Randomized trial on adjuvant treatment with FOLFIRI followed by docetaxel and cisplatin versus 5-fluorouracil and folinic acid for radically resected gastric cancer

BACKGROUND

Some trial have demonstrated a benefit of adjuvant fluoropirimidine with or without platinum compounds compared with surgery alone. ITACA-S study was designed to evaluate whether a sequential treatment of FOLFIRI [irinotecan plus 5-fluorouracil/folinic acid (5-FU/LV)] followed by docetaxel plus cisplatin improves disease-free survival in comparison with 5-FU/LV in patients with radically resected gastric cancer.

PATIENTS AND METHODS

Patients with resectable adenocarcinoma of the stomach or gastroesophageal junction were randomly assigned to either FOLFIRI (irinotecan 180 mg/m(2) day 1, LV 100 mg/m(2) as 2 h infusion and 5-FU 400 mg/m(2) as bolus, days 1 and 2 followed by 600 mg/m(2)/day as 22 h continuous infusion, q14 for four cycles) followed by docetaxel 75 mg/m(2) day 1, cisplatin 75 mg/m(2) day 1, q21 for three cycles (sequential arm) or De Gramont regimen (5-FU/LV arm).

RESULTS

From February 2005 to August 2009, 1106 patients were enrolled, and 1100 included in the analysis: 562 in the sequential arm and 538 in the 5-FU/LV arm. With a median follow-up of 57.4 months, 581 patients recurred or died (297 sequential arm and 284 5-FU/LV arm), and 483 died (243 and 240, respectively). No statistically significant difference was detected for both disease-free [hazard ratio (HR) 1.00; 95% confidence interval (CI): 0.85-1.17; P = 0.974] and overall survival (OS) (HR 0.98; 95% CI: 0.82-1.18; P = 0.865). Five-year disease-free and OS rates were 44.6% and 44.6%, 51.0% and 50.6% in the sequential and 5-FU/LV arm, respectively.

CONCLUSIONS

A more intensive regimen failed to show any benefit in disease-free and OS versus monotherapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01640782.

VEGF-A clinical significance in gastric cancers: immunohistochemical analysis of a wide Italian cohort

PURPOSE

The clinical significance of VEGF-A expression in gastric cancer (GC) has been reported with contradicting results. We analyzed the expression and clinical significance of VEGF-A in a wide Italian cohort of GC specimens.

METHODS

VEGF-A expression was tested by immunohistochemistry in 507 patients with GC of all clinical stages. The impact of VEGF-A on overall survival (OS) was evaluated in conjunction with clinical and pathological parameters.

RESULTS

In the Italian cohort we studied VEGF-A was not an independent prognostic factor neither at the univariate nor at multivariate analysis.

CONCLUSIONS

Although frequently expressed, in our study VEGF-A was not able to discriminate between groups of patients with different risk.

Biological characteristics and medical treatment of breast cancer in young women-a featured population: results from the NORA study

Background. The present paper described the biological characteristics and clinical behavior of young women in the cohort NORA study Patients and Methods. From 2000–2002, patients (N > 3500) were enrolled at 77 Italian hospitals. Women aged ≤50 years (N = 1013) were stratified into age groups (≤35, 36–40, 41–45, and 46–50 years). The relationship between age and patient characteristics, cancer presentation, and treatment was analyzed. Results. Younger women more frequently had tumors with ER/PgR-negative(χ² = 7.07; P = .008), HER2 amplification (χ² = 5.76; P = .01), and high (≥10%) Ki67 labelling index (χ² = 9.53; P = .002). Positive nodal status, large tumors, and elevated Ki67 all associated with the choice for chemotherapy followed by endocrine therapy in hormone receptor-positive patients (P < .0001). At univariate analysis, ER-ve status, chemotherapy and age resulted as the only statistically significant variables (HR = 2.02, P = .004, and >40 versus ≤40, P < .0001, resp.). At multivariate analysis, after adjustment for significant clinical and pathological factors, age remains a significant prognostic variable (HR = 0.93, P = .0021). Conclusion. This cohort study suggests that age per sè is an important prognostic factor. The restricted role of early diagnosis and the aggressive behavior of cancer in this population make necessary the application of targeted medical strategies crucial.

Phase II trial of single-agent oral vinorelbine in elderly (> or =70 years) patients with advanced non-small-cell lung cancer and poor performance status

BACKGROUND

Elderly patients with advanced non-small-cell lung cancer (NSCLC) with poor performance status (PS) are a special population requiring particular attention. Single-agent oral vinorelbine could be an attractive option.

PATIENTS AND METHODS

A total of 43 patients with stage IIIB-IV NSCLC and Eastern Cooperative Oncology Group (ECOG) PS of two or more with good functional status were prospectively recruited. Oral vinorelbine was administered at the dose of 60 mg/m(2) on days 1-8 every 3 weeks. Primary end points were response rate and safety.

RESULTS

Overall response rate was 18.6% with 8 partial responses; 18 of 43 (41.8%) experienced stable disease lasting >12 weeks and 17 of 43 (39.6%) disease progression for an overall clinical benefit of 60.4%. Median time to progression was 4.0 (range 2-22) months and median overall survival 8.0 (range 3-35) months. Treatment was well tolerated. Of 187 cycles, we did not observe any grade 3/4 toxicity with the exception of a single not-febrile G3 neutropenia. Regardless of severity, main toxic effects observed were nausea in 48.1% and vomiting in 22.9% of patients, anemia in 43.2%, fatigue in 32.6% and leukopenia in 23.2%.

CONCLUSION

Single-agent oral vinorelbine is extremely safe in elderly patients with advanced NSCLC and ECOG PS of two or more and may represent a valid option in this very special population.

A randomized trial of gemcitabine (G) versus G plus cisplatin in chemotherapy-naive advanced pancreatic adenocarcinoma: The GIP-1 (Gruppo Italiano Pancreas— GOIM/GISCAD/GOIRC) study

4504

Background: Single-agent gemcitabine (G) remains standard treatment for advanced pancreatic adenocarcinoma (APC). The GIP-1 randomized phase III trial (clinicaltrials.gov ID NCT00813696 ) was performed to compare the combination of cisplatin (P) and G vs. G alone as 1st-line treatment. Methods: Patients (pts) with locally advanced and/or metastatic pancreatic adenocarcinoma, age 18–75, Karnofsky Performance Status (KPS) ≥50, were randomized to receive G (arm A) or G+P (arm B). In arm A, G was administered at 1000 mg/m2 weekly for 7 consecutive wks, and, after a 2-week rest, on day 1, 8, 15 every 4 wks. In Arm B, P 25 mg/m2 weekly (with the exception of day 22) was added to G, same dose used in Arm A (Colucci et al, Cancer 2002; 94:902–10). No maximum number of cycles was planned. Primary endpoint was overall survival (OS). Clinical benefit (CB), objective response rate (ORR), progression-free survival (PFS), toxicity and quality of life were secondary endpoints. To have 80% power of detecting a 0.74 Hazard Ratio (HR) of death (corresponding to increase in median OS from 4.8 to 6.5 months, with bilateral alpha=0.05, 400 pts were planned and 355 deaths were required for final analysis. Results: From April 2002 to April 2007, 400 pts were enrolled (A:199, B; 201) in 46 Italian Institutions. Median age was 63 yrs (range 35–75), 59% were males, 84% stage IV, 83% KPS≥80. After a median follow-up of 38.2 months and 357 deaths, median OS was 8.3 vs 7.2 months in arm A and B, respectively (HR 1.10, 95% CI 0.89–1.35, p=0.38). Median PFS was 3.9 vs 3.8 months in arm A and B, respectively (HR 0.97, 95% CI 0.80–1.19, p=0.80). ORR was 10.1% in arm A and 12.9% in B (p=0.37). CB response was experienced by 23.0% and 15.1% (Arm A vs B, p=0.057). Patients assigned to combination arm experienced more anaemia (all grades: 50% vs 39%, G3: 5% vs 1%), more neutropenia (all grades: 44% vs 36%, G3&4: 25% vs 14%) and more thrombocytopenia (all grades: 57% vs 29%, G3&4: 16% vs 5%). No relevant differences were seen in non-haematological toxicity. Conclusions: Weekly combination of P and G, compared to single-agent G as 1st-line treatment of APC, failed to demonstrate any improvement in OS, PFS, ORR and clinical benefit.

No significant financial relationships to disclose.

Pemetrexed in combination with oxaliplatin as a first-line therapy for advanced gastric cancer: a multi-institutional phase II study

BACKGROUND

This clinical trial assessed the efficacy of pemetrexed combined with oxaliplatin (PEMOX) in patients with advanced gastric cancer (AGC).

PATIENTS AND METHODS

Forty-four patients with untreated AGC were enrolled to evaluate response rate (RR). Patients received pemetrexed (500 mg/m(2)) with vitamin supplementation and oxaliplatin (120 mg/m(2)) every 21 days for six cycles or until disease progression occurred.

RESULTS

Median age was 62 years (range 26-76). The majority of patients (93%) had metastatic disease. Sixteen of the 44 patients achieved confirmed response [RR 36%; 95% confidence interval (CI) 22% to 52%]; four complete responses and 12 partial responses (complete and partial responses according to the RECIST guidelines are the confirmed-responses observed in the study population). Median time to tumor progression (TTP) was 6.2 months (95% CI 4.3-7.5) and median survival was 10.8 months (95% CI 7.7-17.2). A total of 220 cycles were administered, with a median of six cycles. Most common grade 3/4 toxic effects were neutropenia in 41% of patients (19% of cycles) and thrombocytopenia in 11% of patients (4% of cycles). Treatment delays or dose reductions for toxicity occurred in 10% and 5% of cycles, respectively.

CONCLUSIONS

PEMOX is active and well tolerated in AGC. RR, TTP, and survival were comparable to those achieved in studies using different 5-fluorouracil (5-FU)-oxaliplatin combinations, without the inconvenience of prolonged 5-FU schedules.

Impact of recent legislative bills regarding clinical research on Italian ethics committee activity

AIMS AND BACKGROUND

The present work assessed the impact of two decrees on ethics committees in Italy, aimed at bringing the national laws on the conduct of clinical trials into line with the rest of the EC, and regulating and facilitating not-for-profit research.

MATERIAL AND METHODS

Prospectively collected data from an Italian multicentre study were examined with respect to the ethics review process. Administrative and time elements of the review process were audited. Main outcome measures were time between the application submission and the ethics committee definitive opinion, type and number of application submission forms, number of ethics committees that refused fee exemption, and time between the ethics committee approval and the administrative authorisation.

RESULTS

A total of 134 local research ethics committees (LRECs) were approached. Application submission procedures and application forms varied greatly; paper submission was mandatory. The median time from submission to approval was 72 days. Only two LRECs refused the fee exemption. The median time from LREC approval to administrative agreement was 50 days and only 9.6% of local authorities came to a verbal agreement with the sponsor.

CONCLUSIONS

Italian LRECs are still not sufficiently efficient in complying with the Directive 2001/20/EC requirement (60 days). Better coordination of LRECs work is needed although the optimal level of coordination between them is still not known. In the meantime, national guidelines are needed concerning the application of Directive 2001/20/EC. The behaviour of Italian LRECs towards not-for-profit research was excellent although only the fee exemption was requested.

Adjuvant treatment of early breast cancer: do the St Gallen recommendations influence clinical practice? Results from the NORA study

BACKGROUND

The NORA study is a prospective longitudinal cohort study aiming at investigating treatment in patients with early breast cancer. Here, we present the impact of the St Gallen recommendations on clinical practice.

PATIENTS AND METHODS

We compared adjuvant strategies in patients enrolled in 2000-2002 to those in 2003-2004 to verify the impact of the 2003 St Gallen recommendations.

RESULTS

The use of aromatase inhibitors (AIs) doubled: 65/629 patients (10.3%) vs 100/458 patients (21.8) (P < 0.0001). Following chemotherapy, AIs were administered in 8.5% of the retrospective cohort and in 15.1% of the prospective one (P < 0.0001). The use of taxanes plus hormones dropped (P = 0.0026), but not when used as single agents. A marked increase was observed in the use of anthracycline-based chemotherapy (46.3% vs 65.2%), mainly three-drug regimens (33.3% vs 46.6%).

CONCLUSION

Our results suggest that the St Gallen recommendations have had a major impact on clinical practice.

Pathological characteristics and clinical outcome in triple-negative breast cancer (BC) patients (PTS): Results from the NORA study

11014

Background: Different studies have recently focused the attention on the so-called triple-negative pts, defined as ER-/PR- /HER2-. Although triple-negative tumours have been reported to be more aggressive, there are limited long-term data evaluating outcome as a function of this classification. Methods: NORA is an observational study aimed at investigating treatment modalities and clinical outcome of 3515 patients (pts) with early breast cancer (EBC) treated in 77 Oncological Centres in Italy from to 2000 to 2003, whose overall results have been already published. We now compare pathological characteristics and clinical outcome of pts for whom ER and PR andHER2 tests are negative with remaining pts (OTH). Results: 123 (4.1%) of 2968 evaluable pts resulted triple-negative. Out of these 123, 76 pts (61.7% vs 63.2% of OTH) were treated with conservative surgery (CS). Pathological T stage was T1 in55.3% pts (OTH: 59.6%), 47.9% were pN+ (OTH: 45.3%), 63.2 had G3 tumours (OTH: 34.1%). Chemotherapy alone was administered in 89.4% pts, mainly anthracycline-based (54.1%). At a median follow up of 27 months, all triple-negative pts were alive, 11 (8.9%) with relapse. No difference has been observed between two groups both in DFS (HR=0.74; 95%CI: 0.39–1.40; p=0.35) and OS (HR not estimated, p=0.99). Conclusions: Our results suggest that triple-negative pts have pathological characteristics similar to what observed in the other pts, receive CS in the same percentage of the cases, but have a 3-fold increase of undifferentiated tumours. On the contrary to what observed by other Authors, our data show that triple- negative pts do not have worse prognosis. Longer follow up is required to confirm these data.

No significant financial relationships to disclose.

The impact of cetuximab on the gemcitabine/cisplatin combination in first-line treatment of EGFR-positive advanced pancreatic cancer (APC): A randomized phase II trial of GISCAD

4544

Background: Cetuximab, an EGFR antibody inhibitor, has been shown to increase the activity of gemcitabine (GEM) in APC. Based on data from randomised trials and meta-analyses suggesting that the combination of a GEM with a platinum analog significantly improves survival as compared to GEM alone, we assessed the activity and feasibility of a combination of GEM/cisplatin (CDDP) plus cetuximab. Methods: Multicenter, randomised two-arm phase II trial: GEM 1,000 mg/m2 day 1,8 and CDDP 35 mg/m2 day 1,8 every 21 days alone or in combination with cetuximab 250 mg/m2 weekly after a loading dose of 400 mg/m2. Treatment was limited to a maximum of 9 cycles. With 37 patients in each arm the power was 90% to select the truly better arm if the true between arm difference in response rate (RECIST) is at least 15%. The study was open for accrual until June 2005. Results: We present here the results of 74 patients including in the study. In all the patients, the first response rate are available (investigators’ assessment after 3 cycles) as well as toxicity data. Conclusions: Cetuximab does not seem to positively interact with GEM/CDDP combination in terms of activity especially concerning time to progression. Although toxicity was not increased by cetuximab, this combination should not be assessed in a phase III trial.The trial was supported in part by by Merck KGaA.

[Table: see text]

No significant financial relationships to disclose.

Breast cancer in elderly women: a different reality? Results from the NORA study

BACKGROUND

The incidence of breast cancer increases with age, and the disease affects many older women; however, attitudes about prevention and treatment of breast cancer vary based on the patient's age. Older women have less access to clinical trials and fewer opportunities for treatment with innovative therapies. The National Oncological Research observatory on Adjuvant therapy in breast cancer (NORA) study was a cohort study designed to obtain information about adjuvant strategies for treatment of breast cancer after surgery, patterns of recurrence, and possible correlations between cancer-related events and biological factors.

PATIENTS AND METHODS

This report describes patient characteristics, disease status, and local and systemic adjuvant treatments in a population of breast cancer patients aged >or=65 years. The NORA study consecutively enrolled >3500 patients from 2000 through 2002 at 77 Italian hospitals; of these, 1085 were aged >or=65 years. Data on patient characteristics, cancer presentation, and treatments were analyzed to identify possible relationships between these factors and age.

RESULTS

The findings indicate that age is significantly related to later diagnosis and different patterns of treatment. Choice of adjuvant systemic treatment was primarily related to hormone receptor status and tumor stage but was strongly influenced by the patient's age; there was a proportional relationship between endocrine treatment and increasing age. Cyclophosphamide, methotrexate, and 5-fluorouracil as well as anthracyclines were widely used, but the use of taxanes was limited to a very small percentage of patients.

CONCLUSIONS

The findings of the NORA study may help to change attitudes that currently exclude a significant proportion of breast cancer patients from secondary prevention policies, more active treatment strategies, and clinical research trials based on age.

Adjuvant systemic treatment of early breast cancer: the NORA study

BACKGROUND

Despite recommendations contained in international guidelines, factors such as the type of oncology centre, geographic distribution and the introduction of scientific advances into clinical practice can influence the choice of recommended treatment for early breast cancer. The NORA study is a prospective, longitudinal cohort study aimed at investigating tumour characteristics, treatment modalities, and other factors that influence therapeutic choices in early breast cancer patients who have undergone mastectomy or breast-conserving surgery (BCS).

PATIENTS AND METHODS

From January 2000 to early 2004, we collected data on methods of cancer diagnosis, type of surgery and adjuvant medical treatment administered to the first 10 consecutive patients treated in 2000-2002 and the first 20 consecutive patients in 2003 and 2004 at 71 oncology centres in Italy, with the approval of the ethical committee at each centre.

RESULTS

Approximately one-quarter of the cases (26.5%) were detected through screening programmes. BCS was performed in 63.7% and sentinel node biopsy (SNB) occurred in 11.1% of the patients. Of the 3515 total cases, 56.5% were node-negative. Grade 2 cancers comprised 51.3%, and 66.2% were hormone-receptor positive (ER+/PgR+). Chemotherapy (CHT) followed by hormone therapy (HT) was the most prescribed treatment (48.5%). CHT was mainly anthracycline-based (52.9%) and most patients received tamoxifen alone (77.7%) or after CHT (85.2%). For node-negative patients, HR+ and menopause status are the factors influencing the choice to add HT after CHT; patients with HR+ and pT4 tumours are more likely to receive HT instead of CHT. In node-positive patients, the addition of HT is influenced by HR+ status, the opportunity to have HT instead of CHT, and menopause.

CONCLUSIONS

NORA is the first large cohort study to describe the factors that influence therapeutic choices in early breast cancer. Understanding these findings can help physicians in daily clinical practice.

Multicenter phase II study of pemetrexed and oxaliplatin as first-line therapy in advanced gastric cancer

14045

Background: We have previously reported that single-agent pemetrexed is active in metastatic gastric cancer. On the basis of the potential synergism of pemetrexed and oxaliplatin, we explored the combination in patients with locally advanced/metastatic gastric carcinoma. Methods: The primary objective was activity of the combination. Eligible patients had to ≥1 measurable lesion according to RECIST. Pemetrexed 500 mg/m2 was given intravenously over 10 minutes, and oxaliplatin 120 mg/m2 was given over 2 hours; both drugs were given on day 1 of a 21-day cycle. Patients were to receive ≥6 (maximum of 8) cycles unless disease progression occurred. Vitamin supplementation was given as well as dexamethasone. A total of 43 patients were planned in a two-stage design with 13 patients in the first stage. An interim analysis was planned at the end of the first stage, so the trial could be stopped if ≤3 responses were observed. Results: Between May 2004 and January 2005, 13 patients (6 females) entered the study. Median age was 52 years (range, 27–75). One patient (7.8%) had locally advanced disease, and 5 patients (38.5%) retained primary gastric cancer. Main disease sites included lymph nodes (100%) and liver (23.1%). A total of 60 cycles were administered (median 6; range, 2–6). All 13 patients were evaluable for efficacy with 3 complete and 2 partial responses (ORR 38.5%; 95% CI, 13.9%-68.4%). Stable disease occurred in 3 patients (23.1%). G3 toxicities were neutropenia (30.8%), vomiting, hepatic toxicities and leucopenia (7.7%) each; no G4 toxicity were found. Conclusions: This interim analysis suggests that the activity and tolerability of the combination in advanced gastric cancer is very promising. Study accrual was ended in October 2005, and final results will be presented at the meeting.

No significant financial relationships to disclose.