Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer were updated and published online in 2023, and adapted, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with early breast cancer. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with breast cancer representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and KSMO. The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with early breast cancer across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling, as well as the age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Effect of epidural analgesia on cervical ripening using dinoprostone vaginal inserts

OBJECTIVE

To clarify whether the duration from cervical ripening induction to labor onset is prolonged when epidural analgesia is administered following application of dinoprostone vaginal inserts vs. cervical ripening balloon.

METHODS

This retrospective study included mothers with singleton deliveries at a single center between 2020-2021. Nulliparous women who underwent labor induction and requested epidural analgesia during labor after 37 weeks of gestation were included. The duration from cervical ripening induction to labor onset was compared between women using a dinoprostone vaginal insert and those using a cervical ripening balloon and between women who received epidural analgesia before and after labor onset.

RESULTS

In the dinoprostone vaginal insert group, the duration was significantly shorter in the subgroup that received epidural analgesia after labor onset (estimated median, 545 [95% confidence interval: 229-861 min]) than the subgroup that received it before labor onset (estimated median, 1,570 [95% confidence interval: 1,226-1,914] min, p = 0.004). However, in the cervical ripening balloon group, the difference between subgroups was not significant. The length of labor among the groups was also not significantly different.

CONCLUSION

Epidural analgesia as labor relaxant adversely affected the progression of uterine cervical ripening when dinoprostone vaginal inserts were used, whereas it did not affect cervical ripening when a mechanical cervical dilatation balloon was used. The present results are significant for choosing the appropriate ripening method.

Identifying prognostic biomarkers for palbociclib add-on therapy in fulvestrant-resistant breast cancer using cell-free DNA sequencing

BACKGROUND

The FUTURE trial (UMIN000029294) demonstrated the safety and efficacy of adding palbociclib after fulvestrant resistance in patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) advanced and metastatic breast cancer (ABC/MBC). In this planned sub-study, cancer panel sequencing of cell-free DNA (cfDNA) was utilized to explore prognostic and predictive biomarkers for further palbociclib treatment following fulvestrant resistance.

MATERIALS AND METHODS

Herein, 149 cfDNA samples from 65 patients with fulvestrant-resistant disease were analysed at the time of palbociclib addition after fulvestrant resistance (baseline), on day 15 of cycle 1, and at the end of treatment using the assay for identifying diverse mutations in 34 cancer-related genes.

RESULTS

During the course of treatment, mutations in ESR1, PIK3CA, FOXA1, RUNX1, TBX3, and TP53 were the most common genomic alterations observed. Analysis of genomic mutations revealed that before fulvestrant introduction, baseline PIK3CA mutations were marginally lower in metastatic aromatase inhibitor (AI)-treated patients compared to adjuvant AI-treated patients (P = 0.063). Baseline PIK3CA mutations were associated with poorer progression-free survival [hazard ratio: 1.62, P = 0.04]. Comparative analysis between baseline and early-changing gene mutations identified poor prognostic factors including early-changing MAP3K1 mutations (hazard ratio: 4.66, P = 0.04), baseline AR mutations (hazard ratio: 3.53, P = 0.04), and baseline PIK3CA mutations (hazard ratio: 3.41, P = 0.02). Notably, the relationship between ESR1 mutations and mutations in PIK3CA, MAP3K1, and TP53 weakened as treatment progressed. Instead, PIK3CA mutations became correlated with TP53 and FOXA1 mutations.

CONCLUSIONS

Cancer panel testing for cfDNA identified prognostic and predictive biomarkers for palbociclib add-on therapy after acquiring fulvestrant resistance in patients with HR+/HER2- ABC/MBC.

Optimal cervical-ripening method for labor induction in Japan after the era of controlled-release dinoprostone vaginal insert

OBJECTIVE

To investigate the predictive value of obstetric findings when using dinoprostone (prostaglandin E2 [PGE2]) vaginal inserts for cervical ripening, and to assess the optimal cervical-ripening method between PGE2 vaginal insert and/or cervical dilators.

METHODS

This prospective observational study enrolled pregnant women who underwent cervical ripening for labor induction in 37-41 week' gestation in 2020. In evaluation 1, optimal obstetric findings predictive of rapid cervical ripening using PGE2 were assessed. In evaluation 2, the duration from PGE2 administration to labor onset and perinatal outcomes were compared between cases in which only PGE2 was used and cases that were treated with PGE2 after mechanical cervical dilators (Dilapan®) for extremely immature cervical ripening (uterine cervical os <2 cm).

RESULTS

In evaluation 1, uterine dilatation before the use of a PGE2 vaginal insert was mostly correlated with the time from PGE2 administration to labor onset (r = -0.428, p < 0.001). When the uterine cervical os dilatation was ≥2 cm, a shorter time-to-labor onset was found. In addition, os dilatation, effacement, and station at the time of PGE2 vaginal insert removal also significantly progressed. In evaluation 2, the median duration from PGE2 administration to labor onset was 1740 min in cases where only PGE2 was used, and 610 min in those where PGE2 was used after mechanical cervical dilators (p = 0.011).

CONCLUSION

PGE2 vaginal inserts are relatively effective when the uterine cervical os is ≥2 cm in diameter. However, in cases of extremely immature cervical-ripening, it was feasible to use PGE2 vaginal inserts before mechanical cervical dilatation.

Individualized management of vasa previa and neonatal outcomes

OBJECTIVE

To describe our individualized management protocol for women with an antenatal diagnosis of vasa previa (VP) and to report maternal and neonatal outcomes in patients managed according to our protocol.

METHODS

A retrospective study of prospectively collected data of antenatally diagnosed VP managed at our hospital between 2014 and 2021. Obstetric and neonatal outcomes were reviewed and analyzed.

RESULTS

Fourteen cases of antenatally diagnosed VP in 5150 total deliveries were analyzed (0.3%) Five cases (36%) of VP were diagnosed during the routine fetal morphological ultrasound screening, and nine cases (64%) were referred to our hospital due to perinatal complications. There were nine cases that required hospitalization (due to fetal growth restriction [FGR] [1], preterm labor [3], patients' request [5]). The other five were asymptomatic. Eight patients were delivered by scheduled cesarean section at around 36 weeks and only three neonates were admitted to NICU with transient tachypnea of newborn. However, six patients required CS before the scheduled dates because of other complications (preterm labor [3], abnormal cardiotocogram patterns [1], FGR [1] and twin pregnancy [1]). Four neonates born by CS before their scheduled dates were admitted to NICU. No cases required prolonged hospitalization and there were no serious neonatal complications.

CONCLUSION

Individualized management may lead to favorable outcomes with VP. Outpatient management may be considered in patients without risk factors. However, maternal hospitalization and earlier scheduled CS should be considered in symptomatic patients or those at risk for preterm delivery.

Ultrasound Doppler Findings in Fetal Vascular Malperfusion Due to Umbilical Cord Abnormalities: A Pilot Case Predictive for Cerebral Palsy

Fetal Vascular Malperfusion (FVM), a pathologic condition in the feto-placental circulation, is a chronic vaso-occlusive disorder in the umbilical venous blood flow. Microthrombi are caused by the umbilical cord's blood flow deficiency in a congested umbilical vein, which also causes microvascular damage to fetal organs, especially the brain, resulting in cerebral palsy. Thrombo-occlusive events also adversely affect the upstream chorionic or stem vessels in the placenta, resulting in fetal growth restriction and fetal hypoxia. An umbilical cord structural anomaly or multiple entanglements may involve FVM. In the present report, we demonstrate a case of FVM caused by multiple umbilical cord abnormalities obtained from antenatal ultrasound Doppler findings, and we also discuss FVM, which is chronically associated with CP, comparing the ultrasonographic findings to the pathologic findings.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Large-Scale Prospective Genome-Wide Association Study of Oxaliplatin in Stage II/III Colon Cancer and Neuropathy

IMPORTANCE

The severity of oxaliplatin (L-OHP)-induced peripheral sensory neuropathy (PSN) exhibits substantial interpatient variability, and some patients suffer from long-term, persisting PSN.

OBJECTIVE

To identify single-nucleotide polymorphisms (SNPs) predicting L-OHP-induced PSN using a genome-wide association study (GWAS) approach.

DESIGN, SETTING, PARTICIPANTS

A large prospective GWAS including 1,379 patients with stage II/III colon cancer who received L-OHP-based adjuvant chemotherapy (mFOLFOX6/CAPOX) under the phase II (JOIN/JFMC41) or the phase III (ACHIVE/JFMC47) trial.

MAIN OUTCOMES AND MEASURES

First, GWAS comparison of worst grade PSN (grade 0/1 vs. 2/3) was performed. Next, to minimize the impact of ambiguity in PSN grading, extreme PSN phenotypes were selected and analyzed by GWAS. SNPs that could predict time to recovery from PSN were also evaluated. In addition, SNPs associated with L-OHP-induced allergic reactions (AR) and time to disease recurrence were explored.

RESULTS

No SNPs exceeded the genome-wide significance (p < 5.0 × 10^-8) in either GWAS comparison of worst grade PSN, extreme PSN phenotypes, or time to recovery from PSN. Association study focusing on AR or time to disease recurrence also failed to reveal any significant SNPs.

CONCLUSION AND RELEVANCE

Our results highlight the challenges of utilizing SNPs for predicting susceptibility to L-OHP-induced PSN in daily clinical practice.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with early breast cancer: a KSMO-ESMO initiative endorsed by CSCO, ISMPO, JSMO, MOS, SSO and TOS

In view of the planned new edition of the most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of primary breast cancer published in 2015, it was decided at the ESMO Asia Meeting in November 2018, by both the ESMO and the Korean Society of Medical Oncology (KSMO), to convene a special face-to-face guidelines meeting in 2019 in Seoul. The aim was to adapt the latest ESMO 2019 guidelines to take into account the ethnic and geographical differences associated with the treatment of early breast cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with early breast cancer representing the oncology societies of Korea (KSMO), China (CSCO), India (ISMPO) Japan (JSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices, and the drug availability and reimbursement situations, in the individual participating Asian countries.

Abstract OT2-07-05: A phase III trial to compare eribulin mesylate + trastuzumab (H) + pertuzumab (P) with paclitaxel or docetaxel + HP for HER2-positive advanced or metastatic breast cancer (JBCRG-M06/ EMERALD)

Background: Docetaxel + Trastuzumab (H) + Pertuzumab (P) provided progression-free survival (PFS) and overall survival (OS) benefits in HER2-positive advanced or metastatic breast cancer (AMBC) in the CLEOPATRA study as a first-line therapy. However, long-term administration of docetaxel at a dose of 75 mg/m2 every 3 weeks in AMBC patients (pts) is difficult due to the toxicities. Eribulin mesylate (E) is a well-tolerated microtubule inhibitor, and we have reported the efficacy and safety of EHP regimen as first- and second-line therapy for AMBC in a multicenter, phase II study (JBCRG-M03/UMIN000012232). In this M06 study, we address the clinical question as to which is the better chemotherapy partner for HP as first line regimen, in terms of efficacy, toxicity and QOL.

Methods: JBCRG-M06 is a multicenter open-label randomized phase III study for HER2-positive AMBC pts who have received no prior chemotherapy except for the HER2- Antibody-Drug Conjugate (ADC). Pts will be randomized 1:1 to E (1.4mg/m2 on day 1 and 8) + H (8 mg/kg loading dose followed by 6 mg/kg) +P (840 mg loading dose followed by 420 mg) q3wks or standard taxanes (docetaxel 75mg/m2 on day1 or paclitaxel 80mg/m2 on day 1, 8 and 15) + HP q3wks. Stratification factors for randomization are; presence of visceral metastases, number of prior taxanes on perioperative adjuvant treatment, and treatment with prior anti-HER2-ADC. Primary endpoint is PFS and secondary endpoints include overall response rate, duration of response, OS, patient-reported outcomes (PRO) relating to QOL and peripheral neuropathy, new-metastases free survival, and safety. Translational research to search for biomarker for individual precision therapy will be performed. Main eligibility criteria are as follows: pts with HER2-positive AMBC, female aged 20-70 years old, ECOG PS of 0-1, LVEF ≥ 50% at baseline and adequate organ function. Pts who had progressive MBC within 6 months after the end of primary adjuvant systemic chemotherapy are excluded. The sample size was calculated by type1 error (2-sided) of 0.05 and 80% power to estimate the noninferiority margin 1.33 with an expected median PFS of 14.2 months. The target number of pts is 480 recruited over the duration of 3-years. The first patient in was achieved on August 2017. (ClinicalTrials.gov Identifier:NCT03264547).

Citation Format: Masuda N, Yamashita T, Saji S, Araki K, Ito Y, Takano T, Takahashi M, Tsurutani J, Koizumi K, Kitada M, Kojima Y, Sagara Y, Tada H, Iwasa T, Kadoya T, Iwatani T, Hasegawa H, Morita S, Ohno S. A phase III trial to compare eribulin mesylate + trastuzumab (H) + pertuzumab (P) with paclitaxel or docetaxel + HP for HER2-positive advanced or metastatic breast cancer (JBCRG-M06/ EMERALD) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-05.

Abstract P3-13-06: Tailored neoadjuvant endocrine and chemo-endocrine therapy for postmenopausal patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative primary breast cancer

Aims We investigated the efficacy and safety of initial neoadjuvant endocrine therapy with exemestane (EXE) alone followed by subsequent tailored treatment with EXE alone for responders or EXE plus oral metronomic cyclophosphamide (CPA) for non-responders.

Methods In this multicenter open-label phase II study, we enrolled postmenopausal patients with primary invasive estrogen receptor (ER)-positive, HER2-negative, stage I–IIIA (T1c–T3 N0–2 M0) breast cancer and Ki67 index ≤ 30%. Patients first received EXE 25mg/day for 12 weeks. Based on clinical response and change in Ki67 index in response to the initial therapy, patients who achieved complete response (CR), partial response (PR) with Ki67 index ≤5% after treatment, or stable disease (SD) with Ki67 index ≤5% both before and after treatment were defined as responders. Non-responders were defined as patients with PR and Ki67 index &gt;5% after treatment, or SD and Ki67 index &gt;5% before or after treatment. For the subsequent 24 weeks, responders continued the EXE monotherapy (continued EXE group), whereas non-responders switched to combination therapy with EXE plus CPA 50mg/day (EXE+CPA group). The primary endpoint was clinical response (CR and PR) at weeks 24 and 36.

Results A total of 59 patients (median age 69 years, range 53–86 years) were enrolled between January 2011 and July 2015. After exclusion of 3 (2 with progressive disease, 1 with an adverse event, AE) who discontinued treatment in the initial 12-week EXE monotherapy period, 56 remained enrolled to receive subsequent treatment. After 8–12 weeks of the initial EXE monotherapy, 14 patients were classified as responders (9 with PR and Ki67 index ≤5% after treatment; 5 with SD and Ki67 index ≤5% before and after treatment), whereas 42 were classified as non-responders (3 with PR and Ki67 index &gt;5% after treatment; 39 with SD and Ki67 index &gt;5% before or after treatment). Clinical response rates at weeks 24 and 36 were 85% (12/14, 95%CI 57.2–98.2%) and 76% (10/13, 95%CI 46.2–95.0%), respectively, in the continued EXE group, and 56% (23/41, 95%CI 39.7–71.5%) and 76% (30/39, 95%CI 60.7–88.9%), respectively, in the EXE+CPA group. At week 36, no significant difference was found in median Ki67 index between the continued EXE and EXE+CPA groups (3.5% and 4.0%, respectively). The proportion of patients with preoperative endocrine prognostic index (PEPI) 0 was also similar between the continued EXE and EXE+CPA groups (21.4% and 23.8%, respectively). The breast-conserving surgery rate was 71.4% and 69.0%, respectively. Grade 3 AEs were elevated liver enzymes (1 patient) in the continued EXE group, and gastritis, hypertriglyceridemia, and bone mineral density loss (1 patient each) in the EXE+CPA group.

Conclusion Switching from EXE monotherapy to EXE+CPA combination therapy based on clinical response and biological response (change in Ki67 index) to initial therapy improved subsequent clinical response in non-responders. Favorable clinical response to EXE alone was maintained in responders. Tailored neoadjuvant endocrine and chemo-endocrine therapy was shown to be effective in postmenopausal ER-positive breast cancer patients. (JBCRG-11CPA; UMIN000004751)

Citation Format: Masuda N, Sato N, Morimoto T, Ueno T, Kanbayashi C, Kaneko K, Yasojima H, Saji S, Sasano H, Morita S, Ohno S, Toi M. Tailored neoadjuvant endocrine and chemo-endocrine therapy for postmenopausal patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative primary breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-13-06.

Abstract P3-11-06: A phase 1 study of KHK2375 (entinostat) as monotherapy and in combination with exemestane in Japanese patients with hormone receptor-positive, HER2-negative, advanced or recurrent breast cancer

Background: Patients (pts) with hormone receptor-positive (HR+) and non-life threatening advanced or metastatic breast cancer (BC) are usually treated with sequential endocrine therapies. Endocrine therapies are continued until tumor cells acquire resistance to them, following which pts are switched to cytotoxic chemotherapy. Entinostat (ENT) is an oral inhibitor of class I histone deacetylases (HDACs) and is expected to be used for endocrine therapy-resistant pts. The efficacy of ENT in combination with an aromatase inhibitor (AI) for HR+ BC was demonstrated in a previous randomized phase 2 study. Because of the lack of data on safety and pharmacokinetics (PK) in Japanese HR+ BC pts, we performed this dose escalation phase 1 study to investigate the safety of ENT monotherapy and combination therapy with exemestane (EXE) in postmenopausal women with advanced or recurrent HR+ BC. Secondary objectives were to assess PK and efficacy.

Methods: This study was based on a 3+3 dose escalation design. Postmenopausal women with advanced or recurrent HR+ HER2- BC previously treated with nonsteroidal AIs and with ECOG PS 0-1 were enrolled. The dose limiting toxicities (DLT) of ENT monotherapy (3 mg/qw, 5 mg/qw, or 10 mg/q2w) in Cohort 1-3 and those of ENT (5 mg/qw or 3 mg/qw) in combination with EXE 25 mg/qd in Cohort 4-5 were assessed for 7 and 28 days, respectively. Pts continued ENT (3 mg or 5 mg) in combination with EXE even after the DLT observation period until disease progression or discontinuation for other reasons. Adverse events (AEs) were graded per NCI-CTCAE version 4.03. Tumor response was evaluated by RECIST version 1.1 every 8 weeks. ENT concentration was measured intensively. Samples of peripheral blood mononuclear cells (PBMC) were collected to measure protein lysine hyperacetylation and for immune subset analysis. Optional tumor biopsies for biomarker assessment were collected before and during treatment.

Results: Twelve pts were enrolled and three each were assigned to Cohort 1-4 between Nov 2015 and Sept 2016. Neither DLT nor grade 3-5 AE occurred. As no DLT occurred in Cohort 4, Cohort 5 was omitted as originally planned. The drug-related AEs observed in ≥2 pts during the DLT observation period were grade 1-2 hypophosphatemia (1 pt each in Cohort 2, 3, and 4), grade 1 nausea (1 pt in Cohort 3 and 2 pts in Cohort 4), and grade 1-2 platelet count decreased (2 pts in Cohort 4). AUC0-168 increased in a dose proportional manner. As of May 2017, 4 pts continue to receive study treatment, including one treated for more than 18 months. Biomarker data including protein lysine hyperacetylation and immune subset in PBMC and results of paired biopsy samples will be reported.

Conclusions: This study showed the tolerability of the combination therapy of ENT 5 mg with EXE 25 mg in Japanese pts. There were no new safety concerns as compared to those reported previously. Following this result, a randomized phase 2 study for Japanese pts is planned.

Clinical trial information : NCT02623751.

Citation Format: Shimomura A, Masuda N, Tamura K, Yasojima H, Sawaki M, Nishimura Y, Saji S, Iwata H. A phase 1 study of KHK2375 (entinostat) as monotherapy and in combination with exemestane in Japanese patients with hormone receptor-positive, HER2-negative, advanced or recurrent breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-11-06.

A randomized phase III trial comparing S-1 versus UFT as adjuvant chemotherapy for stage II/III rectal cancer (JFMC35-C1: ACTS-RC)

This phase III study is the first study to demonstrate the superiority of new oral fluoropyrimidine S-1 over tegafur–uracil as adjuvant chemotherapy for stage II/III rectal cancer patients with no preoperative treatment in terms of relapse-free survival. S-1 can be considered an important option, especially for patients who have not received preoperative treatment.

Backgrounds

Preventing distant recurrence and achieving local control are important challenges in rectal cancer treatment, and use of adjuvant chemotherapy has been studied. However, no phase III study comparing adjuvant chemotherapy regimens for rectal cancer has demonstrated superiority of a specific regimen. We therefore conducted a phase III study to evaluate the superiority of S-1 to tegafur–uracil (UFT), a standard adjuvant chemotherapy regimen for curatively resected stage II/III rectal cancer in Japan, in the adjuvant setting for rectal cancer.

Patients and methods

The ACTS-RC trial was an open-label, randomized, phase III superiority trial conducted at 222 sites in Japan. Patients aged 20–80 with stage II/III rectal cancer undergoing curative surgery without preoperative therapy were randomly assigned to receive UFT (500–600 mg/day on days 1–5, followed by 2 days rest) or S-1 (80–120 mg/day on days 1–28, followed by 14 days rest) for 1 year. The primary end point was relapse-free survival (RFS), and the secondary end points were overall survival and adverse events.

Results

In total, 961 patients were enrolled from April 2006 to March 2009. The primary analysis was conducted in 480 assigned to receive UFT and 479 assigned to receive S-1. Five-year RFS was 61.7% [95% confidence interval (CI) 57.1% to 65.9%] for UFT and 66.4% (95% CI 61.9% to 70.5%) for S-1 [P = 0.0165, hazard ratio (HR): 0.77, 95% CI 0.63–0.96]. Five-year survival was 80.2% (95% CI 76.3% to 83.5%) for UFT and 82.0% (95% CI 78.3% to 85.2%) for S-1. The main grade 3 or higher adverse events were increased alanine aminotransferase and diarrhea (each 2.3%) in the UFT arm and anorexia, diarrhea (each 2.6%), and fatigue (2.1%) in the S-1 arm.

Conclusion

One-year S-1 treatment is superior to UFT with respect to RFS and has therefore become a standard adjuvant chemotherapy regimen for stage II/III rectal cancer following curative resection.

Large-scale prospective pharmacogenomics study of oxaliplatin-induced neuropathy in colon cancer patients enrolled in the JFMC41-1001-C2 (JOIN Trial)

BACKGROUND

Peripheral sensory neuropathy (PSN) is a dose-limiting toxicity of oxaliplatin-based chemotherapy. Several genetic markers have been shown to predict oxaliplatin-induced PSN; however, results remain to be validated in a large-scale and prospective pharmacogenomics study.

PATIENTS AND METHODS

Among 882 patients enrolled in the JFMC41-1001-C2 (JOIN trial), which was designed to investigate the tolerability of adjuvant-modified FOLFOX6 (mFOLFOX6) in Japanese Patients with stage II or III colon cancers undergoing curative resection, 465 patients were eligible for this pharmacogenomics analysis. Twelve single-nucleotide polymorphisms (SNPs) were selected based on published data. The effect of each genotype on time to PSN onset was evaluated in all patients (n = 465) using the Cox proportional hazard model. For the association analysis between severity of PSN and 12 SNP markers, 84 patients who failed to complete 12 cycles of mFOLFOX6 from grade 0/1 PSN group were excluded because the termination of the protocol treatment had been caused by reasons other than PSN.

RESULTS

Comparison of grade 0/1 PSN with grade 2/3 PSN or grade 3 PSN showed no significant associations with any of the 12 SNP markers after adjustment for total dose of oxaliplatin. Time-to-onset analysis also failed to reveal any significant differences.

CONCLUSIONS

Our large-scale and prospective pharmacogenomics study of Japanese patients receiving protocol treatment of adjuvant mFOLFOX6 could not verify a role for any of the 12 SNP markers reported as being significantly associated with PSN. Considering the OR observed in this study (range: 0.76-1.89), further evaluation of these 12 SNP markers in the context of L-OHP-induced PSN is unlikely to be clinically informative.

Abstract P6-12-04: Delayed hospital visits in patients with breast cancer after the great East Japan earthquake and the subsequent Fukushima Daiichi nuclear power plant accident: A retrospective comparative analysis

Introduction

In breast cancer, delay in first presentation and self-interruption of continuous treatment are associated with lower survival. It has been suggested that risk factors for such behavioral patterns include poor social support.

Minamisoma City, located within a 30 kilometers radius from Fukushima Daiichi nuclear power plant, has experienced rapid change in social structures following the Great East Japan Earthquake and the subsequent power plant accident. There has been a mass evacuation among young and middle-aged generations for fear of potential irradiation, and this has resulted in the separation of families and friends. These changes may have resulted in a deterioration of social support for residents, which could consequently lead to changed patterns of behavior in diseases such as breast cancer.

Objectives

This study compared the behavioral patterns before and after the disasters in patients with breast cancer in Minamisoma City.

Methods

We retrospectively analyzed data from patients with breast cancer who were diagnosed from January 2008 through March 2015 in the two main cancer centers in Minamisoma City. Demographic and clinical information was extracted from medical records, including age, stage, pathological findings, treatment, and the reason for the first hospital visit. The main outcome was a change of interval from the appearance of initial symptoms to the first hospital visit before and after the disasters. We also assessed whether continuous follow-up was maintained after the disasters. We used an unpaired t-test for numerical variables and a chi-squared test for categorical variables.

Results

A total of 102 and 97 patients were diagnosed with breast cancer before and after the disasters, respectively. There were no statistically significant differences between the 2 groups concerning average age (61 years old vs. 61 years old, p=1), stage 3 or 4 cancer (18% vs. 17%, p=0.81), invasive cancer (92% vs. 93%, p=0.87) and symptomatic patients (75% vs. 74%, p=0.74), respectively. However, after the disasters, there were significant increases in the ratio of patients with more than a one-year delay from the appearance of the initial symptom to the first hospital visit (5.4% vs. 15%, p&lt;0.05). The patients with more than a one-year delay had a significantly higher ratio of advanced stage cancer compared with patients who visited a hospital earlier. Continuous follow-up was maintained in all patients diagnosed after the disasters.

Discussion

The characteristics of patients were not significantly different before and after the disasters, while the ratio of patients with more than a one-year delay of the first hospital visit significantly increased after the disasters. Although information on social capital and other sociodemographic factors was not available, we speculate that poor social support due to changed social structures after the disasters might contribute to delay in first presentation in symptomatic breast cancer patients. Further study is warranted to clarify the factors associated with delayed hospital visits, in order to establish effective health interventions in the aftermath of mass disasters.

Citation Format: Ozaki A, Tsubokura M, Nomura S, Morita T, Ochi S, Kato S, Saji S, Yokota T, Leppold C, Tanimoto T, Kami M, Tsukada M, Ohira H. Delayed hospital visits in patients with breast cancer after the great East Japan earthquake and the subsequent Fukushima Daiichi nuclear power plant accident: A retrospective comparative analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-04.

Abstract P1-14-01: Randomized controlled trial of toremifene 120 mg compared with exemestane 25 mg after prior non-steroidal aromatase inhibitor treatment in postmenopausal women with hormone receptor-positive metastatic breast cancer (Hi-FAIR ex study)

(Background) After the failure of a non-steroidal aromatase inhibitor (nsAI) for postmenopausal patients with metastatic breast cancer (mBC), it is uncertain which of endocrine therapy is the most appropriate.

(Methods) A randomized, open-label, multicenter phase II study was conducted to compare the efficacy and safety of daily toremifene 120 mg (TOR120), a selective estrogen receptor modulator, with exemestane 25 mg (EXE), a steroidal aromatase inhibitor. After disease progressed with assigned drug, the patients were subsequently treated with the other drug if patients were suitable for continuation with endocrine treatment. The primary endpoint was clinical benefit rate (CBR). The secondary end points were objective response rate (ORR), progression-free survival (PFS), overall survival (OS), toxicity and antitumor effect of subsequent endocrine treatment. To prove a probability of 90% that TOR120 was superior to EXE, 41 patients were required for each group. To account for dropouts and protocol violation, we planned to recruit 90 patients (45 in each group).

(Results) Initially, a total of 91women was registered in the study and randomly assigned to either TOR120 (n = 46) or EXE (n = 45) from October 2008 to November 2011. Three of the 46 patients in the TOR120 arm were not received treatment, 2 patients having withdrawn from the trial by their preference and one having been dropped due to administration of another SERM. When analyzed after a median observation period of 16.9 months, the intention-to-treat analysis showed that there was no statistical difference between TOR120 (n = 46) and EXE (n = 45) in terms of CBR (41.3% vs. 26.7%, p = 0.14), ORR (10.8% vs. 2.2%, p = 0.083), and OS (Hazard ratio (HR) 0.60, p = 0.22). The PFS of TOR120 was longer than that of EXE, the difference being statistically significant (HR 0.61, p = 0.045). Both treatments were well-tolerated with no severe adverse events, although the treatment of 3 of 43 women with TOR120 was stopped after a few days because of nausea, general fatigue, hot flash and night sweating. Twenty-four patients received subsequent TOR120 after failure of initial EXE treatment. Of these patients, ORR and CBR were 4.2% (1/24) and 33.3% (8/24), respectively. In 23 patients who received EXE after TOR120, ORR and CBR were 17.4% (4/23) and 30.4% (7/23), respectively.

(Conclusion) TOR120, as a subsequent endocrine therapy for mBC patients who failed non-steroidal AI treatment, could be equal to or potentially be more beneficial than EXE. In addition, about one third of patients who progress on either TOR120 or EXE could obtain clinical benefit from subsequent EXE or TOR120.

Trial registration number: UMIN000001841.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-14-01.

Abstract P3-06-18: Increase of serum androgen and its metabolites in postmenopausal primary breast cancer patients with disease progression during neo-adjuvant exemestane treatment; JFMC 34–0601 TR

BACKGROUND: We reported a positive correlation between body mass index (BMI) and clinical response to neo-adjuvant hormonal therapy (NAH) with steroidal aromatase inhibitor, exemestane, in post-menopausal breast cancer patients (Takada M et al. Breast 2012). Here, we examined the relationship between serum concentrations of sex steroids and BMI, and explored their predictive value for clinical response.

PATIENTS AND METHODS: Among the 116 post-menopausal patients enrolled in the JFMC 34–0601 clinical trial of 24 weeks (wks) of NAH with exemestane, serums from 60 patients at pre-treatment, at 4wks and end of the treatment (24wks) were subjected to this study. Estradiol (E2), estrone (E1), dehydroepiandrosterone (DHEA), androstenedione (A-dione), 5-androstene-3β, 17β-diol (Aenediol), 5α-androstane-3β, 17β-diol (Aanediol) were measured using LC-MS/MS analysis and E1- sulfate (E1S) was by RIA.

RESULTS: There were no significant correlations between pre-treatment concentrations of sex steroids and BMI, except for moderate correlation of E2 and BMI (p = 0.004). In multivariate analysis, E1 was an independent predictive factor for objective response [odds 6.0, 95% confidence interval (CI) 1.5 — 34.6, p = 0.011], as well as BMI. All of the estrogens decreased to under-detection levels (0.5 for E1 and E2, 5 pg/assay for E1S) at 4 wks of treatment, and maintained through to the end of treatment in almost all patients independently of clinical response. The geometric mean percentage changes in androgens after NAH were: DHEA −0.2% (95%CI −15.3% — +17.6%) for patients without progressive disease (non-PD) and +44.8% (95%CI +22.1% — +71.8%) for patients with progressive disease (PD); A-dione −2.3% (95%CI −17.3% — +15.4%) for non-PD and +45.6% (95%CI +28.3% — +65.3%) for PD; Aenediol −11.5% (95%CI −20.6% — −1.4%) for non-PD and +24.9% (95%CI +1.9% — +53.0%) for PD; Aanediol +21.3% (95%CI −5.5% — +55.8%) for non-PD and +56.3% (95%CI +5.3% — +132.0%) for PD, respectively. The changes in the concentrations of both DHEA and A-dione in patients with PD were statistically significant (p = 0.008 and p = 0.002, respectively). In all of the PD patients, the serum concentrations of DHEA and A-dione were increased after NAH.

CONCLUSION: Pretreatment serum concentration of E1 was an independent predictive factor for clinical response to NAH with exemestane. Measurement of dynamics of the serum androgen concentrations might be helpful for monitoring treatment response, and mechanism of increase of androgens has a value for further investigation. Our results should be validated using a larger dataset. (UMIN ID; C000000345)

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-18.

Abstract P3-02-06: Survival impact of early detection of recurrence after surgery in early breast cancer patients

Background and Object: Annual mammography and physical examination as the follow-up tests after surgery were recommended to early breast cancer patients based on the two randomized clinical trials (GIVIO and Rosselli Del Turco) which were reported in 1990s. Whereas, radiological imaging and blood test (serum tumor marker) for early detection of recurrence are not recommended due to the lack of evidence from clinical trial. However, the imaging techniques (helical CT, bone scan, PET/CT. MRI et al) to detect minute lesions and therapeutic options for metastatic breast cancer have been remarkably advanced since then. In fact, routine radiological examinations after surgery were performed in several Japanese hospitals for aiming early detection of recurrence as the clinical practice.

We here evaluate the possible benefit of early detection of recurrence by radiological and laboratory examinations during post-operative follow-up period.

Methods: Clinical information of breast cancer patients who were diagnosed as recurrence after surgery during 2005–2006 was collected from 30 hospitals in Japan. Clinical and pathological characteristics such as molecular subtype of breast cancer, survival time from initial therapy or 1st recurrence, detection methods and symptomatic information when they diagnosed as metastasis were analyzed retrospectively.

Results: As the routine examination of post-operative follow-up, serum tumor maker, chest x-ray/CT, abdominal US/CT and bone scan were done in 95%, 57%, 38%, 24% of 30 hospitals, respectively. Of the 698 patients individually evaluated in this analysis, 248 had loco-regional recurrences and 450 had distant metastases. The first distant metastatic site were 35% in bone, 30% in lung, 17% in liver and 11% in lymph node, respectively. All individual patients are divided into symptomatic (45.7%) or asymptomatic groups (54.3%) at the detection of metastases. Asymptomatic metastases were detected by serum tumor marker (26%), bone scan (18%), chest x-ray (17%), chest CT (17%), abdominal US (11%) and abdominal CT (5%), respectively. The median disease-free interval (DFI) was 3.0 years in both groups, but the median survival time after the diagnosis of recurrence to death were 3.7 years in asymptomatic patients and 3.0 years in symptomatic patients, respectively. In addition, asymptomatic group had significantly superior overall survival (from primary surgery to death) than symptomatic group with oligo-metastases such as limited organ disease (P &lt; 0.001).

Conclusions: Our data may support the hypothesis that early detection of breast cancer recurrences has beneficial impact on survival. Randomized clinical trial would be warranted to prove this hypothesis, and we are currently planning this.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-02-06.

P4-01-21: An Estrogen-Inducible Transcription Factor FOXP1 Promotes Estrogen-Dependent Cell Proliferation of Breast Cancer Cells and Is Associated with 5-Year Disease-Free Survival in Patients with Tamoxifen-Treated Breast Cancer

Estrogen signaling pathways are involved in the growth and development of breast tumors through the activation of estrogen receptor a (ERα). ERα is expressed in most breast cancers and involves in estrogen-dependent proliferation by acting as transcription factors activating the expression of target genes. Various coregulators and transcription factors are associated with ERα-mediated transcriptional control of target genes. Therefore, a comprehensive understanding of estrogen signaling pathways in breast cancer is required for both treatment and diagnosis of the disease. Forkhead box P1 (FOXP1) is a member of the forkhead box transcription factor family and has been reported to be associated with various types of tumors. Here, we investigated the expression pattern of FOXP1 by immunohistochemistry in a series of 133 invasive breast cancers and compared it with clinicopathological factors. The expression of FOXP1 was detected in nuclei in 89 cases (67%) and correlated positively with tumor grade and hormone receptor status, including ERα and progesterone receptor (PgR), and negatively with pathological tumor size (pT). And in ERα-positive MCF-7 breast cancer cells, we demonstrated that FOXP1 mRNA was upregulated by estrogen and that ERα recruitment to ER binding sites within the FOXP1 gene region identified by ChIP-chip analysis was increased. We also demonstrated that proliferation of MCF-7 cells was increased by exogenously transfected FOXP1 and decreased by FOXP1-specific siRNA. Moreover, in MCF-7 cells, FOXP1 enhanced estrogen response element (ERE)-driven transcription. Finally, FOXP1 immunoreactivity was significantly more elevated in relapse-free breast cancer patients treated with tamoxifen than in relapse patients treated with it. Taken together, these results suggest that FOXP1 plays an important role in proliferation of breast cancer cells by modulating estrogen signaling and that FOXP1 immunoreactivity might be associated with the estrogen dependency of breast cancer clinically, which may predict favorable prognosis in the patients treated with tamoxifen.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-01-21.

P2-12-21: Impact of Recent Parity on Histopathological Tumor Features and Outcome of Young Women with Breast Cancer

Background

Younger age has been associated with worse outcome in breast cancer patients (pts) and recent parity has been epidemiologically identified as worse prognostic factor among women with breast cancer. The objective of this study was to explore potential factors associated with worse prognosis in young breast cancer pts, and to demonstrate the impact of parity on the histopathological tumor feature and patient outcome.

Materials and Methods: We retrospectively analyzed 634 early breast cancer pts younger than 45 years old who underwent surgery between 2000 and 2009. For statistical analysis, Pearson's and Fisher's exact test were used. Survival analysis was performed only for pts diagnosed before 2006 in order to obtain a minimum follow up 5 years.

Results: 108 women were diagnosed within 5 years since last parity (Group A), 216 were diagnosed &gt; 5 years since last parity (Group B) and 310 were nulliparous (Group C). Median age at diagnosis was 37 (range 26–44), 41 (range 32–44), and 38.5 (range 22–44) and family history (FH) of breast and/or ***ovarian cancer within second degree was found in 23, 22, and 23% of the pts in Groups A, B, and C, respectively. In Groups A, B and C, clinical stage was III in 22, 10 and 12% (p= .025), ER was positive in 65, 69 and 70% (p= .650), PgR was positive in 64, 75 and 74% (p= .057), and HER2 was positive in 25, 14 and 14% (p=.017), respectively. Tumors in Group A had higher histological grade (grade 3: 60/44/47%, p=.019), higher nuclear grade (grade 3: 61/47/48%, p=.036) and more lymph vessel invasion (61/52/45%, p=.015) compared to those in Groups B and C, respectively. Median follow up time was 85.1 months (range 1.8−137.1 months) during which there were 61 deaths. In univariate analysis, age and FH were not correlated with overall survival (OS). OS in Group A was significantly lower than in Group B (hazard ratio (HR) 3.51, 95% confidential interval (CI) 1.80−6.84, p&lt;.001) and in Group C (HR 2.42, 95%CI 1.36−4.29, p=.002), while OS did not differ significantly between Groups B and C. In the pts without FH, the HR of cancer death was more pronounced in Group A than in Group B (HR 4.25, 95%CI 1.97−9.14, p&lt;.001) or Group C (HR 2.67, 95%CI 1.43−5.01, p=.002), while there was no significant difference among the groups in pts with FH. In multivariate analysis among the pts without FH, lymph vessel invasion (HR 4.51, 95%CI 1.89−10.76, p=.001), Group A women (HR 2.28, 95%CI 1.25−4.17, p=.007), histological grade 3 (HR 2.72, 95%CI 1.28−5.77, p=.009), PgR negativity (HR 2.23, 95%CI 1.19−4.18, p=.013) and clinical stage II and III (HR 2.92, 95%CI 1.04−8.21, p=.04) were significantly associated with poor prognosis, adjusting for age.

Conclusion: Recent parity was associated with worse histopathological features in breast cancer of women younger than 45. It was also associated with worse outcome, especially among pts without FH. Recent parity seems to be a confounding factor for the worse outcome in young breast cancer patients, which justifies further studies to elucidate underlying biology.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-21.