Category: Hem/Onc Updates

FDA Approves OGIVRI® as a Biosimilar to HERCEPTIN®

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SUMMARY: The FDA on December 1, 2017 approved OGIVRI® (Trastuzumab-dkst) as a biosimilar to HERCEPTIN® (Trastuzumab), for the treatment of patients with HER2-overexpressing breast or metastatic stomach cancer (gastric or gastroesophageal junction adenocarcinoma). It is estimated that 252,710 new cases of invasive breast cancer and 63,410 new cases of non-invasive breast cancer will be diagnosed in women in 2017 and 28,000 new cases of stomach cancer will be diagnosed during this same period. Approximately 20-25% of primary breast cancers are HER2-positive. The frequency of HER2 overexpression in gastric and gastroesophageal cancer is about 18% with the frequency ranging from 4% to 53%.Biosimilars

Biosimilar product is a biological product that is approved based on its high similarity to an already approved biological product (also known as reference product). Biological products are made from living organisms including humans, animals and microorganisms such as bacteria or yeast and are manufactured through biotechnology, derived from natural sources or produced synthetically. Biological products have larger molecules with a complex structure than conventional drugs (also known as small molecule drugs). Unlike biological products, conventional drugs are made of pure chemical substances and their structures can be identified. A generic drug is a copy of brand name drug and has the same active ingredient and is the same as brand name drug in dosage form, safety and strength, route of administration, quality, performance characteristics and intended use. Therefore, brand name and the generic drugs are bioequivalent. The Affordable Care Act in 2010 created an abbreviated licensure pathway for biological products that are demonstrated to be “Biosimilar” to, or “interchangeable” with an FDA-licensed (FDA approved) biological product (reference product). The Biosimilar must show that it has no clinically meaningful differences in terms of safety and effectiveness from the reference product. A Biosimilar product can only be approved by the FDA if it has the same mechanism of action, route of administration, dosage form and strength as the reference product, and only for the indications and conditions of use that have been approved for the reference product. Biosimilars are not as easy to manufacture as generics (copies of brand name drugs) because of the complexity of the structure of the biologic product and the process used to make a biologic product. The facilities where Biosimilars are manufactured must also meet the FDA’s standards.

The approval of OGIVRI® was based on comparisons of extensive structural and functional product characterization, animal data, human pharmacokinetic and pharmacodynamic data, and clinical studies including clinical immunogenicity between OGIVRI® and HERCEPTIN®. Heritage is a double-blind, randomized phase III trial in which the efficacy and safety of OGIVRI® , a Biosimilar, was compared with HERCEPTIN®. The randomization included 500 patients treated at 95 sites worldwide, with centrally confirmed, measurable HER2 positive metastatic breast cancer, who had not received prior chemotherapy or HERCEPTIN® for their metastatic disease. Patients received either OGIVRI® or HERCEPTIN® along with TAXOTERE® (Docetaxel) or TAXOL® (Paclitaxel) administered every 3 weeks for a minimum of 8 cycles (24 weeks), with the antibody therapy continued, until disease progression. Both antibodies were administered with a loading dose of 8 mg/kg and a maintenance dose of 6 mg/kg every 3 weeks. Approximately 44% of the enrolled patients had hormone receptor positive disease and 84% received TAXOTERE®. The final analysis included 458 patients of whom 230 were in the OGIVRI® group and 228 were in the HERCEPTIN® group. The Primary endpoint was Overall Response Rate (ORR) at 24 weeks and Secondary endpoints include Progression Free Survival (PFS), Overall Survival (OS) and Safety.

The ORR after 24 weeks of treatment was 69.6% for the OGIVRI® group and 64% for the HERCEPTIN® group and this was not statistically significant. The median PFS had not yet been reached. Safety data in both treatment groups were comparable and there was no significant change in cardiac function from baseline to Week 24 in either group. Safety data were also comparable. The dose-normalized maximum concentration, and Area Under the Curve (AUC), were similar for both antibodies.

The authors concluded that OGIVRI® is equivalent to HERCEPTIN®, when given in combination with a Taxane, as first line therapy, for patients with HER2 positive metastatic breast cancer. Heritage: A phase III safety and efficacy trial of the proposed trastuzumab biosimilar Myl-1401O versus Herceptin. Rugo HS, Barve A, Waller CF, et al. J Clin Oncol 34, 2016 (suppl; abstr LBA503)

Platelet Transfusion for Patients with Cancer American Society of Clinical Oncology Clinical Practice Guideline Update

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SUMMARY: The ASCO convened an Expert Panel and updated evidence-based guidance on the use of platelet transfusion in patients with cancer. This guideline updates is based on a systematic review of the medical literature published from September 1, 2014, through October 26, 2016 and this review builds on two 2015 systematic reviews that were conducted by the AABB and the International Collaboration for Transfusion Medicine Guidelines. This ASCO guideline replaces the previous ASCO platelet transfusion guideline published initially in 2001. The updated ASCO review included 24 more recent publications which included 3 clinical practice guidelines, 8 systematic reviews, and 13 observational studies.

Target Population: Adults and children (4 months of age or older) with hematologic malignancies, solid tumors, or hypoproliferative thrombocytopenia.

Target Audience: Clinician’s administering intensive therapies to patients with cancer.

Clinical Questions and Recommendations:

(1) How should platelets for transfusion be prepared?

Platelets can be prepared either by separation of units of platelet concentrates from whole blood using either the buffy coat or the platelet-rich plasma method, which can then be pooled before administration, or by apheresis from single donors. Studies have shown that the post-transfusion increments, hemostatic benefit, and adverse effects are similar with any of these platelet products and they can be used interchangeably. However, single-donor platelets from selected donors are necessary when histocompatible platelet transfusions are needed.

(2) In what circumstances should providers take steps to prevent Rh alloimmunization resulting from platelet transfusion?

Prevention of RhD alloimmunization resulting from platelet transfusions to RhD-negative recipients can be achieved either through the exclusive use of platelet products collected from RhD-negative donors or via anti-D immunoprophylaxis. These approaches may be used for female children and female adults of child-bearing potential being treated with curative intent. However, because of the low rate of RhD alloimmunization in patients with cancer, these approaches need not be applied universally.

(3) In what circumstances should providers use leukoreduced blood products to prevent alloimmunization?

Providing leukoreduced blood products to patients with Acute Myeloid Leukemia from the time of diagnosis is appropriate, as the incidence of alloantibody-mediated refractoriness to platelet transfusion can be decreased in patients receiving induction chemotherapy, when both platelet and RBC products are leukoreduced before transfusion. It is likely that alloimmunization can also be decreased in patients with other types of leukemia and in other patients with cancer who are receiving chemotherapy. The same holds true for patients with Aplastic Anemia, and Myelodysplasia not receiving chemotherapy, in the same time periods that the transfusions are being administered. In the United States and in several other countries, majority of blood products are leukoreduced at the time of blood collection and component preparation. Prestorage leukoreduction can result in a substantial reduction in transfusion reactions and in transmission of cytomegalovirus (CMV) infection

(4) Should platelet transfusions be given prophylactically or therapeutically?

Prophylactic platelet transfusion should be administered to patients with thrombocytopenia resulting from impaired bone marrow function to reduce the risk of hemorrhage, when the platelet count falls below a predefined threshold level. This threshold level for transfusion varies according to the patient’s diagnosis, clinical condition, and treatment modality.

(5) What is the appropriate threshold for prophylactic platelet transfusion in patients with hematologic malignancies?

The Panel recommends a threshold of less than 10×109/L for prophylactic platelet transfusion in patients receiving therapy for hematologic malignancies. Transfusion at higher levels may be advisable in patients with signs of hemorrhage, high fever, hyperleukocytosis, rapid fall of platelet count, or coagulation abnormalities (eg, acute promyelocytic leukemia) and in those undergoing invasive procedures or in circumstances in which platelet transfusions may not be readily available in case of emergencies, as might be the case for outpatients who live at a distance from the treatment center.

(6) What is the appropriate threshold for prophylactic platelet transfusion in the setting of Hematopoietic Stem Cell Transplantation (HSCT)?

The Panel recommends a threshold of less than 10×109/L for prophylactic platelet transfusion in adult and pediatric patients undergoing allogeneic HSCT. Prophylactic platelet transfusion may be administered at higher counts based on clinician judgment. In adult recipients of autologous HSCT, randomized trials have demonstrated similar rates of bleeding with decreased platelet usage when patients are transfused at the first sign of bleeding rather than prophylactically, and this approach may be used in experienced centers. This recommendation is not generalizable to pediatric patients.

(7) Is there a role for prophylactic platelet transfusion in patients with chronic, stable, severe thrombocytopenia who are not receiving active treatment?

Patients with chronic, stable, severe thrombocytopenia, such as individuals with Myelodysplasia or Aplastic Anemia, who are not receiving active treatment may be observed without prophylactic transfusion, reserving platelet transfusions for episodes of hemorrhage or during times of active treatment.

(8) What is the appropriate threshold for prophylactic platelet transfusion in patients with solid tumors?

The risk of bleeding in patients with solid tumors during chemotherapy-induced thrombocytopenia is related to the depth and duration of the platelet nadir, although other factors contribute as well. The Panel recommends a threshold of less than 10×109/L for prophylactic platelet transfusion. Platelet transfusion at higher levels is appropriate in patients with active localized bleeding, which can sometimes be seen in patients with necrotic tumors.

(9) At what platelet count can surgical or invasive procedures be performed?

The Panel recommends a threshold of 40×109/L to 50×109/L for performing major invasive procedures in the absence of associated coagulation abnormalities. Certain procedures, such as bone marrow aspirations and biopsies, and insertion or removal of central venous catheters, can be performed safely at counts 20×109/L or more. If platelet transfusions are administered before a procedure, it is critical that a post-transfusion platelet count be obtained to prove that the desired platelet count level has been reached. Platelet transfusions should also be available on short notice, in case intraoperative or postoperative bleeding occurs. For alloimmunized patients, histocompatible platelets must be available in these circumstances.

(10) When and how should patients be monitored for refractoriness to platelet transfusion?

The Panel recommends that when refractoriness is suspected, platelet counts should be performed 10-60 minutes after transfusion. Because patients may have a poor increment to a single transfusion and yet have excellent platelet increments with subsequent transfusions, a diagnosis of refractoriness to platelet transfusion should only be made when at least two transfusions of ABO-compatible units, stored for less than 72 hours, result in poor increments (less than 5000/microliter).

(11) How should refractoriness to platelet transfusion be managed?

Alloimmunization is usually due to antibody against HLA antigens and only rarely to platelet-specific antigens. Patients with alloimmune-refractory thrombocytopenia, as defined previously, are best managed with platelet transfusions from histocompatible donors matched for HLA-A and HLA-B antigens. For patients( 1) whose HLA type cannot be determined, (2) who have uncommon HLA types for whom suitable donors cannot be identified, or (3) who do not respond to HLA-matched platelets, histocompatible platelet donors can often be identified using platelet cross-matching techniques. In many patients, these two techniques are complementary.

Platelet Transfusion for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Schiffer CA, Bohlke K, Delaney M, et al. J Clin Oncol. 2017 Nov 28:JCO2017761734. doi: 10.1200/JCO.2017.76.1734. [Epub ahead of print]

FDA Approves FoundationOne CDx Next Generation Sequencing Based Assay to Tailor Cancer Therapies

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SUMMARY: The FDA on November 30, 2017, granted marketing approval to FoundationOne CDx (F1CDx), a Next Generation Sequencing (NGS) based, in vitro diagnostic (IVD) assay, to detect genetic mutations in 324 genes and two genomic signatures, in any solid tumor type. The test can also identify which patients with Non Small Cell Lung Cancer (NSCLC), Melanoma, Breast cancer, ColoRectal cancer, or Ovarian cancer may benefit from 15 different FDA-approved targeted treatment options.

The basic premise of cancer genomics is that cancer is caused by somatically acquired mutations, and is therefore a disease of the genome. Tumor genomic profiling enables the identification of specific genomic alterations and thereby can provide personalized treatment options with targeted therapies that are specific for those molecular targets. A genomic test can be performed on a tumor specimen or on cell-free DNA in plasma (“liquid biopsy”) or an ImmunoHistoChemistry (IHC) test can be performed on tumor tissue for protein expression that demonstrates a genomic variant known to be a drug target, or to predict sensitivity to a chemotherapeutic drug.NGS Overview

Next-Generation Sequencing (NGS) platforms or second-generation sequencing, unlike the first-generation sequencing, known as Sanger sequencing, perform massively parallel sequencing, which allows sequencing of millions of fragments of DNA from a single sample. With this high-throughput sequencing, the entire genome can be sequenced in less than 24 hours. This is in contrast to Sanger sequencing technology which has required over a decade to decipher the human genome. There are a number of different NGS platforms using different sequencing technologies and NGS can be used to sequence and systematically study the cancer genomes in their entirety or specific areas of interest in the genome or small numbers of individual genes. Recently reported genomic profiling studies, performed in patients with advanced cancer suggest that actionable mutations are found in 20-40% of patients’ tumors.

The application for F1CDx , was reviewed by the FDA using a coordinated, cross-agency approach and clinical performance of the test was established by comparing F1CDx to previously FDA-approved companion diagnostic tests, that are currently used to determine patient eligibility for certain treatments. It was noted that F1CDx assay’s ability to detect select mutation types (substitutions and short insertions and deletions) representative of the entire 324 gene panel was accurate approximately 94.6% of the time. This 324 gene panel included EGFR, KRAS, BRAF, BRCA1/2, ALK, and several other genes with emerging therapies, such as NTRK1/2/3. This assay can additionally detect MicroSatellite Instability (MSI) and Tumor Mutational Burden, which can predict response to immunotherapy.

The FDA noted that this is the first device with the FDA’s “Breakthrough Device” designation to complete the PreMarket Approval (PMA) process, and it is the second IVD authorized under the FDA and Centers for Medicare & Medicaid Services’ (CMS) Parallel Review program. Under this program, the CMS issued a proposed national coverage determination of the F1CDx for Medicare beneficiaries with recurrent, metastatic, or advanced Stage IV cancer, who have not been previously tested using NGS technology, and who continue to remain candidates for further therapy. https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm587387.htm

FDA Approves Adjuvant Therapy with SUTENT® in High-Risk Renal Cell Carcinoma after Nephrectomy

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SUMMARY: The FDA on November 16, 2017 approved SUTENT® (Sunitinib malate) for the adjuvant treatment of adult patients at high risk of recurrent Renal Cell Carcinoma following nephrectomy. The American Cancer Society estimates that about 62,700 new cases of kidney cancer will be diagnosed in the United States in 2016 and over 14,000 patients will die from this disease. The prognosis for patients with Renal Cell Carcinoma (RCC) is dependent on the stage of disease and risk factors. Two validated models, the University of California Los Angeles Integrated Staging System (UISS) and the Stage, Size, Grade, and Necrosis (SSIGN) score were developed, to assess the risk for relapse. UISS is based on ECOG Performance Status, Fuhrman nuclear grading and TNM pathological stage, whereas the SSIGN score takes Stage, Size, Grade and Necrosis into consideration. Approximately 16% of patients with RCC present with Locoregional disease, and up to 40% of these patients relapse with metastatic disease, following nephrectomy. The 5-year survival for locoregional (stage III) disease is 53%, and 8% for metastatic disease. The standard management of high risk patients following nephrectomy has been surveillance, as there has been limited data demonstrating the benefit of adjuvant therapy in reducing the risk of relapse.MOA of SUTENT

SUTENT® (Sunitinib) is a MultiKinase Inhibitor (MKI) which simultaneously targets the tumor cell wall, vascular endothelial cell wall as well as the pericyte/fibroblast/vascular/ smooth vessel cell wall and is capable of specifically binding to tyrosine kinases, inhibiting the earlier signaling events and thereby inhibits phosphorylation of VEGF receptor, PDGF receptor, FLT-3 and c-KIT. SUTENT® is indicated for the treatment of advanced Renal Cell Carcinoma and in a multi-center, randomized study, demonstrated superior Progression Free Survival and Objective Response Rate, when compared with Interferon Alfa, in patients with treatment-naïve Renal Cell Carcinoma. The authors in this study examined the efficacy and safety of SUTENT® in patients with locally advanced RCC, at high risk for tumor recurrence, following nephrectomy.

Sunitinib as Adjuvant Treatment for Patients at High Risk of Recurrence of Renal Cell Carcinoma Following Nephrectomy (S-TRAC) is a randomized, double blind, phase III trial in which 615 patients with locoregional, high risk, clear cell Renal Cell Carcinoma were randomly assigned to receive SUTENT® (N=309) or placebo (N=306). Treatment consisted of either SUTENT® 50 mg PO daily or placebo, on a 4-weeks-on, 2-weeks-off schedule, for 1 year or until disease recurrence or unacceptable toxicity. Eligible patients had tumor Stage III or higher, regional lymph node metastasis, or both and were required to have absence of macroscopic residual or metastatic disease after nephrectomy, as confirmed by a CT scan. The primary end point was Disease Free Survival and secondary end points included Overall Survival, and Safety.

It was noted that the median duration of Disease Free Survival was 6.8 years in the SUTENT® group and 5.6 years in the placebo group (HR=0.76; P=0.03). Overall Survival data were not mature at the time of this analysis. Grade 3 or 4 adverse events were more frequent in the SUTENT® group compared to the placebo group and dose reductions, dose interruptions and discontinuations were more frequent in the SUTENT® group as well. The most commonly reported adverse events were skin toxicity (palmar-plantar erythrodysesthesia), hypertension, and fatigue, with declines in quality of life while on active therapy. In a previously published adjuvant trial (ASSURE trial), there was no improvement in Disease Free Survival in patients receiving Sunitinib or Sorafenib as compared with placebo. This has been attributed to the ASSURE trial including many patients with early (Stage 1) tumors as well as those with non-clear cell histology. Additionally, the dosing schedule in the ASSURE trial was lower than this present study.

It was concluded that adjuvant treatment with SUTENT® following nephrectomy in patients with high risk disease, results in significantly improved Disease Free Survival but this benefit may be associated with higher rate of toxicities during treatment. Adjuvant Sunitinib in High-Risk Renal-Cell Carcinoma after Nephrectomy. Ravaud A, Motzer RJ, Pandha HS, et al. for the S-TRAC Investigators. N Engl J Med 2016; 375:2246-2254

FDA Approves ADCETRIS® for Cutaneous T-Cell Lymphoma

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SUMMARY: The FDA on November 9, 2017 granted regular approval to ADCETRIS® (Brentuximab vedotin), for the treatment of adult patients with primary cutaneous Anaplastic Large Cell Lymphoma (pcALCL) or CD30-expressing Mycosis Fungoides (MF), who have received prior systemic therapy. Primary Cutaneous T Cell Lymphoma (CTCL) is a type of Non Hodgkin Lymphoma and includes a spectrum of diseases that primarily involve the skin, but may ultimately involve lymph nodes, blood and visceral organs such as spleen, liver and lungs. The prevalence in the US is approximately 16,000-20,000 patients and the incidence is higher in blacks than Caucasians or Asians. It is more common in men, and the median age at diagnosis is 50 years. Mycosis Fungoides/Sezary Syndrome is the most common type of CTCL accounting for 44% of cases. Patients with Stage I disease have an excellent prognosis. However for those with advanced disease, durable responses are rare with present available therapies and outcomes are poor.Classification of T-Cell Lymphomas

ADCETRIS® (Brentuximab vedotin) is an Antibody-Drug Conjugate (ADC) that targets CD30. ADCETRIS® consists of the anti-CD30 monoclonal antibody SGN-30 conjugated to the cytotoxic agent, MonoMethyl Auristatin E (MMAE) via a peptide linker. When administered intravenously, ADCETRIS® is internalized by CD30 expressing tumor cells, causing the release of MMAE into the cytosol through the enzymatic cleavage of the peptide linker.

The FDA approval was based on international, multicentre, open-label, randomized, phase III trial (ALCANZA), which enrolled 131 previously treated patients with CD30-positive Mycosis Fungoides (MF) or primary cutaneous Anaplastic Large Cell Lymphoma (pcALCL). Patients with MF were required to have received at least one prior systemic therapy and those with pcALCL were required to have prior radiation therapy or at least one systemic therapy. Patients were randomly assigned (1:1) to receive ADCETRIS® 1.8 mg/kg IV once every 3 weeks, for up to 16 cycles (N=66), or physician's choice of Methotrexate 5-50 mg orally once per week or Bexarotene 300 mg/m2 orally once daily for up to 48 weeks (N=65). There were more pcALCL patients with extracutaneous disease in the ADCETRIS® group (44% versus 27%). The Primary endpoint was the proportion of patients achieving an Objective Response Rate lasting at least 4 months (ORR4). Secondary outcome measures included Complete Response (CR) rate, Progression Free Survival (PFS), and reduction in the burden of symptoms during treatment.

At a median follow-up of 22.9 months, the proportion of patients achieving an objective global response lasting at least 4 months was 56.3% with ADCETRIS® versus 12.5% with physician's choice of treatment (P<0.0001). The CR rate in the ADCETRIS® group was 16% versus 2% in the physicians choice group (P=0.007). The median PFS was 16.7 months in the ADCETRIS® arm versus 3.7 months in the physicians choice arm (HR=0.27; P<0.001). The most common adverse reactions in those patients receiving ADCETRIS®: were anemia, neutropenia, peripheral neuropathy, nausea, diarrhea and fatigue. The most common adverse event leading to treatment discontinuation was peripheral neuropathy.

It was concluded that treatment with ADCETRIS® resulted in significant improvement in Objective Response Rate and Progression Free Survival, among patients with advanced CD30-positive Mycosis Fungoides or primary cutaneous Anaplastic Large Cell Lymphoma, fulfilling an unmet need for this patient group. Brentuximab vedotin or physician's choice in CD30-positive cutaneous T-cell lymphoma (ALCANZA): an international, open-label, randomised, phase 3, multicentre trial. Prince HM, Kim YH, Horwitz SM, et al. Lancet. 2017;390:555-566.

Long Term Risk of Breast Cancer Recurrence after Stopping Endocrine Therapy at 5 Years

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SUMMARY: Breast cancer is the most common cancer among women in the US and about 1 in 8 women (12%) will develop invasive breast cancer during their lifetime. It is estimated that 252,710 new cases of invasive breast cancer and 63,410 new cases of non-invasive breast cancer will be diagnosed in women in 2017 and 40,610 women are expected to die from the disease.

It has been well established that treatment with 5 years of endocrine therapy in early stage, Estrogen Receptor (ER) positive breast cancer, significantly reduces the risks of locoregional and distant recurrence, contralateral breast cancer, death from breast cancer, and therefore death from any cause. Extended adjuvant endocrine therapy with either Tamoxifen or an Aromatase Inhibitor (AI) beyond 5 years can further reduce breast cancer recurrence. This however can result in treatment related side effects. Therefore, when considering extended adjuvant endocrine therapy beyond 5 years, the potential benefits should be weighed against the associated risk with such therapy. The absolute benefit of continuing endocrine therapy after 5 years depends on the absolute risk of later recurrence, if patient’s receives no further therapy.

The authors in this publication reported the influence of original tumor characteristics, on the incidence of breast cancer outcomes, over a 20 year period. This meta-analysis included data from 88 trials in the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) database of randomized trials, involving 62,923 women with ER-positive breast cancer, who were disease-free after 5 years of adjuvant endocrine therapy. Data was analyzed from women who had T1 disease (Tumor diameter 2 cm or less) or T2 disease (Tumor diameter more than 2 cm up to 5 cm), no positive nodes (N0), 1-3 positive nodes (N1-3), 4-9 positive nodes (N4-9), and no distant metastases. The authors then assessed the associations of Tumor diameter and Nodal status (TN), tumor grade, and other factors with patients’ outcomes, during the period from 5 to 20 years.

It was noted that distant breast cancer recurrences occurred at a steady rate for at least another 15 years after completing 5 years of adjuvant hormonal treatment. The risk of distant recurrence strongly correlated with the original Tumor diameter and Nodal status (TN status).

Among women with T1 disease, the risk of distant recurrence was 13% in those with T1N0 disease, 20% in those with T1N1-3 disease and 34% in those with T1N4-9 disease. Even in those women with low grade T1N0 breast cancer, the absolute risk of distant recurrence from 5-20 years was 10%.

Among those with T2 disease, the risk of distant recurrence was 19% with T2N0 disease, 26% with T2N1-3 disease, and 41% with T2N4-9 disease. TN status was also a strong determinant of locoregional recurrence, but not predictive for contralateral breast cancer.

There was a strong association of tumor grade and Ki-67 status with the risk of distant recurrence during the first 5 years but had limited additional prognostic relevance during years 5-20. Similarly, patients with negative Progesterone Receptor (PR) had a worse prognosis during the first 5 years but not thereafter.

The authors concluded that even after 5 years of adjuvant endocrine therapy, women with ER-positive, early stage breast cancer, continue to be at risk for recurrence and death from breast cancer, for at least 20 years after the original diagnosis. This risk varies from 10-41% and is strongly dependent on TN status at the time of initial diagnosis. Even those with low-grade T1N0 disease were at an appreciable risk of distant recurrence. Extended adjuvant endocrine therapy beyond 5 years may reduce this risk, and this study highlights the need for new approaches to reduce late recurrence. 20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years. Pan H, Gray R, Braybrooke J, et al. for the EBCTCG. N Engl J Med 2017; 377:1836-1846

TAGRISSO® Superior to First Generation EGFR TKIs in Advanced Non-Small Cell Lung Cancer

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Approximately 10% to 15% of Caucasian patients and 35-50% of Asian patients with Adenocarcinomas, harbor activating EGFR (Epidermal Growth Factor Receptor) mutations and 90% of these mutations are either Exon 19 deletions or L858R point mutations in Exon 21. EGFR-Tyrosine Kinase Inhibitors (TKIs) such as TARCEVA® (Erlotinib), IRESSA® (Gefitinib) and GILOTRIF® (Afatinib), have demonstrated a 60% to 70% response rate as monotherapy when administered as first line treatment, in patients with metastatic NSCLC, who harbor the sensitizing EGFR mutations. However, majority of these patients experience disease progression within 9 to 14 months. This resistance to frontline EGFR TKI therapy has been attributed to acquired T790M “gatekeeper” point mutation in EGFR, identified in 50% – 60% of patients.
TAGRISSO® (Osimertinib), is a third-generation Epidermal Growth Factor Receptor (EGFR) TKI and in a randomized, double blind, phase III clinical trial, demonstrated superior efficacy and tolerability compared to the Standard of Care, as first-line therapy in patients with advanced EGFR mutation positive NSCLC. This benefit was seen even in those with CNS metastases at study entry. These new finding are very likely to change the treatment paradigm for NSCLC patients whose tumors harbor EGFR mutations.

 

MisMatch Repair Deficiency and MicroSatellite Instability May Predict Perioperative Chemotherapy Benefit in Operable GastroEsophageal Cancers

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SUMMARY: The American Cancer Society estimates that about 28,000 new cases of stomach cancer will be diagnosed in the United States for 2017 and about 10,960 people will die of this disease. It is a leading cause of cancer-related deaths in the world. Patients with operable Gastric or GastroEsophageal adenocarcinoma frequently receive perioperative or neoadjuvant chemotherapy prior to surgical resection, as this has been associated with a modest improvement in Overall Survival (OS), compared with surgery alone. However, approximately 50% of the patients undergoing surgical resection will die of recurrent disease. Further perioperative chemotherapy can be associated with significant toxicities. For patients with GastroEsophageal cancer receiving neoadjuvant treatment, there are presently no validated prognostic biomarkers, and patient selection is based on preoperative clinical staging.

The DNA MisMatchRepair (MMR) system is responsible for molecular surveillance and works as an editing tool that identifies errors within the microsatellite regions of DNA and removes them. Defective MMR system leads to MSI (Micro Satellite Instability) and hypermutation, triggering an enhanced antitumor immune response. MSI (Micro Satellite Instability) is therefore a hallmark of defective/deficient DNA MisMatchRepair (MMR) system and occurs in 15% of all colorectal cancers. Defective MisMatchRepair can be a sporadic or heritable event. Approximately 65% of the MSI colon tumors are sporadic and when sporadic, the DNA MisMatchRepair gene is MLH1. Defective MisMatchRepair can also manifest as a germline mutation occurring in 1 of the 4 MisMatchRepair genes which include MLH1, MSH2, MSH6, PMS2. This produces Lynch Syndrome (Hereditary Nonpolyposis ColoRectal Carcinoma – HNPCC), an autosomal dominant disorder and is the most common form of hereditary colon cancer, accounting for 35% of the MSI colorectal cancers. MSI tumors tend to have better outcomes and this has been attributed to the abundance of Tumor Infiltrating Lymphocytes in these tumors, from increased immunogenicity. These tumors are susceptible to PD-1 blockade and respond to treatment with checkpoint inhibitors such as KEYTRUDA® (N Engl J Med 372:2509-2520, 2015). Other MSI-High and dMMR (MMR deficient) tumors include, Endometrial and GastroIntestinal tumors and to a lesser extent Breast, Prostate, Bladder and Thyroid tumors.

MSI (Micro Satellite Instability) testing is performed using a PCR based assay and MSI-High refers to instability at 2 or more of the 5 mononucleotide repeat markers and MSI-Low refers to instability at 1 of the 5 markers. Patients are considered Micro Satellite Stable (MSS) if no instability occurs. MSI-L and MSS are grouped together because MSI-L tumors are uncommon and behave similar to MSS tumors. Tumors considered MSI-H have deficiency of one or more of the DNA MisMatchRepair genes. MMR gene deficiency can be detected by ImmunoHistoChemistry (IHC). MLH1 gene is often lost in association with PMS2. Approximately 10-20% of Gastric cancers are MSI high or MMR Deficient. Several retrospective studies have suggested favorable outcomes in patients with Gastric cancer with high MSI tumors, although none of these studies had a control group.

In the MAGIC trial (The UK Medical Research Council Adjuvant Gastric Infusional Chemotherapy), which is an open-label, multicenter, phase III study, patients with resectable GastroEsophageal cancer were randomized to receive either 6 cycles of perioperative Epirubicin, Cisplatin, and Infusional 5-FU (3 cycles before and 3 cycles after resection) plus surgery, or undergo surgery alone. In this study, patients treated with perioperative chemotherapy had improved Overall Survival (OS) compared with patients treated with surgery alone (5-year OS 36% versus 23%; HR=0.75; P=0.009).

The authors in this study additionally evaluated patients with operable GastroEsophageal cancers with High MicroSatellite Instability (MSI-H) or MMR deficiency (dMMR), and compared their survival with patients who had MicroSatellite Stable (MSS) GastroEsophageal cancer, when these patients were treated with surgery alone or surgery plus perioperative chemotherapy. The authors thus assessed survival outcomes based on MSI/MMR deficiency. Of the 503 clinical trial participants, MSI results were available for 303 patients and both MSI and MMR results were available in 254 patients. Patients who had High MSI or MMR deficiency treated with surgery alone, had a median OS that was Not Reached (NR) compared with a median Overall Survival (OS) of 20.5 months, among those who had neither high MSI nor MMR deficiency (HR=0.42; P=0.09). In contrast, patients who had either a High MSI or MMR deficiency, treated with surgery plus perioperative chemotherapy had a median OS of 9.6 months compared with a median OS of 19.5 months, among those who had neither High MSI nor MMR deficiency (HR=2.18; P=0.03). The overall concordance rate between MSI-H and MMR deficient status was 97.6%.

Based on these findings the authors concluded that patients with operable GastroEsophageal cancer with High MicroSatellite Instability or MMR deficiency, did not benefit from perioperative chemotherapy and could be spared from the toxicities of chemotherapy. These patients may benefit from therapy with PD-1 inhibitors, although this will need to be further investigated. If independently validated, MSI or MMR deficiency, determined by preoperative biopsies, could be used to select patients for perioperative chemotherapy. Mismatch Repair Deficiency, Microsatellite Instability, and Survival. An Exploratory Analysis of the Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) Trial. Smyth EC, Wotherspoon A, Peckitt C, et al. JAMA Oncol. 2017;3:1197-1203.

TAGRISSO® Superior to First Generation EGFR TKIs in Advanced Non-Small Cell Lung Cancer

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SUMMARY: Lung cancer is the second most common cancer in both men and women and accounts for about 13% of all new cancers and 27% of all cancer deaths. The American Cancer Society estimates that for 2017 about 222,500 new cases of lung cancer will be diagnosed and over 155,000 patients will die of the disease. Lung cancer is the leading cause of cancer-related mortality in the United States. Non Small Cell Lung Cancer (NSCLC) accounts for approximately 85% of all lung cancers. Of the three main subtypes of Non Small Cell Lung Cancer (NSCLC), 30% are Squamous Cell Carcinomas (SCC), 40% are Adenocarcinomas and 10% are Large cell carcinomas. With changes in the cigarette composition and decline in tobacco consumption over the past several decades, Adenocarcinoma now is the most frequent histologic subtype of lung cancer. Approximately 10% to 15% of Caucasian patients and 35-50% of Asian patients with Adenocarcinomas, harbor activating EGFR (Epidermal Growth Factor Receptor) mutations and 90% of these mutations are either Exon 19 deletions or L858R point mutations in Exon 21. EGFR-Tyrosine Kinase Inhibitors (TKIs) such as TARCEVA® (Erlotinib), IRESSA® (Gefitinib) and GILOTRIF® (Afatinib), have demonstrated a 60% to 70% response rate as monotherapy when administered as first line treatment, in patients with metastatic NSCLC, who harbor the sensitizing EGFR mutations. However, majority of these patients experience disease progression within 9 to 14 months. This resistance to frontline EGFR TKI therapy has been attributed to acquired T790M “gatekeeper” point mutation in EGFR, identified in 50% – 60% of patients.

TAGRISSO® (Osimertinib), is a third-generation Epidermal Growth Factor Receptor (EGFR) TKI presently approved by the FDA, for the treatment of patients with metastatic EGFR T790M mutation-positive NSCLC, who had progressed on prior systemic therapy, including an EGFR-TKI. Previously published studies suggested that TAGRISSO® may also be effective as initial therapy for EGFR mutation-positive advanced NSCLC.

FLAURA is a randomized, double blind, phase III clinical trial, conducted to compare the efficacy and safety of first line TAGRISSO® to TARCEVA® or IRESSA® (which are considered Standard of Care as first line therapy), in NSCLC patients with activating mutations EGFR Exon 19 deletions or L858R substitution mutation on Exon 21. This study randomized 556 advanced NSCLC treatment naïve patients, with EGFR Exon 19 or 21 mutations in a 1:1 ratio, to TAGRISSO® 80 mg orally once daily (N=279) or Standard of Care EGFR-TKI, IRESSA® 250 mg or TARCEVA® 150 mg, orally once daily (N=277). Patients were stratified by mutation status (Exon 19 vs 21 mutations) and race (Asian vs non-Asian). Patients with CNS metastases who were neurologically stable, were allowed in this study. The Primary endpoint was Progression Free Survival (PFS).

The median PFS was 18.9 months with TAGRISSO® compared to 10.2 months for the standard therapy (HR=0.46; P<0.0001), suggesting a 54% reduction in the risk of disease progression, compared with Standard of Care. TAGRISSO® extended the median Time To Progression by about 9 months. This PFS benefit was consistent across all subgroups of patients, including those with and without CNS metastases at study entry. The Objective Response Rate (ORR) with TAGRISSO® was 80% compared with 76% for TARCEVA® and IRESSA®. The median Duration of Response with TAGRISSO® was 17.2 versus 8.5 months in the comparator arm. The median Overall Survival was not reached. Grade 3 and 4 toxicities were lower for TAGRISSO® (34%) compared with 45% for TARCEVA® and IRESSA®. Toxicities led to treatment discontinuation for 13% and 18% of patients in the TAGRISSO® and comparator groups, respectively.

It was concluded that TAGRISSO® demonstrated superior efficacy and tolerability compared to the Standard of Care, as first-line therapy in patients with advanced EGFR mutation positive NSCLC. Studies are underway, assessing treatments, following resistance to TAGRISSO®. Osimertinib vs standard of care (SoC) EGFR-TKI as first-line therapy in patients (pts) with EGFRm advanced NSCLC: FLAURA. Ramalingam S, Reungwetwattana T, Chewaskulyong B, et al. Presented at: 2017 ESMO Congress; Madrid, Spain; September 9-12, 2017. Abstract LBA2_PR.

Alcohol and Cancer A Statement of the American Society of Clinical Oncology

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Alcohol consumption is an established risk factor for several malignancies, and is a potentially modifiable risk factor for cancer. The International Agency for Research on Cancer (IARC), a branch of WHO, classified alcohol as a group 1 carcinogen. The American Heart Association, American Cancer Society, and US Department of Health and Human Services all recommend that men limit intake to one to two drinks per day and women to one drink per day. People who do not currently drink alcohol should not start for any reason. There is a clear association between alcohol and upper aerodigestive tract cancers (larynx, esophagus, and oral cavity/pharynx). A recent meta-analysis of cohort studies among 209,597 cancer survivors showed an 8% increase in overall mortality and a 17% increased risk for recurrence in the highest versus lowest alcohol consumers. The benefit of alcohol consumption on cardiovascular health likely has been overstated and the net effect of alcohol is harmful. Alcohol consumption should therefore not be recommended to prevent cardiovascular disease or all-cause mortality.