Efficacy of niraparib by time of surgery and postoperative residual disease status: A post hoc analysis of patients in the PRIMA/ENGOT-OV26/GOG-3012 study.

OBJECTIVE: To evaluate the association between surgical timing and postoperative residual disease status on the efficacy of niraparib first-line maintenance therapy in patients with newly diagnosed advanced ovarian cancer at high risk of recurrence. METHODS: Post hoc analysis of the phase 3 PRIMA/ENGOT-OV26/GOG-3012 (NCT02655016) study of niraparib in patients with newly diagnosed primary advanced ovarian, primary peritoneal, or fallopian tube cancer with a complete/partial response to first-line platinum-based chemotherapy. Progression-free survival (PFS) was assessed by surgical status (primary debulking surgery [PDS] vs neoadjuvant chemotherapy/interval debulking surgery [NACT/IDS]) and postoperative residual disease status (no visible residual disease [NVRD] vs visible residual disease [VRD]) in the intent-to-treat population. RESULTS: In PRIMA (N = 733), 236 (32.2%) patients underwent PDS, and 481 (65.6%) received NACT/IDS before enrollment. Median PFS (niraparib vs placebo) and hazard ratios (95% CI) for progression were similar in PDS (13.7 vs 8.2 months; HR, 0.67 [0.47-0.96]) and NACT/IDS (14.2 vs 8.2 months; HR, 0.57 [0.44-0.73]) subgroups. In patients who received NACT/IDS and had NVRD (n = 304), the hazard ratio (95% CI) for progression was 0.65 (0.46-0.91). In patients with VRD following PDS (n = 183) or NACT/IDS (n = 149), the hazard ratios (95% CI) for progression were 0.58 (0.39-0.86) and 0.41 (0.27-0.62), respectively. PFS was not evaluable for patients with PDS and NVRD because of sample size (n = 37). CONCLUSIONS: In this post hoc analysis, niraparib efficacy was similar across PDS and NACT/IDS subgroups. Patients who had NACT/IDS and VRD had the highest reduction in the risk of progression with niraparib maintenance.

Breast cancer, placing drug interactions in the spotlight: is polypharmacy the cause of everything?

Breast cancer is the most prevalent and lethal cancer among women. Forty-one percent of cases occur in people ≥ 70 years, hindering their treatment given its comorbidities and polypharmacy (PP). Potential drug–drug interactions (PDDI) were analyzed in elderly breast cancer patients between daily and oncospecific treatments and their associations with Age, BMI, Mini Nutritional Assessment (MNA), Frailty categorization, PP, and adverse effects. Patients/methods A cohort of 77 patients ≥ 70 years with breast cancer who underwent a Comprehensive Geriatric Assessment (CGA) were included. Clinical characteristics were collected using medical records. PDDI between treatments were analyzed using two databases. Data were assessed using linear regression, Chi-square, Mann–Whitney U, and Kruskal–Wallis tests. Finally, a multivariate logistic regression model was built and tested to predict adverse effects. Results From 719 PDDI, 530 (74%) were moderate (r2 = 0.72) and the median number of drugs during oncospecific treatment (r2 = 0.73) was 9 (range 3–26). Overall, 59 patients (77%) had adverse effects associated with Frailty categorization and MNA (p < 0.05). The distribution of major, moderate, minor, and total PDDI was associated with PP at CGA and during oncospecific treatment (p < 0.05). Moreover, it was verified that Frailty categorization protects from adverse effects given the intervention made at CGA. Conclusions CGA should be applied in oncologic elderly patients to assess clinical outcomes and categorize them according to their frailty but also to analyze PDDI. Furthermore, we encourage the use of the model in clinical practice for predicting the occurrence of adverse effects, improving therapeutic conciliation (AU)

Breast cancer, placing drug interactions in the spotlight: is polypharmacy the cause of everything?

PURPOSE: Breast cancer is the most prevalent and lethal cancer among women. Forty-one percent of cases occur in people ≥ 70 years, hindering their treatment given its comorbidities and polypharmacy (PP). Potential drug-drug interactions (PDDI) were analyzed in elderly breast cancer patients between daily and oncospecific treatments and their associations with Age, BMI, Mini Nutritional Assessment (MNA), Frailty categorization, PP, and adverse effects. PATIENTS/METHODS: A cohort of 77 patients ≥ 70 years with breast cancer who underwent a Comprehensive Geriatric Assessment (CGA) were included. Clinical characteristics were collected using medical records. PDDI between treatments were analyzed using two databases. Data were assessed using linear regression, Chi-square, Mann-Whitney U, and Kruskal-Wallis tests. Finally, a multivariate logistic regression model was built and tested to predict adverse effects. RESULTS: From 719 PDDI, 530 (74%) were moderate (r2 = 0.72) and the median number of drugs during oncospecific treatment (r2 = 0.73) was 9 (range 3-26). Overall, 59 patients (77%) had adverse effects associated with Frailty categorization and MNA (p < 0.05). The distribution of major, moderate, minor, and total PDDI was associated with PP at CGA and during oncospecific treatment (p < 0.05). Moreover, it was verified that Frailty categorization protects from adverse effects given the intervention made at CGA. CONCLUSIONS: CGA should be applied in oncologic elderly patients to assess clinical outcomes and categorize them according to their frailty but also to analyze PDDI. Furthermore, we encourage the use of the model in clinical practice for predicting the occurrence of adverse effects, improving therapeutic conciliation.

Derived Neutrophil-to-Lymphocyte Ratio Predicts Pathological Complete Response to Neoadjuvant Chemotherapy in Breast Cancer.

BACKGROUND: Derived neutrophil-to-lymphocyte ratio (dNLR) is a biomarker associated with clinical outcome in breast cancer (BC). We analyzed the association of dNLR with pathological complete response (pCR) in triple-negative BC (TNBC) patients receiving neoadjuvant chemotherapy (CT). METHODS: This is a retrospective analysis of two randomized studies involving early stage/locally advanced TNBC patients receiving anthracycline/taxane-based CT+/-carboplatin (GEICAM/2006-03) or nab-paclitaxel/paclitaxel followed by anthracycline regimen (ETNA). dNLR was calculated as the ratio of neutrophils to the difference between total leukocytes and neutrophils in peripheral blood before CT (baseline) and at the end of treatment (EOT). Logistic regression analyses were used to explore dNLR association with pCR. RESULTS: In total, 308 TNBC patients were analyzed, 216 from ETNA and 92 from GEICAM/2006-03. Baseline median dNLR was 1.61 (interquartile range (IQR): 1.25-2.04) and at EOT 1.53 (IQR: 0.96-2.22). Baseline dNLR showed positive correlation with increased tumor size (p-value = 1e-04). High baseline dNLR, as continuous variable or using median cutoff, was associated with lower likelihood of pCR in univariate analysis. High EOT dNLR as continuous variable or using quartiles was also associated with lower pCR rate in uni- and multivariate analyses. CONCLUSIONS: High baseline and EOT dNLR correlates with lower benefit from neoadjuvant CT in TNBC.

Comparing Neoadjuvant Nab-paclitaxel vs Paclitaxel Both Followed by Anthracycline Regimens in Women With ERBB2/HER2-Negative Breast Cancer-The Evaluating Treatment With Neoadjuvant Abraxane (ETNA) Trial: A Randomized Phase 3 Clinical Trial.

IMPORTANCE: Studies of neoadjuvant chemotherapy regimens using anthracyclines followed by taxanes have reported a doubling of pathological complete remission (pCR) rates compared with anthracycline-based regimens alone. A reverse sequence did not reduce activity. Nab-paclitaxel is an albumin-bound nanoparticle of paclitaxel that allows for safe infusion without premedication, and its use led to a significantly higher rate of pCR in the GeparSepto trial. OBJECTIVE: To determine whether nab-paclitaxel improves the outcomes of early and locally advanced human epidermal growth factor receptor 2 (ERBB2/HER2)-negative breast cancer compared with paclitaxel when delivered in a neoadjuvant setting. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter, open-label study, in collaboration with Grupo Español de Investigación en Cáncer de Mama (GEICAM) and Breast Cancer Research Center-Western Australia (BCRC-WA), patients with newly diagnosed and centrally confirmed ERBB2/HER2-negative breast cancer were recruited. Participants were randomly allocated to paclitaxel, 90 mg/m2 (349 patients), or nab-paclitaxel, 125 mg/m2 (346 patients). The 2 drugs were given on weeks 1, 2, and 3 followed by 1 week of rest for 4 cycles before 4 cycles of an anthracycline regimen per investigator choice. MAIN OUTCOMES AND MEASURES: The primary end point was the rate of pCR, defined as absence of invasive cells in the breast and axillary nodes (ie, ypT0/is ypN0) at the time of surgery. A secondary end point was to assess tolerability and safety of the 2 regimens. RESULTS: From May 2013 to March 2015, 814 patients were registered to the study; 695 patients met central confirmation eligibility and were randomly allocated to receive either paclitaxel (349), or nab-paclitaxel (346) (median age, 50 years; range, 25-79 years). The intention-to-treat analysis of the primary end point pCR revealed that the improved pCR rate after nab-paclitaxel (22.5%) was not statistically significant compared with paclitaxel (18.6%; odds ratio [OR], 0.77; 95% CI, 0.52-1.13; P = .19). Overall, 38 of 335 patients (11.3%) 11.3% of patients had at least 1 serious adverse event in the paclitaxel arm and 54 of 337 patient (16.0%) in the nab-paclitaxel arm. Peripheral neuropathy of grade 3 or higher occurred in 6 of 335 patients (1.8%) and in 15 of 337 (4.5%), respectively. CONCLUSIONS AND RELEVANCE: The improved rate of pCR after nab-paclitaxel was not statistically significant. The multivariate analysis revealed that tumor subtype (triple-negative vs luminal B-like) was the most significant factor (OR, 4.85; 95% CI, 3.28-7.18) influencing treatment outcome. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01822314.

Bone turnover markers as predictive indicators of outcome in patients with breast cancer and bone metastases treated with bisphosphonates: results from a 2-year multicentre observational study (ZOMAR study).

BACKGROUND: We evaluated the evolution and predictive value of bone turnover markers (BTMs) and circulating tumor cells (CTCs) with respect to mortality, disease progression (DP) and skeletal-related events (SREs), in patients with bone metastatic breast cancer (BmBCa). The correlation between BTMs and CTCs was also studied. METHODS: In a 2-year observational, multicenter study, the levels of three BTMs (N- and C-terminal telopeptides of collagen I [NTX and αα-CTX], and bone-specific alkaline phosphatase [BSAP]) and CTCs were analyzed every three months. Patients received zoledronic acid (4mg every 28days) from the baseline visit. RESULTS: 234 patients were analyzed. The levels of the BTMs were increased at baseline and significantly decreased after 3months (P<0.05). In the Cox regression univariate analyses significant hazard ratios (HRs) for death were found for pathological BSAP values at baseline (5.03 [95% CI: 1.214-20.839; P=0.0259]) and at 3months (3.41 [95% CI: 1.367-8.498; P=0.0085]). HRs >2 were found for increased baseline and 3-month levels of NTX and CTC (P<0.05). Only increased baseline BSAP levels were associated with DP (HR=2.25 [95% CI: 1.391-3.626; P=0.0009]). No biomarker was associated with SREs. In the multivariate analysis, pathologic levels at 3months of NTX and BSAP were significantly associated with mortality (HRs=3.59 [95% CI: 1.375-9.382; P=0.0091] and 3.25 [95% CI: 1.293-8.189; P=0.0120], respectively). CTC and BSAP were correlated during all study timepoints (P<0.05). CONCLUSIONS: Baseline levels of NTX, BSAP and CTCs, and changes after treatment initiation with bisphosphonates, may be useful for the prognostic assessment of patients with BmBCa. BSAP showed the strongest prognostic value.

Multicenter, phase II, nonrandomized study of docetaxel plus trastuzumab every 21 days as the primary therapy in metastatic breast cancer overexpressing HER2.

Different anthracycline-free regimens have demonstrated activity, without serious cardiac events. This study was conducted to evaluate the activity and toxicity of docetaxel and trastuzumab given every 21 days in patients with metastatic breast cancer (MBC). The primary endpoint was time to progression and the secondary aims included response rate, safety, duration of response, and overall survival. Eligible patients were those with MBC human epidermal growth factor receptor-2+ (HER2+) with no previous chemotherapy for advanced disease. Patients received six cycles of docetaxel (100 mg/m) plus trastuzumab (8 mg/kg loading dose and 6 mg/kg every 21 days thereafter), followed by maintenance treatment with trastuzumab monotherapy every 21 days until disease progression. Forty-nine patients with HER2+ MBC were included. The overall response rate was 44.9% (22/49). With a median follow-up of 16.6 months, the median time to progression was 8.3 months and the median overall survival was 25.7 months. Nineteen patients did not receive treatment continuation with trastuzumab monotherapy. The most common toxicity was febrile neutropenia. A total of 10 patients were taken off the study due to treatment-related toxicity, mainly cardiac events. First-line trastuzumab combined with docetaxel is an effective and well tolerated regimen for HER2+ MBC.

Time-to-progression in breast cancer: a stratification model for clinical trials.

The development of new anti-tumour drugs without clear cytoreductive activity has necessitated changes in the design of clinical trials. Defining the "time" parameter has become the essential objective of the majority of these trials. However, in breast cancer, this parameter is highly variable and, as such, difficult to quantify. We developed a useful tool that takes into account the inter-relatedness of all the variables known to have the capacity to predict the time-to-progression (TTP) in advanced breast cancer. From the Alamo database (GEICAM), we selected 1798 patients diagnosed as having metastatic breast cancer. Univariate analysis was performed using the method of Kaplan-Meier. Multivariate analysis was with the Cox regression method. The variables that were shown to have independent predictive value for the TTP were: non-visceral metastatic disease, single metastases, hormonal receptor positive N/T ratio<2 and disease-free interval (DFI) > or = 24 months. Taking into account the variables that had reached an independent predictive value, we constructed a model of scoring in which the patients were grouped according to the TTP. Using our new scoring model, it is possible to group patients with metastatic breast cancer according to the predicted TTP. This can be a useful tool at the time of selecting and stratifying patients on entry into new randomised clinical trials.

Does polysomy of chromosome 17 have a role in ERBB2 and topoisomerase IIalpha expression? Gene, mRNA and protein expression: a comprehensive analysis.

OBJECTIVES: ERBB2 is an oncogene with prognostic and predictive value. Topoisomerase IIalpha is an enzyme encoding close to the ERBB2 oncogene, that represents a molecular target for anthracyclines. An indirect mechanism of increasing ERBB2 and topoisomerase IIalpha gene copy number is chromosome 17 polysomy. The aim of the present study was to clarify the implication of polysomy 17 in ERBB2 and topoisomerase IIalpha expression. In addition, we assessed the relation of ERBB2 and topoisomerase IIalpha gene dosage to mRNA and protein levels. METHODS: We selected 83 cases diagnosed as invasive breast cancer. We analysed ERBB2 and topoisomerase IIalpha genes, mRNA and protein by fluorescence in situ hybridisation, real-time reverse-transcription polymerase chain reaction and immunohistochemistry. RESULTS: We observed a progressive increase in mRNA expression from 0+ to 3+ and also a significant difference in the ERBB2 RNA levels between normal and amplified cases. We found that polysomy of chromosome 17 does not affect the ERBB2 expression and that topoisomerase IIalpha mRNA expression is not related to gene status. CONCLUSIONS: Our results demonstrate that polysomy of chromosome 17 is not related to ERBB2 expression. Thereby, it is important to use centromeric probes to clearly discriminate between true ERBB2 gene amplification and polysomy of chromosome 17.

Pitfalls and caveats in BRCA sequencing.

Between 5 and 10% of breast cancer cases are considered to result from hereditary predisposition. Germ-line mutations in BRCA1 and BRCA2 are responsible for an inherited predisposition of breast and ovarian cancer. Direct nucleotide sequencing is considered the gold standard technique for mutation detection for genes such as BRCA1 and BRCA2. In many laboratories that analyze BRCA1 and BRCA2, previous to direct sequencing, screening techniques to identify sequence variants in the PCR amplicons are performed. The mutations detected in these genes may be frameshift mutations (insertions or deletions), nonsense mutations, or missense mutations. The clinical interpretation of the mutation as the cause of the disease may be difficult to establish in the case of missense mutations. Only in 30-70% of the families in which a hereditary component is suspected, a mutation in BRCA1 and/or BRCA2 is detected. Negative results may be due to: wrong selection of the proband; mutations in the regulatory portion of the genes; gene silencing due to epigenetic phenomena; or large genomic rearrangements that produce deletions of whole exons. Another possibility that explains the lack of detection of alterations in BRCA1 or BRCA2 is the presence of mutations in undiscovered genes or in genes that interact with BRCA1 and/or BRCA2, which may be low-penetrance genes, like CHEK2.

The MYC oncogene in breast cancer progression: from benign epithelium to invasive carcinoma.

One hypothesis for breast cancer development suggests that breast carcinogenesis involves a progression of events leading from benign epithelium to hyperplasia (with or without atypia) to carcinoma in situ and then invasive carcinoma. The MYC gene (alias c-Myc) is a transcriptional regulator whose expression is strongly associated with cell proliferation and cell differentiation. The present study is a descriptive analysis of MYC status throughout the hypothesized stages of invasive ductal carcinoma progression. A tissue microarray (TMA) was constructed including representative selected areas (normal cells, hyperplasia, in situ carcinoma, and invasive carcinoma) from each of 15 patients. Fluorescence in situ hybridization (FISH) with the LSI c-MYC/CEN8/IgH probe was performed. Two cases displayed MYC amplification (13%), showing this amplification only in the invasive carcinoma zones selected. Five cases displayed polysomy of chromosome 8 (33%), detected only in ductal in situ and invasive zones selected. Benign lesions and normal adjacent cells were classified as normal. None of the hyperplasia specimens and normal specimens analyzed showed any alterations in MYC status or any aneusomies of chromosome 8. The presence of MYC amplification only in invasive cells suggests that the finding of MYC amplification could reflect an advanced tumor progression.

Characterization of HER1 (c-erbB1) status in locally advanced breast cancer using fluorescence in situ hybridization and immunohistochemistry.

Epidermal growth factor receptor (EGFR) is a 170-kDa transmembrane glycoprotein encoded by the HER1 protooncogene, located at 7p12. This receptor is related to the pathogenesis of breast cancer. The aim of this study was to analyze the status of HER1 using fluorescence in situ hybridization (FISH) and immunohistochemistry in a series of 48 patients with locally advanced breast cancer (LABC). Before neoadjuvant chemotherapy, core biopsies were taken from patients with LABC and were processed into paraffin blocks. Biopsies were then studied using FISH with a HER1 probe (Vysis, Downers Grove, Ill., USA). They were also analyzed immunohistochemically using two different EGFR antibodies from DakoCytomation (Denmark, A/S) and from Zymed (San Francisco, Calif., USA). HER1 amplifications were not found, although 31% of the cases presented aneusomy of chromosome 7. Only 2 cases presented EGFR expression. LABC presented a low level of EGFR expression. HER1 amplification was not present in LABC, although the polysomy of chromosome 7 was a common finding.

[Epidemiological study of the GEICAM group about breast cancer in Spain (1990-1993): El Alamo project]. / Estudio epidemiológico del grupo GEICAM sobre el cáncer de mama en España (1990-1993): proyecto El Alamo.

BACKGROUND AND OBJECTIVE: The aim of the El Alamo project was to define the demographic and clinic characteristics, treatment and evolution of women with invasive breast cancer diagnosed in hospitals of the GEICAM group (Spanish Breast Cancer Research Group) between 1990 and 1993. PATIENTS AND METHOD: Data from 4,532 patients were included. Forms were completed according to the medical history of patients, and collected in the GEICAM scientific office, where they were added to a data base. RESULTS: 32 hospitals from 19 provinces and 11 regional communities participated in the study. Mean age of the 4,532 patients was 56.72 years, 1,428 (31.5%) were premenopausal and 2,988 (65.9%) were postmenopausal. Stage II tumors were most frequent (55.5%). Among patients with stage I, II and III at diagnosis, surgery was the first treatment in most (90.7%), radical mastectomy being the most frequent procedure performed (79.7%). 70.4% of 1941 patients with positive axillary node and 37.4% of 1,806 patients without axillary affection received adjuvant chemotherapy with or without hormone therapy. CONCLUSIONS: El Alamo project represents the largest data base on breast cancer in Spain and the results are similar to those observed in other countries such as the USA.

Estudio epidemiológico del grupo GEICAM sobre el cáncer de mama en España (1990-1993): proyecto "El Álamo" / Epidemiological study of the GEICAM group about breast cancer in Spain (1990-1993): "El Álamo" project

FUNDAMENTO Y OBJETIVO: El objetivo del proyecto "El Álamo" fue definir las características demográficas y clínicas, los tratamientos y la evolución de las mujeres diagnosticadas de cáncer de mama invasivo en hospitales del Grupo Español de Investigación en Cáncer de Mama entre los años 1990 y 1993. PACIENTES Y MÉTODO: Se incluyeron datos de 4.532 pacientes, recogidos entre diciembre de 1999 y diciembre de 2000. Los formularios completados a partir de las historias clínicas se incorporaron a una base de datos. RESULTADOS: En el estudio participaron 32 hospitales de 11 comunidades autónomas. La edad media de las 4.532 pacientes incluidas era de 56,72 años, de las que 1.428 (31,5 por ciento) eran premenopáusicas y 2.988 (65,9 por ciento) posmenopáusicas. Los tumores de estadio II fueron los más frecuentes (55,5 por ciento). Entre las enfermas con estadios I, II y III en el momento del diagnóstico, la cirugía fue el tratamiento de inicio de la mayoría (90,7 por ciento), siendo la mastectomía radical la intervención más frecuente (79,7 por ciento). El 70,4 por ciento de las 1.941 pacientes con ganglios axilares positivos y el 37,4 por ciento de las 1.806 sin afectación axilar recibieron quimioterapia adyuvante con o sin hormonoterapia. La mediana de supervivencia global de las 4.532 pacientes aún no se ha alcanzado. CONCLUSIONES: El proyecto "El Álamo" constituye una base de datos extensa sobre el cáncer de mama en España. La distribución por estadios en el momento del diagnóstico fue desfavorable respecto a la observada en otros países occidentales en el mismo período; sin embargo, los resultados terapéuticos por estadio son prácticamente similares (AU)