequently taught self-injection techniques. The median number of nursing visits was 2 (range: 1-3 visits). Most patients were satisfied with the home care and g-csf teaching they received.

CONCLUSIONS

Most of the g-csf used in breast cancer treatment during the study period was given for primary prophylaxis. A major reason for the decision to use g-csf appears to have been physician-perceived risk of febrile neutropenia. Delivery of g-csf by home-care nurses was well received by patients.

Abstract P2-12-02: How Common Is Sexual Dysfunction among Women with Early Stage Breast Cancer?

Background: Despite the high prevalence of sexual problems (50—90%) among women with early stage breast cancer (EBC), relatively little is known about the prevalence of clinically significant post-systemic treatment sexual dysfunction (SD) and its impact on quality of life (QOL). According to the American Psychiatric Association (APA), SD consists of sexual problems causing marked personal distress. While 40% of healthy US women report sexual problems, only 12% experience SD. No study has applied the APA criterion to document the prevalence of SD in women with EBC who have completed systemic therapy. The goal of this study is to address this gap and to examine some correlates (anxious predispositions and menopausal symptoms) of SD and the impact of SD on QOL. Methods: Post-menopausal women receiving cancer therapy for EBC or early colon cancer were approached for this study. Sexual problems were evaluated with the Female Sexual Function Index while sexual distress was assessed with the Female Sexual Distress Scale. QOL was measured with FACT-B, using its endocrine symptoms subscale (ES) to assess menopausal symptoms. Spielberger State-Trait Anxiety Inventory measured anxious predispositions. Participants completed questionnaires upon completion of adjuvant chemotherapy but prior to initiation of hormonal therapy (estrogen sensitive EBC). SD was assessed using the APA classification. Results: Between January 2009 and May 1 2010, 70 EBC patients entered this study. The proportion of women (mean age 61) reporting 1 or more sexual problems was high (93%) and included problems with 1) frequency (66%) and level (65%) of sexual desire, 2) frequency (66%), level (52%) and satisfaction (43%) of arousal, 3) frequency (21%) of vaginal dryness and difficulty becoming lubricated (47%) during sexual activity, 4) satisfaction with their sexual life (30%) and 5) pain during intercourse (18%). However, the APA criterion identified only 30% of patients as having SD. Multiple logistic regression showed that anxiety predispositions and menopausal symptoms predicted SD (p&lt; .01). Women classified as having SD had higher anxiety scores (No SD=34 SD=41, p&lt;.05) as well as higher levels of menopausal symptoms (i.e, lower ES scores; No SD= 62 SD=54, p&lt;.01). QOL was negatively impacted by SD (r=-0.42, p&lt;.01). Discussion: Despite the fact that an overwhelming majority of patients had sexual difficulties, the APA distress criterion identified far fewer patients (30 %) with SD. Nevertheless, we found a high prevalence rate of SD, which was 2.5 times higher (%2 &lt; .01) than that reported in women without a cancer diagnosis. Women with anxious predispositions and high menopausal symptoms may be at risk for SD and may benefit from early interventions to prevent SD.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-12-02.

Endocrine therapy for male breast cancer: rates of toxicity and adherence

PURPOSE

Most male breast cancer tumours are hormone receptor-positive; the patients therefore receive endocrine therapy. There is, however, a paucity of published data on toxicities experienced by male breast cancer patients who are prescribed endocrine therapy. In the present study, we examined rates of adherence to and toxicity from endocrine treatments in male breast cancer patients treated at a single institution.

PATIENTS AND METHODS

We conducted a retrospective study of male patients diagnosed with breast cancer at The Ottawa Hospital Cancer Centre during 1981-2003. Data collected included patient age, hormone receptor status, therapy adherence, self-reported toxicities, and type and duration of endocrine therapies.

RESULTS

The review located 59 cases of early-stage and metastatic male breast cancer. Median patient age was 68.0 years. Tamoxifen was given to 38 patients (64.4%), anastrozole to 8 (13.6%), and letrozole to 5 (8.5%). Of patients who received endocrine therapy, 10 (25%) received adjuvant systemic chemotherapy. Toxicity was reported by 19 patients taking tamoxifen (50%), with hot flashes being the most common complaint (18.4%). Decreased libido, weight gain, and malaise were reported by 5 patients (13.2%). Rash and erectile dysfunction were reported by 3 patients (7.9%). Increased liver enzymes, pulmonary embolism, superficial thrombophlebitis, myalgia, depression, visual blurring, and loose stools were each reported in 1 patient (2.6%). Tamoxifen therapy was discontinued secondary to toxicity in 9 patients (23.7%). Of the patients treated with anastrozole, 3 (37.5%) reported toxicity, with 1 report each of decreased libido, leg swelling, and depression (12.5%). Toxicity was reported in 2 patients taking letrozole (40%), with both reporting peripheral edema, and 1 reporting hot flashes. No patient discontinued anastrozole or letrozole because of toxicity.

CONCLUSIONS

Few studies specifically report data on adherence to and toxicities from endocrine therapies in male breast cancer patients. The rate of discontinuation at our institution because of toxicity (23.7%) is similar to that reported in the female breast cancer population. Future prospective studies should explore strategies to improve adherence to endocrine therapy in this population.

Toxicities and adherence rates of hormone treatment in male breast cancer patients treated at a tertiary care center

e11613

Background: Male breast cancer (BC) comprises approximately 1% of all breast cancer cases, and over 80% of male BC tumours express the estrogen receptor (ER). Male BC patients (pts) are often offered hormonal treatment (HT) with tamoxifen (T), or more recently aromatase inhibitors (AI's). There is a paucity of information in the literature on the toxicities (Tx) and adherence rates of HT in this population. Methods: We conducted a retrospective chart review of 24 pts diagnosed with male BC at the Ottawa Regional Cancer Centre from 1986–2003. Data collected included pt age, ER status, progesterone receptor (PR) status, systemic chemotherapy, HT, and Tx of treatment. Results: Median age of 24 male BC pts was 70.0 years (r: 46–83 years). The majority (16/24) of pts had ER/PR testing: 12 (75.0%) ER/PR +, 1 (6.3%) ER +/PR-, 2 (12.5%) ER +/PR unknown, and 1 (6.3%) ER/PR-. Of the 15 pts who were ER +, 13 received T and 5 received anastrozole (A) monotherapy during their treatment. One ER - pt received adjuvant T. Three pts with ER status unknown received T. Median duration of treatment with T (17 pts) was 38.0 months (r: 2–79 months). Hot flashes (23.5 %) was the most common reported Tx. Decreased libido, weight gain, rash, and malaise were reported in 2 pts (11.8%) each. Increased liver enzymes, pulmonary embolism, and erectile dysfunction were reported in 1 pt (5.9%) each. Five pts (29.4%) terminated treatment early due to T toxicity (median treatment 15 months; r: 2–54 months). Five pts were treated with A (median 10 months; r: 3–60 months), 4 of whom received prior T treatment. One pt reported loss of libido, and 1 significant depression /suicidal ideation requiring psychiatric treatment. Conclusions: This study provides contemporary data on toxicities and adherence rates of HT in male BC pts in a non-clinical trial setting. Approximately 30 % of male BC pts discontinued T therapy due to Tx, potentially having a negative impact on clinical outcome. Future studies will examine differences in adherence rates and outcomes between T and A in male BC pts.

No significant financial relationships to disclose.

Adjuvant trastuzumab (T) in early stage breast cancer (EBC): Is cardiac dysfunction (CD) clinically significant?

11072

Background: T was funded for women with EBC in Ontario in Aug 05. Clinicians remain concerned about the potential cardiotoxicity of T in women with EBC. The purpose of this retrospective study is to evaluate CD in women with EBC prescribed adjuvant T therapy. Methods: Women with HER2-overexpressing EBC who were initiated on T and chemotherapy (CT) at TOHRCC between Aug 05 and Nov 06 were included in this analysis. A retrospective chart review collected: demographics, CT regimen, T treatment (dose delays, termination of T), CD (defined by the New York Heart Association functional classification, 2002), and management. Results: Outcomes reflect the preliminary results of 108 patients (pts) initiated on adjuvant T therapy. Median age was 52 years (range 30–79). 107 pts (95%) received T and CT; 1 pt received T alone. Pts received an average of 6 cycles of CT (range 1–12), including anthracycline (A; 99%) (A alone 55%; A-taxane 44%) and non-A (1%) regimens. 18 pts (28%) were treated with concurrent T and taxol. Therapy with T has been completed (median 46.7 weeks) in 28 pts (26%) while 72 pts (67%) remain on T. 85% of pts underwent at least 3 MUGA scans during T treatment. CD was observed in 18 pts (17%): congestive heart failure (2 pts), decrease in left ventricular ejection fraction (LVEF) of =10% to less than 55% (14 pts) or decrease in LVEF >20% (2pts). Of 18 pts with CD, 7 underwent a treatment delay (median 8 weeks) 3 permanently stopped T (median 45 weeks) and 8 pts continued T. 31 pts experiencing any decrease in LVEF were managed successfully through: delay, (16 pts), referral to a cardiologist (14 pts) and medical treatment with: ACE-inhibitors (5 pts), beta blockers (1 pt), or combination (2 pts). Discussion: The results of this first analysis indicate that outside of a clinical trial setting, the majority of women receive adjuvant T according to treatment guidelines, do not experience significant CD and are able to complete therapy uninterrupted. The long term consequences of CD in these pts are unknown.

No significant financial relationships to disclose.

Quality indicators for end-of-life breast cancer care: Is there agreement between stakeholder groups?

16034

Background: Quality indicators (QIs) are tools designed to measure quality of care and help enhance quality through identifying areas needing improvement. Breast cancer offers a disease model to examine QIs for end-of-life (EOL) care. The objective of this study was to assess agreement among stakeholder groups in two Canadian provinces on QIs for EOL breast cancer. Methods: A qualitative study design using a modified Delphi method and focus groups at each study site. After a literature review, an expert panel identified 19 QIs that were potentially measurable using administrative data. The Delphi panels and focus group sessions incorporated the 19 QIs as discussion topics in Halifax, NS and Ottawa, Ont. The Delphi panels involved a multidisciplinary group of oncology health care professionals. Separate focus groups were conducted with women with metastatic breast cancer and bereaved caregivers. All group sessions were audio-taped, transcribed verbatim, audited and a thematic analysis was conducted. Results: A total of 23 health care professionals, 16 patients, 7 bereaved caregivers participated in the study. Participants attended only one group discussion, depending on group assigned. There was good agreement on QIs among patient and caregiver groups in both cities. The need for effective communication was identified as a major theme. The Delphi process yielded overall moderate agreement with QIs among health care professionals. Conclusion: Aspects of quality EOL care important to stakeholders may not be measurable from administrative data. Results from the Delphi panels indicate that patient preferences and differences in health care delivery between different jurisdictions modulated extent of agreement with QIs.

No significant financial relationships to disclose.

Changing demographics of locally advanced breast cancer: Data from a regional cancer centre

10780

Background: Locally advanced breast cancer (LABC) (including inflammatory breast cancer (IBC)) accounts for less than 5% of women diagnosed with breast cancer in North America each year. This population of women continues to represent a challenge in terms of timely diagnosis and treatment. Methods: A retrospective database was developed using the American Joint Committee on Cancer (AJCC)2002 staging classification for all women who presented to TOHRCC with LABC between Jan 1/02 - April 1/05. Information was abstracted from clinic charts and the patient self-reported health questionnaires. Results: These results reflect the demographics of the first 50 women entered into our database. Median age at presentation was 57 years (range 28–88); 62% were post-menopausal and 28% had a 1st/2nd degree relative with breast cancer. Clinical diagnosis was made by: self-detection (79%); mammography (5%), routine physical exam (9%) and CT scan (2%). Clinical tumour stage at presentation was: IIIA (25.6%); IIIB (53.5%) and IIIC (9.3%). The majority of women were diagnosed with infiltrating ductal carcinoma (72%). Women with T4d tumours (IBC) (38%) tended to be younger (54.5 vs 59.2 years); presented earlier (2.7 vs. 6.3 months); had larger tumours at the time of diagnosis (9.7 vs 5.5 cm); were more likely grade III (30 vs 20%) and were more often ER negative (42.1% vs 33.3%) and PR negative (63.2% vs. 50%). Only 13% of women in this database were tested for HER-2 of whom 70% were positive. Conclusions: This data utilizing the new AJCC (2002) staging system reflects important shifts in LABC that will influence clinical care in the future. Compared to historical databases, patients tended to be younger and have more aggressive disease including ER negative and HER-2 positive disease. Supplemental microarray studies to further explore this entity are planned. We will present clinical management outcomes in an additional submission.

No significant financial relationships to disclose.

Trends in systemic management (SM) for the treatment of locally advanced breast cancer: Data from a regional cancer centre

10728

Background: Locally advanced breast cancer (LABC) accounts for less than 5% of women diagnosed with breast cancer in North America each year. The scarcity of clinical trials addressing the SM of these women continues to represent a challenge for clinicians. Methods: A retrospective database was developed using the American Joint Committee on Cancer (AJCC) 2002 staging classification for all women who presented to TOHRCC with LABC between Jan 1/02-April 1/05. Information was obtained from clinic charts and patient self-reported questionnaires. Results: Outcomes reflect the SM of the first 50 women entered into our database. Median age at presentation was 57 years (range 28–88); 62% were post-menopausal; and hormonal status was 52% estrogen receptor (ER) positive and 54% progesterone receptor (PR) positive. Surgery was performed prior to chemotherapy in 50% of patients (pts).The majority (90%) of pts received SM as follows: 38% anthracyclines (A) alone (52% epirubicin, 26% adriamycin, 2% both); 7% taxanes (T) alone (33% paclitaxel, 66% docetaxel), 53% received both T and A regimens, and 2% received other types of chemotherapy (gemcitabine,vinorelbine,capecitabine). The addition of trastuzumab to the SM of HER2-positive pts has also been observed. Hormone therapy was given to 22 pts (44%) of whom 82% were ER or PR-positive: tamoxifen (27%); aromatase inhibitors (AIs; 50%); both tamoxifen and AIs (23%). Pts were treated with AIs as follows: anastrozole (73%); fulvestrant (9%), and atemestane (9%). In pts with measurable disease receiving neoadjuvant SM; 7(35%) had a complete clinical response and 13 (65%) had a partial response; mean tumour size decreased from 7.5 cm (range 2–22) to 2.8 cm (range 0–8). Pathological complete response rates and improved survival rates have been observed and will be reported in detail. Conclusions: These results represent our first analysis of treatment outcomes in women with LABC using the new AJCC system. This database highlights the increased utilization of T and AIs in the SM of these pts, which seems to translate into the increasingly observed improvements in overall survival. Microarray studies to further explore predictability of treatment outcomes are planned.

No significant financial relationships to disclose.

Phase II Study of Troxacitabine (BCH-4556) in Patients with Advanced Non-Small-Cell Lung Cancer

Troxacitabine. a promising new L-nucleoside, inhibits DNA polymerase and leads to complete DNA chain termination. The National Cancer Institute of Canada Clinical Trials Group (NCIC-CTG) conducted a phase II study to assess the efficacy and toxicity of troxacitabine in untreated patients with advanced non-small-cell lung cancer (NSCLC). Previously untreated patients were eligible if they had inoperable stage IIIB or IV NSCLC, ECOG PS < or = 2, adequate hematology and biochemistry, and at least one bidimensionally measurable lesion. Patients with prior malignancy or brain metastases were excluded. Troxacitabine (10 mg/m(2)) was administered intravenously over 30 minutes every 3 weeks. Between June 1999 and May 2000, 17 eligible patients received treatment. Patient characteristics included: median age 64 years; female 41%; stage IV (94%); PS 0 (12%), 1 (59%), and 2 (29 %), 3 or more disease sites (59%). In 17 patients, there were 8 stable disease, 9 disease progression, and no objective responses. Median duration of stable disease was 3.6 months (range = 2.0-7.1). A total of 56 cycles were administered (median = 3), and 88% of patients received 90% or more of the planned dose intensity. The majority (82%) of patients experienced skin rash. Hematologic and biochemical toxicities, grade 3/4 (%) were: granulocytopenia (41), anemia (12), thrombocytopenia (6), and hyperglycemia (6). Troxacitabine appears to have little activity in NSCLC in the dose and schedule tested.

Second primary malignancies following the treatment of early stage ovarian cancer: update of a study by the National Cancer Institute of Canada--Clinical Trials Group (NCIC-CTG)

BACKGROUND

Ovarian cancer is the leading cause of death from gynecological malignancies and the fourth most frequent fatal malignancy in women. Despite improved surgical techniques as many as 20% of women with early stage disease will eventually relapse and die from their disease. The post-operative management of these women remains controversial. Here we present the long term follow-up data of our previously published study, as well as the incidence of second primary malignancies in these women.

PATIENTS AND METHODS

Two hundred fifty-seven eligible patients with stage I, IIA 'high risk' ovarian carcinoma and IIB, IIIO (disease confined to pelvis) were randomized to either whole abdominal radiotherapy 2.250 rads in ten fractions (107 patients), melphalan 8 mg/m2/d x 4 weeks x 18 courses (106 patients) or intraperitoneal chromic phosphate 10-20 mCi (44 patients). All patients were initially treated with pelvic radiotherapy.

RESULTS

Overall survival estimates at 10 years were: 45% in the whole abdominal radiotherapy arm; 49% in the melphalan arm and 50% in the intraperitoneal chromic phosphate arm (P = 0.30). Relapse-free survival estimates at 10 years were: 50% in the whole abdominal radiotherapy arm, 62% in the melphalan arm and 51% in the chromic phosphate arm (P = 0.147). Long term follow-up has not demonstrated a significant difference between treatment arms. Second primary malignancies developed in 29 women (11%) after 2,229 person years of follow-up. This compares to 18.7 second primary malignancies which would have been expected in this group of age-matched controls and was statistically significant (P = 0.018). There was no significant difference in the total number of second primary malignancies between treatment arms. Melphalan appeared to be associated with an increased risk of developing leukemia/myelodysplastic syndrome compared to the whole abdominal radiotherapy arm (P = 0.06).

CONCLUSIONS

Long-term follow-up has not demonstrated a significant difference in overall or disease free survival between treatment arms. An excess of second primary malignancies (35%) was observed suggesting that lifelong surveillance is required in this population. Further research with newer treatment programs are needed to improve the cure rates in this population.

Phase I trial design: are new methodologies being put into practice?

BACKGROUND

The primary goal of phase I studies is to efficiently and accurately determine the recommended dose of a new agent for further investigation. Issues of concern ranging from the ethics of these trials to selection of starting dose and rapidity of dose escalation, have led to suggested modifications of the traditional phase I design. We wanted to assess the frequency with which these new approaches are being applied to recent phase I trials and, if possible, their impact.

METHODS

Reports of phase I trials of single agent cytotoxics published between 1993 and 1995 were identified by computer search and review of cancer journals. Data on starting dose, toxicology, dose escalation method, definition of dose limiting toxicity (DLT), actual maximum tolerated dose (MTD) and recommended phase II dose were abstracted.

RESULTS

Reports of 46 phase I trials were identified: 27 were the first clinical studies of 17 new cytotoxic agents (group A) and 19 were repeat studies of 14 agents (group B). Starting doses in group A were based on preclinical animal toxicology (usually mouse or dog) and for group B on previous clinical experience. Dog toxicology appropriately influenced starting dose in 3 of 6 trials. The majority of group A (19/27) studies employed modified Fibonacci dose escalation; group B studies commonly escalated doses by fixed increments. The definition of DLT was highly variable across studies. MTD was usually defined as the dose level at which > 2/6 patients experienced DLT but several studies required 3-4/6 patients. In 30 trials, the recommended phase II dose was one dose level below the MTD; but in 10 trials the terms MTD and recommended phase II dose were considered synonymous.

CONCLUSION

Despite proposed new methodologies (particularly dose escalation) for phase I trials, very few are being employed in practice. A concerted effort should be made to prospectively evaluate these to determine which provides the best combination of safety and efficacy. In addition, the lack of standardization in the definition of limiting toxicity is surprising. Those involved in drug development should strive for agreement on the acceptable degree of toxicity for phase II dose selection.