Patient perception of the benefit of a BRAF inhibitor in metastatic melanoma: quality-of-life analyses of the BREAK-3 study comparing dabrafenib with dacarbazine.

BACKGROUND: In a randomized phase III study (BREAK-3), dabrafenib showed prolonged progression-free survival (PFS) (median 5.1 versus 2.7 months; hazard ratio = 0.30; 95% confidence interval 0.18-0.53; P < 0.0001) compared with dacarbazine (DTIC) in patients with BRAF V600E metastatic melanoma. Assessing how these results are transformed into a real health benefit for patients is crucial. METHODS: The EORTC QLQ-C30 questionnaire assessed quality of life (QoL) at baseline and follow-up visits. RESULTS: For DTIC, all functional dimensions except role dimension worsened from baseline at follow-up. For dabrafenib, all functionality dimensions remained stable relative to baseline or improved at week 6; mean change in seven symptom dimensions improved from baseline, with appetite loss, insomnia, nausea and vomiting, and pain showing the greatest improvement. In the DTIC arm, symptom dimensions were unchanged or worsened from baseline for all symptoms except pain (week 6), with the greatest exacerbations observed for fatigue and nausea and vomiting. Mixed-model-repeated measures analyses showed significant (P < 0.05) and/or clinically meaningful improvements from baseline in favor of dabrafenib for emotional and social functioning, nausea and vomiting, appetite loss, diarrhea, fatigue, dyspnea, and insomnia at weeks 6 and/or 12. After crossing over to dabrafenib upon progression (n = 35), improvements in all QoL dimensions were evident after receiving dabrafenib for 6 (n = 31) to 12 (n = 25) weeks. CONCLUSIONS: This first reported QoL analysis for a BRAF inhibitor in metastatic melanoma demonstrates that the high tumor response rates and PFS superiority of dabrafenib over DTIC is not only a theoretical advantage, but also transforms in a rapid functional and symptomatic benefit for the patient. ClinicalTrials.gov Identifier: NCT01227889.

Functional and symptom impact of trametinib versus chemotherapy in BRAF V600E advanced or metastatic melanoma: quality-of-life analyses of the METRIC study.

BACKGROUND: In a randomized phase III study, trametinib prolonged progression-free survival and improved overall survival versus chemotherapy in patients with BRAF V600 mutation-positive melanoma. PATIENTS AND METHODS: Patients' quality of life (QOL) was assessed at baseline and follow-up visits using the European Organisation for Research and Treatment of Cancer Core QOL questionnaire. RESULTS: In the primary efficacy population (BRAF V600E+, no brain metastases) from baseline to weeks 6 and 12, patients' global health status scores worsened by 4-5 points with chemotherapy but improved by 2-3 points with trametinib. Rapid and substantive reductions in QOL functionality (e.g. role functioning, 8-11 points at weeks 6 and 12) and symptom exacerbation (e.g. fatigue, 4-8 points; nausea and vomiting, 5 points, both at weeks 6 and 12) were observed in chemotherapy-treated patients. In contrast, trametinib-treated patients reported small improvements or slight worsening from baseline at week 12, depending on the functional dimension and symptom. The mean symptom-scale scores for chemotherapy-treated patients increased from baseline (symptoms worsened) for seven of eight symptoms at week 6 (except insomnia) and six of eight symptoms at week 12 (except dyspnea and insomnia). In contrast, at weeks 6 and 12, the mean symptom-scale scores for trametinib decreased from baseline (symptoms improved) for pain (11-12 points), insomnia (10-12 points), and appetite loss (1-5 points), whereas those for diarrhea worsened (15-16 points). Mixed-model repeated-measures analyses showed significant (P < 0.05) and/or clinically meaningful improvements (small to moderate) from baseline in favor of trametinib for global health; physical, role, and social functioning; fatigue; pain; insomnia; nausea and vomiting; constipation; dyspnea; and appetite at weeks 6 and/or 12. QOL results for the intent-to-treat population were consistent. CONCLUSIONS: This first QOL assessment for a MEK inhibitor in metastatic melanoma demonstrated that trametinib was associated with less functional impairment, smaller declines in health status, and less exacerbation of symptoms versus chemotherapy.

Reasons for nonuse of antiviral treatment in patients with chronic hepatitis C infection and thrombocytopaenia: a retrospective chart review from five European countries.

Antiviral therapy has been shown to reduce the risk of disease progression, liver damage and death in patients with chronic hepatitis C virus (HCV) infection. While interferon labels recommend that patients with platelet counts below 50 × 10(3) /µL not receive interferon-based therapy, it is unknown to what extent thrombocytopaenia influences treatment decisions in practice. This study profiles the reasons for withholding antiviral treatment in HCV patients with thrombocytopaenia in five European countries. Medical records of 466 patients who had HCV infection and thrombocytopaenia (platelet count <100 × 10(3) /µL) in 2006 were retrospectively reviewed for clinical characteristics. Collected data included use of antiviral therapy and reasons for withholding therapy. In total 184 of 466 patients (39.5%) did not receive interferon-based therapy during the study period, with treatment withheld most frequently due to multiple clinical characteristics including hepatic cirrhosis (16.3%), thrombocytopaenia (16.3%) and age >60 years (10.9%). The reasons for lack of treatment varied among countries, with thrombocytopaenia as a reason being more common in Italy (10.9%) and Spain (20.0%), and less common in France, Germany and the UK (3.2-7.1%). Overall, thrombocytopaenia was reported as the only reason for withholding treatment in 4.9% of untreated patients. This study demonstrates that thrombocytopaenia is one of many factors, indicative of the poor clinical state of the patient, that contributes to withholding antiviral treatment. In 4.9% of untreated patients, thrombocytopaenia can be considered as a modifiable factor to enable more HCV patients to receive guideline-recommended therapy and thus improved clinical outcomes.

Growth inhibiting activity of volatile oil from Cistus creticus L. against Borrelia burgdorferi s.s. in vitro.

Borreliosis patients from self-help groups reported considerable pain relief after ingestion of Cistus creticus leaf preparations. C. creticus leaf extracts of different polarities such as aqueous, ethyl acetate, hexane extracts as well as the volatile oil fraction obtained by steam distillation were tested for their antibacterial activity against Borrelia burgdorferi sensu stricto (Bbss) in vitro using the antibiotic amoxicilline as standard and polysorbate 80 as solubilizer for lipophilic extracts. Comparison of the four plant preparations shows that the volatile oil exerts the strongest growth inhibitory effect. Even concentrations of 0.02% (w/v) volatile oil in cultivation media reduced the total number of bacteria to 2% in comparison to a growth control after an eight-day cultivation period. While the aqueous extract did not reduce bacterial growth, incubation with hexane and ethyl acetate extracts clearly inhibited microbial growth. The main volatile components of the three active extracts tested were analyzed by GC-MS. The number of different labdane-type diterpenes as well as the total relative amount of diterpenes in the samples tested was highest in the essential oil of C. creticus. Identification of ten different volatile labdane-type diterpenes was assigned to the essential oil of C. creticus. Among these, manoyl oxide, 13-epi-manoyl oxide, 3-acetoxy-manoyl oxide and the monoterpene carvacrol were determined to be major constituents, accompanied by minor amounts of 3-hydroxy-manoyl oxide, all of which are known to exert antimicrobial activity.

Adriamycin: the role of lipid peroxidation in cardiac toxicity and tumor response.

The antitumor antibiotic, adriamycin, induces severe cardiac toxicity associated with peroxidation of cardiac lipids in mice. Both this lipid peroxidation and cardiac toxicity of adriamycin are reduced by prior treatment of the animals with the free radical scavenger tocopherol. Such treatment with tocopherol does not, however, alter the magnitude or duration of the adriamycin-induced suppression of DNA synthesis in P388 ascites tumor, nor does it diminish the antitumor responsiveness of P388 ascites tumor. These results suggest that adriamycin has at least two mechanisms of tissue damage: one, which involves lipid peroxidation, is blocked by tocopherol and results in cardiac toxicity; the other, which involves binding to DNA, is not antagonized by tocopherol and is responsible for tumor response.

Inhibition of human ovarian cancer colony formation by adriamycin and its major metabolites.

We have examined the in vitro sensitivity to Adriamycin of human ovarian cancer colonies cloned in soft agar. In the 26 patients tested, 3 different patterns of sensitivity to Adriamycin were observed: (a) in 75% of the previously untreated patients, there was greater than 70% reduction in colony-forming cells after exposure to Adriamycin (1.0 micrograms/ml), a level which approximates the peak plasma level after i.v. therapy; (b) in all the patients who had progressive disease while on a chemotherapy regimen without Adriamycin, a greater than 70% reduction in colony-forming cells was observed only at a concentration of 10 micrograms/ml, a level not achievable by i.v. administration; (c) in 80% of patients with progressive disease after treatment with Adriamycin as part of the primary chemotherapy regimen, a 70% reduction in tumor colony-forming cells could not be achieved even at 10 micrograms/ml. These in vitro results are in agreement with clinical observations regarding the effectiveness of Adriamycin in previously untreated patients (42% response rate) with ovarian cancer as well as its ineffectiveness (0 to 6% response rate) as a second-line therapy in relapsed patients. The results also have provided a rationale for an ongoing Phase I trial of i.p. Adriamycin in patients with ovarian cancer from Group b above since cytotoxic levels can be produced i.p. using large-volume dialysis via a Tenckhoff dialysis catheter. The relative cytotoxicity of Adriamycin to its two major metabolites, adriamycinol and adriamycin aglycone, was also determined in the clonogenic assay. Both derivatives produced suppression of ovarian cancer colony formation; however, Adriamycin was more cytotoxic that was either metabolite.

Characterization of a xenograft model of human ovarian carcinoma which produces ascites and intraabdominal carcinomatosis in mice.

We have used in vivo and in vitro procedures to select a subpopulation of cells from the human ovarian carcinoma cell line, NIH:OVCAR-3, with the capacity to grow i.p. in female nude athymic mice. After i.p. injection of these cells, animals develop metastatic spread similar to that of clinical ovarian cancer. Disease progression is characterized by the development of massive ascites, extensive invasive i.p. tumors, and pulmonary metastases. The malignant ascites cells are transplantable, manifest cytoplasmic androgen and estrogen receptors, and express the ovarian cancer associated antigen CA125 (116,000 units/ml of ascites supernatant). The cells also have the same chromosome markers which were present in the original cell line, NIH:OVCAR-3. Survival following i.p. passage of ascites is dependent on tumor cell inoculum ranging from a median survival of 39 days with 40 million cells to 84 days for 11.5 million transplanted cells. The characteristics of this unique in vivo model make it well suited for the evaluation of new drugs and novel experimental therapies in ovarian cancer. In addition, this in vivo model, together with ovarian cancer cell lines, may prove particularly useful for the study of pharmacological ways to specifically increase the cytotoxicity of anticancer agents in tumor cells while not increasing toxicity in normal tissues. The presence of hormone receptors should facilitate the experimental evaluation of hormonal therapy in ovarian cancer.

Radiation survival parameters of antineoplastic drug-sensitive and -resistant human ovarian cancer cell lines and their modification by buthionine sulfoximine.

The optimum integration of chemotherapy and irradiation is of potential clinical significance in the treatment of ovarian cancer. A series of human ovarian cancer cell lines have been developed in which dose-response relationships to standard anticancer drugs have been determined, and the patterns of cross-resistance between these drugs and irradiation have been established. By stepwise incubation with drugs, sublines of A2780, a drug-sensitive cell line, have been made 100-fold, 10-fold, and 10-fold more resistant to Adriamycin (2780AD), melphalan (2780ME), and cisplatin (2780CP). Two additional cell lines, NIH:OVCAR-3nu(Ag+) and NIH:OVCAR-4(Ag+), were established from drug-refractory patients. 2780ME, 2780CP, OVCAR-3nu(Ag+), and OVCAR-4(Ag+) are all cross-resistant to irradiation, with DOS of 146, 187, 143, and 203, respectively. However, 2780AD remains sensitive to radiation, with a DO of 111, which is similar to that of A2780 (101). Glutathione (GSH) levels are elevated in 2780ME, 2780CP, OVCAR-3nu(Ag+), and OVCAR-4(Ag+) to 4.58, 6.13, 12.10, and 15.14 nmol/10(6) cells as compared to A2780, with 1.89 nmol/10(6) cells. However, the GSH level in 2780AD is only minimally higher than that in A2780 (2.94 nmol/10(6) cells). Buthionine sulfoximine, a specific inhibitor of GSH synthesis, significantly increases the radiation sensitivity of 2780ME (changing the DO from 143 to 95) and 2780CP to a lesser extent, suggesting that intracellular GSH levels may play an important role in the radiation response of certain neoplastic cells. These results suggest that the sequential use of irradiation following chemotherapy with melphalan and cisplatin may be less effective than a combined modality approach, which integrates radiation and chemotherapy prior to the development of drug resistance and cross-resistance to irradiation.

Characterization of a cis-diamminedichloroplatinum(II)-resistant human ovarian cancer cell line and its use in evaluation of platinum analogues.

Human ovarian cancer cell lines with stable cisplatin resistance have been developed by chronic exposure of the parent cisplatin-sensitive A2780 line to increasing concentrations of cisplatin. 2780CP8 (CP8 refers to this cell line's growth in medium containing 8 microM cisplatin) has several clonal cytogenetic abnormalities but lacks homogeneously staining regions or double-minute chromosomes. It has a significantly greater monolayer growth rate, cloning efficiency in agarose, and total glutathione content compared to the A2780 line, but similar activities of several glutathione-dependent enzymes. The 2780CP8 subline is 7.3-fold resistant to cisplatin compared to the A2780 line, as well as cross-resistant to irradiation and melphalan. It is not cross-resistant to Adriamycin, but this develops with increased cisplatin resistance (14-fold) obtained by further cisplatin exposure of 2780CP8. Of the cisplatin analogues tested which are of current clinical interest, carboplatin, iproplatin, and tetraplatin, only the latter is more cytotoxic than cisplatin in the A2780 and 2780CP8 lines. The 2780CP8 subline is also cross-resistant to these analogues in the relative order carboplatin greater than iproplatin greater than tetraplatin (most to least cross-resistant). Treatment of a highly cisplatin resistant cell line (2780CP70) with either melphalan or cisplatin was associated with a significant increase in [3H]thymidine incorporation into DNA in the presence of 10 mM hydroxyurea compared with the parent sensitive cell line which showed essentially no capacity to repair DNA damage by these drugs. A2780 and its cisplatin-resistant cell lines may thus be useful in studying drug resistance mechanisms, in screening new drugs for activity (especially against drug resistant tumors), and in formulating induction and salvage therapies for ovarian cancer.

Characterization of a human ovarian carcinoma cell line (NIH:OVCAR-3) with androgen and estrogen receptors.

A cell line, NIH:OVCAR-3, has been established from the malignant ascites of a patient with progressive adenocarcinoma of the ovary after combination chemotherapy with cyclophosphamide, Adriamycin, and cisplatin. OVCAR-3 grows as a cobblestone-like monolayer with foci of multilayering, is tumorigenic in athymic mice, clones in agarose, and has an abnormal karyotype which includes a homogeneous staining region and a double minute chromosome. The cultured cells and xenografts contain cytoplasmic androgen- and estrogen-binding macromolecules with the specificity of the respective steroid hormone receptors. These components have sedimentation coefficients of 7 to 9S in low-salt sucrose-density gradients, have dissociation constants of 250 and 9.6 pM, and are present at concentrations of 30 and 28 fmol/mg cytosol protein characteristic of androgen and estrogen receptors, respectively. OVCAR-3 is resistant in vitro to clinically relevant concentrations of Adriamycin (5 X 10(-8) M), melphalan (5 X 10(-6) M), and cisplatin (5 X 10(-7) M) with survival compared to untreated controls of 43, 45, and 77%, respectively. Furthermore, there are multiple histological similarities between the patient's original tumor, the cell line, and the transplantable tumor. These data indicate that OVCAR-3 may be of use for investigations as to the significance of androgens and estrogens and the mechanisms of cytotoxic drug resistance in ovarian cancer.

Adriamycin accumulation and metabolism in adriamycin-sensitive and -resistant human ovarian cancer cell lines.

Adriamycin accumulation and metabolism were studied in three distinct groups of human ovarian cancer cell lines: those derived from previously untreated patients, those from clinically refractory (relapsed) patients, and those with induced resistance to adriamycin in vitro. The 2-hr [14C] adriamycin accumulation in cell lines from previously untreated patients (A2780 and A1847 [Eva et al., Nature, Lond. 295, 116 (1982)] and OVCAR-5 [National Institutes of Health human OVarian CAR-cinoma cell line no. 5]) was 11-14 ng/10(6) cells. 2780AD and 1847AD (variants with in vitro induced resistance to adriamycin) accumulated one-third as much adriamycin after 2 hr (4 ng/10(6) cells). However, three cell lines derived from clinically refractory patients accumulated the same amount of adriamycin as cell lines from untreated patients (8-13 ng/10(6) cells). A high-performance liquid chromatography (HPLC) assay for adriamycin and its analogs confirmed these results and demonstrated only parent drug (no metabolites) in any of the cell lines tested. These results demonstrate that the primary mechanism of adriamycin resistance in some ovarian cancer cells from clinically refractory patients is not enhanced metabolism of drug or a transport defect leading to a decreased net accumulation such as has been described for cells with in vitro induced resistance to adriamycin.

Modulation of induced resistance to adriamycin in two human breast cancer cell lines with tamoxifen or perhexiline maleate.

The clinical utility of adriamycin in the treatment of patients with metastatic breast cancer is often-limited by the development of drug resistance. It has been recognized that in addition to the development of primary resistance against adriamycin, malignant cells can simultaneously develop cross-resistance to other agents. An adriamycin-resistant human breast cancer cell line (MCF 7Ad) was developed by exposing the parent line (MCF 7) to gradually increasing concentrations of adriamycin while the cells were being grown in monolayer. Using these lines in a clonogenic assay, the relative drug sensitivities to adriamycin, vinblastine, melphalan, 5-fluorouracil and methotrexate were studied. MCF 7Ad was 12.5-fold more resistant to adriamycin than MCF 7 and 500-fold cross-resistant to vinblastine. There was no cross-resistance to melphalan, 5-fluorouracil or methotrexate. The resistance of MCF 7Ad was decreased by simultaneous exposure to tamoxifen (by a factor of 3.33) or perhexiline maleate (by a factor of 7.50). This decreased resistance was evidenced by a shift to the left of the sensitivity curves. However, there was no consistent change in the sensitivity curves of MCF 7. At the selected concentration of tamoxifen and perhexiline maleate, the cloning efficiency of MCF 7 and MCF 7Ad was 80%-90% of control values in medium without tamoxifen, perhexiline maleate or cytotoxic drugs. The resistance of MCF 7Ad to adriamycin was associated with a lower accumulation of [14C]adriamycin than exhibited by the sensitive MCF 7 line. There was no consistent change in [14C]adriamycin accumulation in MCF 7 or MCF 7Ad when tamoxifen was added, but when perhexiline maleate was added the [14C] accumulation increased. These results suggest that the tamoxifen-induced change in MCF 7Ad adriamycin resistance was not due to an increase in the amount of cell-associated adriamycin, but rather to some other mechanism that increased the cytotoxicity of the adriamycin.

Preclinical evaluation of aclacinomycin A for the intraperitoneal treatment of human ovarian carcinoma.

Combination chemotherapy regimens have produced a pathological complete response rate of only 1%-25% in patients with advanced ovarian cancer. Patients with small-volume residual disease after treatment are refractory to further systemic therapy, and most eventually die of their disease. Intraperitoneal (i.p.) chemotherapy, particularly with adriamycin or cisplatin has shown promise in these patients. However, the dose-limiting painful peritonitis associated with i.p. adriamycin makes this regimen potentially too toxic for many patients. Aclacinomycin A, another anthracycline antibiotic, has been found to have activity against a wide variety of murine tumors and human xenografts. It has also demonstrated clinical efficacy in phase I and II trials against refractory ovarian cancer and has less pronounced vesicant properties than adriamycin, making it an ideal candidate for i.p. use in ovarian cancer patients. In vitro clonogenic assays utilizing a battery of adriamycin-sensitive and -resistant human ovarian carcinoma cell lines have shown that aclacinomycin A is more cytotoxic than adriamycin in all cell lines tested. In addition, aclacinomycin A was found to prolong survival in a nude mouse xenograft of i.p. human ovarian cancer. These results have provided the experimental rationale for an ongoing clinical trial of i.p. aclacinomycin in refractory ovarian cancer patients at the Medicine Branch, NCI.