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Nonanthracycline-Based Regimens in the Neoadjuvant Treatment of HER2-Positive Breast Cancer
Although efficacy of anthracycline or nonanthracycline-based regimens is similar in the adjuvant setting for patients with local HER2-positive breast cancer, data in the neoadjuvant setting are limited. In a phase III trial of over 400 patients with stage II to III HER2-positive breast cancer randomly assigned to nonanthracycline- or anthracycline-based neoadjuvant chemotherapy with concurrent pertuzumab and trastuzumab, the rates of pathologic complete response rate (pCR) did not differ between the arms (67 versus 68 percent, respectively). Rates of febrile neutropenia and decline in left ventricular ejection fraction were higher among those receiving anthracyclines. These data support our approach of offering nonanthracycline-based chemotherapy, together with HER2-directed therapy, to women receiving neoadjuvant treatment for HER2-positive breast cancer.
Laparoscopic Versus Open Surgery for Rectal Cancer
Transabdominal rectal cancer surgery can be performed via open, laparoscopic, or robotic approaches. In a systematic review and meta-analysis of 14 randomized trials, laparoscopic surgery resulted in a higher rate of noncomplete total mesorectal excision than open surgery (13 versus 10 percent). Other technical outcomes were not different. Long-term data are needed to determine whether the higher rate of noncomplete total mesorectal excision will result in worse survival. In the absence of these data, the best surgical approach needs to be determined individually by tumor and patient characteristics, as well as surgeon experience.
Adjuvant Ipilimumab in Stage III Melanoma
Ipilimumab is approved at a dose of 10 mg/kg as adjuvant therapy for stage III melanoma based on prolongation of overall survival. An unplanned exploratory analysis of the E-1609 trial was presented at the 2017 American Society of Clinical Oncology meeting comparing the 10 mg/kg versus 3 mg/kg dosage schedule of ipilimumab in the adjuvant setting. Toxicity was significantly decreased with the 3 mg/kg schedule and there was no difference in the three-year relapse-free survival rate. While stronger evidence supports the use of the 10 mg/kg dose, there are currently inadequate data to require the selection of this dose over the 3 mg/kg dose in the adjuvant setting.
Duration of Postradiation Temozolomide in Glioblastoma
Postradiation monthly temozolomide is a standard component of initial therapy for glioblastoma, but the number of cycles has been subject to variation, with some centers treating beyond six cycles for patients with stable disease. In a retrospective study of over 600 patients with glioblastoma enrolled in four randomized trials who were free of progression after six cycles of adjuvant temozolomide, receipt of more than six cycles was associated with a slight improvement in progression-free survival but no difference in overall survival. Since extended adjuvant therapy exposes patients to ongoing treatment-related toxicities, these results support our practice of stopping adjuvant therapy after six cycles of monthly temozolomide.
Sequential Induction Chemotherapy and Chemoradiotherapy for Locally Advanced Head and Neck Cancer
The outcome of sequential therapy (induction chemotherapy followed by concurrent chemoradiotherapy) has yielded conflicting results in multiple clinical trials. An Italian phase III trial demonstrated improved overall survival with sequential therapy compared with concurrent chemoradiotherapy alone. Sequential therapy may offer advantages over concurrent chemoradiotherapy alone in select situations. Choice of therapy should be an individual clinician/patient decision, but generally, sequential therapy is reserved for healthy patients at high risk for both distant and locoregional recurrence.
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