1. Neuropathy Is Not Associated With Clinical Outcomes in Patients Receiving Adjuvant Taxane-Containing Therapy for Operable Breast Cancer Bryan P. Schneider, Fengmin Zhao, Molin Wang, Vered Stearns Silvana Martino, Vicky Jones, Edith A. Perez, Tom Saphner, Antonio C. Wolff, George W. Sledge Jr, William C. Wood Nancy E. Davidson, and Joseph A. Sparano J Clin Oncol 30:3051-3057. © 2012 by American Society of Clinical Oncology 혈액종양내과 R2 이정록 /prof 백선경

2.  adjuvant taxanes to standard anthracycline-based therapy : reduced the risk of recurrence, improved survival in patients with node-positive breast cancer.  Taxanes : standard therapy for breast cancer in the metastatic setting.  Neuropathy : most common nonhematologic toxicities associated with taxanes, especially weekly paclitaxel  Previous studies : incidence of neuropathy increased with older age, diabetes, alcohol use, and black race. No other validated clinical characteristics associated with an increased risk of neuropathy No established predictive biomarkers: determine highest risk for this toxicity  In this analysis object: determine relationship between taxane-induced neuropathy and outcomes in patients who received adjuvant weekly paclitaxel and other taxane- based regimens in E1199. Introduction

3.  Patients  Patients enrolled trial E1199: 5,052 patients with axillary node-positive or high-risk, node-negative breast cancer.  All patients received four cycles of intravenous doxorubicin (60mg/m2) and cyclophosphamide (600mg/m2) every 3 weeks for four treatment P3: paclitaxel 175 mg/m2 every 3 weeks for four cycles P1: paclitaxel 80 mg/m2 weekly for 12 cycles, D3: docetaxel 100 mg/m2 every 3 weeks for four cycles D1: docetaxel 35 mg/m2 weekly for 12 cycles Methods

4.  Neuropathy and Efficacy Parameters  National Cancer Institute Common Toxicity Criteria (version2.0) grading scale evaluated was the occurrence of grade 2 to 4 neuropathy motor neuropathy, sensory neuropathy, neuropathic pain, the last measurement that occurred 3 weeks after the conclusion of therapy.  Grade 2 neuropathy: the dose reduced by 25%  Grade 3 or 4 neuropathy: the dose was held until resolution to less than grade 2  Grade 3 or 4 toxicity persisted longer than 3 weeks: therapy was discontinued.  Three end point Overall survival (OS): included death as a result of any cause Disease free survival (DFS): included recurrence (local/regional or distant), contralateral breast cancer Recurrence-free survival (RFS): same as DFS, not include contralateral breast cancer events Methods

5.  Statistical Analysis  Multivariable logistic regression association between baseline patient characteristics and neuropathy. baseline patient characteristics included age as a categorical variable ( 45, 46 to 65, and 65 years), race (black v others), obesity (body massindex 30 kg/m2 v others), and menopausal status (premenopausal v postmenopausal)  Kaplan-Meier curves estimate event-time distribution  Log-rank test distribution difference between patients with or without neuropathy Using landmark method, with 7 months from random assignment as the landmark time point.  Cox proportional hazards methods neuropathy was treated as a time-varying covariate Used estimate unadjusted and adjusted hazards ratios for neuropathy. Methods

7. Results

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10. Results age, race, obesity, menopausal status, tumor size, nodal status, treatment arm, treatment-associated grade 2 to 4 hyperglycemia.

11.  Treatment-related grade 2 to 4 hyperglycemia and neuropathy and also with clinical outcomes. Hyperglycemia during treatment was associated with an increased risk of neuropathy as hypothesized.  Race and obesity strong trend and increased risk of neuropathy Did not reach statistical significance (multivariable logistic regression analysis)  Weekly paclitaxel arm nonsignificant trend for increased risk with black race.  Age significantly noe associated with the risk of neuropathy E5103 (12.9% increased risk with each decade of life; P.004) Discussion

12.  Several studies SNP(single nucleotide polymorphisms) associated with the likelihood of developing paclitaxel-induced neuropathy.  Our findings from the E1199 trial no relationship between paclitaxel- or docetaxel induced neuropathy and clinical outcomes  E1199 was a landmark study(tested two taxanes with two different schedules by using a two-by-two factorial) between the weekly schedule and docetaxel, no significant difference when taxane types or schedules were compared  Compared with the standard arm (3-week paclitaxel arm) the weekly paclitaxel arm was associated with improved DFS and OS the every 3-week docetaxel arm was associated with improved DFS. Because both OS and DFS were improved, and there was less overall toxicity Discussion

13.  Other studies have shown a benefit for docetaxel containing regimens associated with more overall grade 3 to 4 toxicity but lower neuropathy rates than observed with weekly paclitaxel.  Other studies have also evaluated the relationship between taxane-induced neuropathy and clinical outcomes. patients with HER2/neu overexpressing disease treated in intergroup trial N9831 doxorubicin and cyclophosphamide followed by a weekly paclitaxel regimen similar to that used in E1199 and E5103, there was an association between neuropathy and improved outcomes. For that study, patients in the control arm who had grade 2 to 4 neuropathy had an improved 3-year DFS (84.2% v 77.8%; HR, 0.64;P.01)  Our study patients with HER2/neu overexpressing disease who developed neuropathy showed a trend toward improved DFS, OS, and RFS, but this was not statistically significant. Discussion

14.  This analysis  neuropathy does not correlate with improved outcomes in patients with operable breast cancer treated with adjuvant taxane therapy. Conslussion