A Novel Biomarker Panel Examining Response to Gemcitabine with or without Erlotinib for Pancreatic Cancer Therapy in NCIC Clinical Trials Group PA.3
David B Shultz, Jonathan Pai, Wayland Chiu, Kendall Ng, Madeline G Hellendag, Gregory Heestand, Daniel T Chang, Dongsheng Tu, Malcolm J Moore, Wendy R Parulekar, Albert C Koong, David B Shultz, Jonathan Pai, Wayland Chiu, Kendall Ng, Madeline G Hellendag, Gregory Heestand, Daniel T Chang, Dongsheng Tu, Malcolm J Moore, Wendy R Parulekar, Albert C Koong
Abstract
Purpose: NCIC Clinical Trials Group PA.3 was a randomized control trial that demonstrated improved overall survival (OS) in patients receiving erlotinib in addition to gemcitabine for locally advanced or metastatic pancreatic cancer. Prior to therapy, patients had plasma samples drawn for future study. We sought to identify biomarkers within these samples.
Experimental design: Using the proximity ligation assay (PLA), a probe panel was built from commercially available antibodies for 35 key proteins selected from a global genetic analysis of pancreatic cancers, and used to quantify protein levels in 20 uL of patient plasma. To determine if any of these proteins levels independently associated with OS, univariate and mulitbaraible Cox models were used. In addition, we examined the associations between biomarker expression and disease stage at diagnosis using Fisher's exact test. The correlation between Erlotinib sensitivity and each biomarkers was assessed using a test of interaction between treatment and biomarker.
Results and conclusion: Of the 569 eligible patients, 480 had samples available for study. Samples were randomly allocated into training (251) and validation sets (229). Among all patients, elevated levels of interleukin-8 (IL-8), carcinoembryonic antigen (CEA), hypoxia-inducible factor 1-alpha (HIF-1 alpha), and interleukin-6 were independently associated with lower OS, while IL-8, CEA, platelet-derived growth factor receptor alpha and mucin-1 were associated with metastatic disease. Patients with elevated levels of receptor tyrosine-protein kinase erbB-2 (HER2) expression had improved OS when treated with erlotinib compared to placebo. In conclusion, PLA is a powerful tool for identifying biomarkers from archived, small volume serum samples. These data may be useful to stratify patient outcomes regardless of therapeutic intervention.
Trial registration: ClinicalTrials.gov NCT00040183.
Conflict of interest statement
Competing Interests: The authors have read the journal's policy and the authors of this manuscript have the following competing interests: GH has served as a consultant for Bayer, Merrimack, and Genomic Health. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.
Figures
![Fig 1. Univariate (A) and multivariable (B)…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4725948/bin/pone.0147995.g001.jpg)
Fig 2. Odds ratios (OR) of having…
Fig 2. Odds ratios (OR) of having stage III disease (locally advanced) for biomarker concentration,…
Fig 3. Erlotinib sensitivity is associated with…
Fig 3. Erlotinib sensitivity is associated with Her2 expression.
Median overall survival (with 95% CI)…
- Postmarketing surveillance study of erlotinib plus gemcitabine for pancreatic cancer in Japan: POLARIS final analysis.Furuse J, Gemma A, Ichikawa W, Okusaka T, Seki A, Ishii T. Furuse J, et al. Jpn J Clin Oncol. 2017 Sep 1;47(9):832-839. doi: 10.1093/jjco/hyx075. Jpn J Clin Oncol. 2017. PMID: 28541474 Free PMC article.
- Randomized, phase I/II study of gemcitabine plus IGF-1R antagonist (MK-0646) versus gemcitabine plus erlotinib with and without MK-0646 for advanced pancreatic adenocarcinoma.Abdel-Wahab R, Varadhachary GR, Bhosale PR, Wang X, Fogelman DR, Shroff RT, Overman MJ, Wolff RA, Javle M. Abdel-Wahab R, et al. J Hematol Oncol. 2018 May 30;11(1):71. doi: 10.1186/s13045-018-0616-2. J Hematol Oncol. 2018. PMID: 29843755 Free PMC article. Clinical Trial.
- Molecular predictors of outcome in a phase 3 study of gemcitabine and erlotinib therapy in patients with advanced pancreatic cancer: National Cancer Institute of Canada Clinical Trials Group Study PA.3.da Cunha Santos G, Dhani N, Tu D, Chin K, Ludkovski O, Kamel-Reid S, Squire J, Parulekar W, Moore MJ, Tsao MS. da Cunha Santos G, et al. Cancer. 2010 Dec 15;116(24):5599-607. doi: 10.1002/cncr.25393. Epub 2010 Sep 7. Cancer. 2010. PMID: 20824720 Clinical Trial.
- Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial.Hammel P, Huguet F, van Laethem JL, Goldstein D, Glimelius B, Artru P, Borbath I, Bouché O, Shannon J, André T, Mineur L, Chibaudel B, Bonnetain F, Louvet C; LAP07 Trial Group. Hammel P, et al. JAMA. 2016 May 3;315(17):1844-53. doi: 10.1001/jama.2016.4324. JAMA. 2016. PMID: 27139057 Clinical Trial.
- Efficacy and safety of gemcitabine plus erlotinib for locally advanced or metastatic pancreatic cancer: a systematic review and meta-analysis.Wang Y, Hu GF, Zhang QQ, Tang N, Guo J, Liu LY, Han X, Wang X, Wang ZH. Wang Y, et al. Drug Des Devel Ther. 2016 Jun 13;10:1961-72. doi: 10.2147/DDDT.S105442. eCollection 2016. Drug Des Devel Ther. 2016. PMID: 27358556 Free PMC article. Review.
- The Achilles' Heel of Pancreatic Cancer: Targeting pancreatic cancer's unique immunologic characteristics and metabolic dependencies in clinical trials.Siolas D, Morrissey C, Oberstein PE. Siolas D, et al. J Pancreatol. 2020 Sep;3(3):121-131. doi: 10.1097/JP9.0000000000000052. J Pancreatol. 2020. PMID: 33133736 Free PMC article. No abstract available.
- Clinical and Pre-Clinical Evidence of Carbonic Anhydrase IX in Pancreatic Cancer and Its High Expression in Pre-Cancerous Lesions.Strapcova S, Takacova M, Csaderova L, Martinelli P, Lukacikova L, Gal V, Kopacek J, Svastova E. Strapcova S, et al. Cancers (Basel). 2020 Jul 22;12(8):2005. doi: 10.3390/cancers12082005. Cancers (Basel). 2020. PMID: 32707920 Free PMC article. Review.
- The prognostic value of hypoxia-inducible factor-1α in advanced cancer survivors: a meta-analysis with trial sequential analysis.Han S, Huang T, Hou F, Yao L, Wang X, Wu X. Han S, et al. Ther Adv Med Oncol. 2019 Sep 24;11:1758835919875851. doi: 10.1177/1758835919875851. eCollection 2019. Ther Adv Med Oncol. 2019. PMID: 31579115 Free PMC article.
- Proteomic biomarkers in body fluids associated with pancreatic cancer.Jimenez-Luna C, Torres C, Ortiz R, Dieguez C, Martinez-Galan J, Melguizo C, Prados JC, Caba O. Jimenez-Luna C, et al. Oncotarget. 2018 Mar 27;9(23):16573-16587. doi: 10.18632/oncotarget.24654. eCollection 2018 Mar 27. Oncotarget. 2018. PMID: 29662668 Free PMC article. Review.
- Multiplex Proximity Ligation Assay to Identify Potential Prognostic Biomarkers for Improved Survival in Locally Advanced Pancreatic Cancer Patients Treated With Stereotactic Body Radiation Therapy.Rao AD, Liu Y, von Eyben R, Hsu CC, Hu C, Rosati LM, Parekh A, Ng K, Hacker-Prietz A, Zheng L, Pawlik TM, Laheru DA, Jaffee EM, Weiss MJ, Le DT, Hruban RH, De Jesus-Acosta A, Wolfgang CL, Narang AK, Chang DT, Koong AC, Herman JM. Rao AD, et al. Int J Radiat Oncol Biol Phys. 2018 Feb 1;100(2):486-489. doi: 10.1016/j.ijrobp.2017.10.001. Epub 2017 Oct 12. Int J Radiat Oncol Biol Phys. 2018. PMID: 29157747 Free PMC article.
-
- Klinkenbijl JH, Jeekel J, Sahmoud T, van Pel R, Couvreur ML, Veenhof CH, et al. Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC gastrointestinal tract cancer cooperative group. Annals of surgery. 1999;230(6):776–82; discussion 82–4. - PMC - PubMed
-
- Neoptolemos JP, Stocken DD, Friess H, Bassi C, Dunn JA, Hickey H, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. The New England journal of medicine. 2004;350(12):1200–10. - PubMed
-
- Steinberg W. The clinical utility of the CA 19–9 tumor-associated antigen. The American journal of gastroenterology. 1990;85(4):350–5. - PubMed
-
- Micke O, Bruns F, Schafer U, Kurowski R, Horst E, Willich N. CA 19–9 in the therapy monitoring and follow-up of locally advanced cancer of the exocrine pancreas treated with radiochemotherapy. Anticancer research. 2003;23(2A):835–40. - PubMed
- Clinical Trial, Phase III
- Randomized Controlled Trial
- Research Support, Non-U.S. Gov't
- Antineoplastic Agents / administration & dosage
- Antineoplastic Agents / therapeutic use*
- Biomarkers, Tumor / blood*
- Deoxycytidine / administration & dosage
- Deoxycytidine / analogs & derivatives*
- Deoxycytidine / therapeutic use
- Double-Blind Method
- Erlotinib Hydrochloride / administration & dosage
- Erlotinib Hydrochloride / therapeutic use*
- Gemcitabine
- Humans
- Pancreatic Neoplasms / drug therapy*
- Placebos
- Antineoplastic Agents
- Biomarkers, Tumor
- Placebos
- Deoxycytidine
- Erlotinib Hydrochloride
- Gemcitabine
- ClinicalTrials.gov/NCT00040183
- Full Text Sources
- Other Literature Sources
- Medical
- Research Materials
- Miscellaneous
![Fig 2. Odds ratios (OR) of having…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4725948/bin/pone.0147995.g002.jpg)
Fig 3. Erlotinib sensitivity is associated with…
Fig 3. Erlotinib sensitivity is associated with Her2 expression.
Median overall survival (with 95% CI)…
![Fig 3. Erlotinib sensitivity is associated with…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4725948/bin/pone.0147995.g003.jpg)
References
- Klinkenbijl JH, Jeekel J, Sahmoud T, van Pel R, Couvreur ML, Veenhof CH, et al. Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC gastrointestinal tract cancer cooperative group. Annals of surgery. 1999;230(6):776–82; discussion 82–4.
- Neoptolemos JP, Stocken DD, Friess H, Bassi C, Dunn JA, Hickey H, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. The New England journal of medicine. 2004;350(12):1200–10.
- Steinberg W. The clinical utility of the CA 19–9 tumor-associated antigen. The American journal of gastroenterology. 1990;85(4):350–5.
- Koom WS, Seong J, Kim YB, Pyun HO, Song SY. CA 19–9 as a predictor for response and survival in advanced pancreatic cancer patients treated with chemoradiotherapy. International journal of radiation oncology, biology, physics. 2009;73(4):1148–54. 10.1016/j.ijrobp.2008.06.1483
- Micke O, Bruns F, Schafer U, Kurowski R, Horst E, Willich N. CA 19–9 in the therapy monitoring and follow-up of locally advanced cancer of the exocrine pancreas treated with radiochemotherapy. Anticancer research. 2003;23(2A):835–40.
- Moore MJ, Goldstein D, Hamm J, Figer A, Hecht JR, Gallinger S, et al. Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the National Cancer Institute of Canada Clinical Trials Group. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 2007;25(15):1960–6.
- Fredriksson S, Dixon W, Ji H, Koong AC, Mindrinos M, Davis RW. Multiplexed protein detection by proximity ligation for cancer biomarker validation. Nature methods. 2007;4(4):327–9.
- Chang ST, Zahn JM, Horecka J, Kunz PL, Ford JM, Fisher GA, et al. Identification of a biomarker panel using a multiplex proximity ligation assay improves accuracy of pancreatic cancer diagnosis. Journal of translational medicine. 2009;7:105 10.1186/1479-5876-7-105
- Harsha HC, Kandasamy K, Ranganathan P, Rani S, Ramabadran S, Gollapudi S, et al. A compendium of potential biomarkers of pancreatic cancer. PLoS Med. 2009;6(4):e1000046 10.1371/journal.pmed.1000046
- Barrett T, Troup DB, Wilhite SE, Ledoux P, Rudnev D, Evangelista C, et al. NCBI GEO: mining tens of millions of expression profiles—database and tools update. Nucleic acids research. 2007;35(Database issue):D760–5.
- Edgar R, Domrachev M, Lash AE. Gene Expression Omnibus: NCBI gene expression and hybridization array data repository. Nucleic acids research. 2002;30(1):207–10.
- Holmer R, Goumas FA, Waetzig GH, Rose-John S, Kalthoff H. Interleukin-6: a villain in the drama of pancreatic cancer development and progression. Hepatobiliary & pancreatic diseases international: HBPD INT. 2014;13(4):371–80.
- Chen Y, Shi M, Yu GZ, Qin XR, Jin G, Chen P, et al. Interleukin-8, a promising predictor for prognosis of pancreatic cancer. World journal of gastroenterology: WJG. 2012;18(10):1123–9. 10.3748/wjg.v18.i10.1123
- Tas F, Karabulut S, Ciftci R, Sen F, Sakar B, Disci R, et al. Serum levels of LDH, CEA, and CA19-9 have prognostic roles on survival in patients with metastatic pancreatic cancer receiving gemcitabine-based chemotherapy. Cancer chemotherapy and pharmacology. 2014;73(6):1163–71. 10.1007/s00280-014-2450-8
- Shibaji T, Nagao M, Ikeda N, Kanehiro H, Hisanaga M, Ko S, et al. Prognostic significance of HIF-1 alpha overexpression in human pancreatic cancer. Anticancer research. 2003;23(6C):4721–7.
- Colbert LE, Fisher SB, Balci S, Saka B, Chen Z, Kim S, et al. High nuclear hypoxia-inducible factor 1 alpha expression is a predictor of distant recurrence in patients with resected pancreatic adenocarcinoma. International journal of radiation oncology, biology, physics. 2015;91(3):631–9. 10.1016/j.ijrobp.2014.11.004
- Lang SA, Moser C, Gaumann A, Klein D, Glockzin G, Popp FC, et al. Targeting heat shock protein 90 in pancreatic cancer impairs insulin-like growth factor-I receptor signaling, disrupts an interleukin-6/signal-transducer and activator of transcription 3/hypoxia-inducible factor-1alpha autocrine loop, and reduces orthotopic tumor growth. Clinical cancer research: an official journal of the American Association for Cancer Research. 2007;13(21):6459–68.
- Shi Q, Le X, Abbruzzese JL, Wang B, Mujaida N, Matsushima K, et al. Cooperation between transcription factor AP-1 and NF-kappaB in the induction of interleukin-8 in human pancreatic adenocarcinoma cells by hypoxia. Journal of interferon & cytokine research: the official journal of the International Society for Interferon and Cytokine Research. 1999;19(12):1363–71.
- Kitamoto S, Yokoyama S, Higashi M, Yamada N, Takao S, Yonezawa S. MUC1 enhances hypoxia-driven angiogenesis through the regulation of multiple proangiogenic factors. Oncogene. 2013;32(39):4614–21. 10.1038/onc.2012.478
- Sahraei M, Roy LD, Curry JM, Teresa TL, Nath S, Besmer D, et al. MUC1 regulates PDGFA expression during pancreatic cancer progression. Oncogene. 2012;31(47):4935–45. 10.1038/onc.2011.651
- Stock AM, Hahn SA, Troost G, Niggemann B, Zanker KS, Entschladen F. Induction of pancreatic cancer cell migration by an autocrine epidermal growth factor receptor activation. Experimental cell research. 2014;326(2):307–14. 10.1016/j.yexcr.2014.04.022
- Weissmueller S, Manchado E, Saborowski M, Morris JPt, Wagenblast E, Davis CA, et al. Mutant p53 drives pancreatic cancer metastasis through cell-autonomous PDGF receptor beta signaling. Cell. 2014;157(2):382–94. 10.1016/j.cell.2014.01.066
- Chou A, Waddell N, Cowley MJ, Gill AJ, Chang DK, Patch AM, et al. Clinical and molecular characterization of HER2 amplified-pancreatic cancer. Genome medicine. 2013;5(8):78 10.1186/gm482
- Schaefer G, Shao L, Totpal K, Akita RW. Erlotinib directly inhibits HER2 kinase activation and downstream signaling events in intact cells lacking epidermal growth factor receptor expression. Cancer research. 2007;67(3):1228–38.
- Harder J, Ihorst G, Heinemann V, Hofheinz R, Moehler M, Buechler P, et al. Multicentre phase II trial of trastuzumab and capecitabine in patients with HER2 overexpressing metastatic pancreatic cancer. British journal of cancer. 2012;106(6):1033–8. 10.1038/bjc.2012.18
- Safran H, Iannitti D, Ramanathan R, Schwartz JD, Steinhoff M, Nauman C, et al. Herceptin and gemcitabine for metastatic pancreatic cancers that overexpress HER-2/neu. Cancer investigation. 2004;22(5):706–12.
- Varga Z, Noske A, Ramach C, Padberg B, Moch H. Assessment of HER2 status in breast cancer: overall positivity rate and accuracy by fluorescence in situ hybridization and immunohistochemistry in a single institution over 12 years: a quality control study. BMC cancer. 2013;13:615 10.1186/1471-2407-13-615
- Bauer TM, El-Rayes BF, Li X, Hammad N, Philip PA, Shields AF, et al. Carbohydrate antigen 19–9 is a prognostic and predictive biomarker in patients with advanced pancreatic cancer who receive gemcitabine-containing chemotherapy: a pooled analysis of 6 prospective trials. Cancer. 2013;119(2):285–92. 10.1002/cncr.27734
- Haas M, Heinemann V, Kullmann F, Laubender RP, Klose C, Bruns CJ, et al. Prognostic value of CA 19–9, CEA, CRP, LDH and bilirubin levels in locally advanced and metastatic pancreatic cancer: results from a multicenter, pooled analysis of patients receiving palliative chemotherapy. Journal of cancer research and clinical oncology. 2013;139(4):681–9. 10.1007/s00432-012-1371-3
- Vainshtein JM, Schipper M, Zalupski MM, Lawrence TS, Abrams R, Francis IR, et al. Prognostic significance of carbohydrate antigen 19–9 in unresectable locally advanced pancreatic cancer treated with dose-escalated intensity modulated radiation therapy and concurrent full-dose gemcitabine: analysis of a prospective phase 1/2 dose escalation study. International journal of radiation oncology, biology, physics. 2013;86(1):96–101. 10.1016/j.ijrobp.2012.11.020
- Dumitra S, Jamal MH, Aboukhalil J, Doi SA, Chaudhury P, Hassanain M, et al. Pancreatic cancer and predictors of survival: comparing the CA 19-9/bilirubin ratio with the McGill Brisbane Symptom Score. HPB: the official journal of the International Hepato Pancreato Biliary Association. 2013;15(12):1002–9.
- Hammel P, Huguet F, Van Laethem JL, et al. Comparison of chemoradiotherapy (CRT) and chemotherapy (CT) in patients with a locally advanced pancreatic cancer (LAPC) controlled after 4 months of gemcitabine with or without erlotinib: Final results of the international phase III LAP 07 study. 2013. 2013;31 (suppl; abstract LB4003)
Source: PubMed