Chemotherapy-induced diarrhea (cid) is a common side effect of cancer treatment and can cause significant morbidity and mortality. Diarrhea is frequently severe enough to require a dose reduction of, a delay in, or a discontinuation of chemotherapy. Diarrhea-associated mortality has been reported to be as high as 3.5% in clinical trials of irinotecan and bolus 5-fluorouracil in colorectal cancer. The frequency of cid and its impact on patient management are frequently under-recognized in clinical practice. A Canadian working group, consisting of medical oncologists and an oncology pharmacist, was formed in 2001 to review the optimal approach to managing cid and to identify and implement new areas of research. The recommendations that follow are the result of the group’s work. Acute medical management of cid includes loperamide or diphenoxylate as first-line agents. Subcutaneous octreotide is recommended for intractable grade 2 diarrhea and may be considered for grade 1 cid that does not resolve with high-dose loperamide. Hospitalization is recommended for patients with grades 3 and 4 cid; in-hospital care includes rehydration, antibiotic therapy, and octreotide. A chemotherapy dose reduction is generally advised for patients who have experienced grade 3 or 4 diarrhea in a previous chemotherapy cycle. If a dose reduction is not desired, prophylaxis with intramuscular long-acting release octreotide may be considered. The foregoing recommendations are based on expert opinion and require validation in prospective clinical trials.
3553 Background: The DREAM phase III clinical trial aimed to assess the efficacy and tolerability of maintenance bevacizumab (B) plus erlotinib (E) after a bevacizumab-based induction therapy in patients with unresectable metastatic colorectal cancer (Tournigand C. et al. Lancet Oncol. 2015). The addition of E to B improved maintenance progression-free survival (PFS) (median B: 4.9months; median B+E: 5.4 months; Hazard Ratio (HR) = 0.78 [0.68-0.96], P = 0.036) and overall survival (OS). This study presents the results of health-related quality of life (HRQoL) data (secondary endpoint). Methods: HRQoL was assed using EuroQoL EQ-5D generic questionnaire before maintenance randomization (T0), at 2 (T1) and 4 months (T2). Analysis of baseline missing data profile was done comparing responders to non responders according to baseline patients’ characteristics and OS. The longitudinal analysis of the visual analogue scale (VAS) of the EQ-5D was done with a linear mixed model (LMM) by including the arm, the time and their interaction. Time to HRQoL deterioration (TTD) was defined as the time from randomization to the first deterioration of 5-point at least of the VAS score as compared to T0. Univariate cox regression analyses were performed to estimate HR of the treatment effect with its 95% confidence interval. Results: Between 2007 and 2011, 700 patients were included. After induction therapy, 452 patients without disease progression were randomized in B arm (N = 228) or B+E arm (N = 224). Among them, 111 patients (24.5%) completed the EQ-5D at T0, 78 (17.3%) at T1 and 54 (11.9%) at T2. Effects introduced in the LMM were not significant: arm effect (coeff = 0.93 (ref = Arm A), P = 0.83), time effect (coeff = 0.25, P = 0.88) and treatment by time interaction (coeff = 1.80, P = 0.42) reflecting a similar HRQoL among arms throughout its measurement. Median of TTD was 4.5 months (2.7-NA) for B vs. 4.1 months (2.3-NA) for B+E (HR = 1.46 [0.67-3.19], P = 0.34). Conclusions: These HRQoL results suggest that the added value of erlotinib to bevacizumab is not associated with a HRQoL deterioration, while it allows to improve maintenance PFS and OS. Clinical trial information: NCT00265824.
The annual Eastern Canadian Colorectal Cancer Consensus Conference was held in Halifax, Nova Scotia, October 20-22, 2011. Health care professionals involved in the care of patients with colorectal cancer participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of rectal cancer, including pathology reporting, neoadjuvant systemic and radiation therapy, surgical techniques, and palliative care of rectal cancer patients. Other topics discussed include multidisciplinary cancer conferences, treatment of gastrointestinal stromal tumours and pancreatic neuroendocrine tumours, the use of folfirinox in pancreatic cancer, and treatment of stage ii colon cancer.
LBA3500^ Background: Therapy targeting VEGF or EGFR demonstrated clinical activity in combination with chemotherapy (CT) in mCRC but monoclonal antibodies cannot be associated. The DREAM trial compares a maintenance therapy (MT) with bev +/- EGFR tyrosine kinase inhibitor erlotinib (E) after a first-line Bev-based induction therapy (IT) in pts with mCRC. Methods: Pts with previously untreated and unresectable mCRC were eligible. After a Bev-based IT with FOLFOX or XELOX or FOLFIRI, pts without disease progression were randomized to MT between Bev alone (Bev 7.5 mg/kg q3w; arm A) or Bev+E (B 7.5 mg/kg q3w, E 150 mg/day continuously; arm B). Pts were treated until progression or unacceptable toxicity. The primary endpoint was PFS on MT. Results: The study enrolled 700 pts from 01/2007 to 11/2011 in 3 countries (France, Canada, Austria). 446 (63.7%) pts were randomized for MT (arm A, N=224; arm B, N=222). Among the 446 randomized pts, IT regimen was FOLFOX-Bev in 265 pts (59.4%), XELOX-Bev in 135 pts (30.3%), and FOLFIRI-Bev in 46 pts (10.3%). Baseline characteristics of randomized pts were (arm A/B): ECOG PS 0, 60% in both arms; normal LDH level 47%/49%; normal alkaline phosphatase level 48%/50%; synchronous metastasis 83%/82%. The median no of MT cycles was 6 in both arms. With a median follow-up of 31.0 months, 327 PFS events were observed. Median MT-PFS were 4.6 m in arm A vs 5.8 m in arm B (HR 0.73 [95%CI: 0.59-0.91], P=.005). Median PFS from inclusion were 9.2 m vs 10.2 m. During MT, in arm A vs arm B, grade 3-4 diarrhea (<1% vs 9%) and grade 3 skin toxicity (0% vs 19%) were the main differences in toxicity. Severe adverse events from randomization related to B or E were 6 in arm A and 7 in arm B. Overall survival is not mature. Conclusions: The addition of erlotinib to bevacizumab after induction therapy significantly improves the duration of maintenance PFS, following induction with first-line chemotherapy plus bevacizumab, in patients with unresectable metastatic colorectal cancer.
The annual Eastern Canadian Colorectal Cancer Consensus Conference held in Montreal, Quebec, 17-19 October 2013, marked the 10-year anniversary of this meeting that is attended by leaders in medical, radiation, and surgical oncology. The goal of the attendees is to improve the care of patients affected by gastrointestinal malignancies. Topics discussed during the conference included pancreatic cancer, rectal cancer, and metastatic colorectal cancer.
Abstract Dinaciclib is a potent, selective inhibitor of CDKs 1, 2, 5, and 9 with preclinical activity against NSCLC cell lines and tumor xenografts. NSCLC tumors have numerous defects in cell cycle regulation (abnormal p16/cyclin D/Rb pathway, cyclin E overexpression, loss of p27/KIP1). The rationale for this study is that abnormal cell cycle regulation may predispose NSCLC cells to the pro-apoptotic effects of dinaciclib. A randomized, multicenter, open-label phase 2 study was conducted to compare the efficacy of dinaciclib and erlotinib (150 mg PO QD) in patients (pts) with locally advanced previously treated Non-Small Cell Lung Cancer (NSCLC). Dinaciclib 50 mg/m2 was administered by 2-hour i.v. infusion once every 21 days. Key inclusion criteria included ≤ 2 prior chemotherapy regimens and measurable disease. Patients were randomized to treatment with dinaciclib or erlotinib using an adaptive Bayesian design to adjust the randomization ratio in favor of the more active arm. Patients could cross-over to dinaciclib after progressing on erlotinib. This design provides a comparison of dinaciclib versus erlotinib and assesses dinaciclib activity in patients who've progressed on erlotinib. Primary endpoints: Time-to-progression (TTP) for pts receiving upfront treatment; and response rate (RR) for pts who crossed over to dinaciclib. Sixty-four pts received upfront treatment with either erlotinib (n=49) or dinaciclib (n=15). Seventeen patients crossed over from upfront erlotinib arm to dinaciclib. Median age was 65 (range 46-82) with a median of 1 (range 1-2) prior chemotherapy regimens and median ECOG performance status of 1 (0-2). The median number of treatment cycles was 2 (range 1-19), with 27/32 treated pts receiving > 1 cycle of treatment with dinaciclib. Tumor responses were assessed using RECIST. No dinaciclib responses were observed in either upfront or cross over arms. Two of forty-nine (4%) evaluable subjects receiving upfront erlotinib were reported to have partial responses (PR). Analysis of TTP will be presented at the meeting. Treatment-related grade 1 and 2 toxicities, occurring in >30% of pts included diarrhea (76%), neutropenia (66%), vomiting (59%), nausea (55%), fatigue (38%) and leukopenia (38%). The most common treatment-related grade 3 and 4 toxicities, occurring in 2 or more pts were neutropenia (60%), leukopenia (32%), vomiting (20%), diarrhea (16%), fatigue (12%), nausea (12%), electrolyte imbalance (8%) and hyperuricemia (8%). PK results are pending and will be included in the final abstract. Dinaciclib has acceptable safety and tolerability in patients with NSCLC but did not demonstrate anti-tumor activity. In accordance with pre-specified rules of the adaptive design, patient enrollment was stopped initially in the crossover stage and in the upfront stage of the trial. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2242. doi:10.1158/1538-7445.AM2011-2242
Single-agent immune checkpoint inhibition has not shown activities in advanced refractory colorectal cancer (CRC), other than in those patients who are microsatellite-instability high (MSI-H).
Objective
To evaluate whether combining programmed death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte–associated protein 4 (CTLA-4) inhibition improved patient survival in metastatic refractory CRC.
Design, Setting, and Participants
A randomized phase 2 study was conducted in 27 cancer centers across Canada between August 2016 and June 2017, and data were analyzed on October 18, 2018. Eligible patients had histologically confirmed adenocarcinoma of the colon or rectum; received all available standard systemic therapies (fluoropyrimidines, oxaliplatin, irinotecan, and bevacizumab if appropriate; cetuximab or panitumumab ifRASwild-type tumors; regorafenib if available); were aged 18 years or older; had adequate organ function; had Eastern Cooperative Oncology Group performance status of 0 or 1, and measurable disease.
Interventions
We randomly assigned patients to receive either 75 mg of tremelimumab every 28 days for the first 4 cycles plus 1500 mg durvalumab every 28 days, or best supportive care alone (BSC) in a 2:1 ratio.
Main Outcomes and Measures
The primary end point was overall survival (OS) and a 2-sided P<.10 was considered statistically significant. Circulating cell-free DNA from baseline plasma was used to determine microsatellite instability (MSI) and tumor mutation burden (TMB).
Results
Of 180 patients enrolled (121 men [67.2%] and 59 women [32.8%]; median [range] age, 65 [36-87] years), 179 were treated. With a median follow-up of 15.2 months, the median OS was 6.6 months for durvalumab and tremelimumab and 4.1 months for BSC (hazard ratio [HR], 0.72; 90% CI, 0.54-0.97;P = .07). Progression-free survival was 1.8 months and 1.9 months respectively (HR, 1.01; 90% CI, 0.76-1.34). Grade 3 or 4 adverse events were significantly more frequent with immunotherapy (75 [64%] patients in the treatment group had at least 1 grade 3 or higher adverse event vs 12 [20%] in the BSC group). Circulating cell-free DNA analysis was successful in 168 of 169 patients with available samples. In patients who were microsatellite stable (MSS), OS was significantly improved with durvalumab and tremelimumab (HR, 0.66; 90% CI, 0.49-0.89;P = .02). Patients who were MSS with plasma TMB of 28 variants per megabase or more (21% of MSS patients) had the greatest OS benefit (HR, 0.34; 90% CI, 0.18-0.63;P = .004).
Conclusions and Relevance
This phase 2 study suggests that combined immune checkpoint inhibition with durvalumab plus tremelimumab may be associated with prolonged OS in patients with advanced refractory CRC. Elevated plasma TMB may select patients most likely to benefit from durvalumab and tremelimumab. Further confirmation studies are warranted.
