A phase II study of enzastaurin as second- or third-line treatment of non-small cell lung cancer (NSCLC)

7543

Background: Enzastaurin, an oral serine/threonine kinase inhibitor, suppresses signaling through PKC and the PI3K/AKT pathway, induces tumor cell apoptosis, reduces proliferation, and suppresses tumor-induced angiogenesis. Over-expression and activity of PKC and PI3K/AKT are associated with poor prognosis and treatment resistance in NSCLC. This multicenter phase II trial of enzastaurin as second- and third-line treatment of NSCLC determined the rate of progression-free survival (PFS) at 6 months (mos). Secondary objectives included safety and the rate of overall survival (OS) at 12 mos. Methods: Eligibility included metastatic (stage IV and wet IIIB) NSCLC and prior platinum-based chemotherapy. Patients (pts) received 500 mg of oral enzastaurin, once daily, until disease progression or unacceptable toxicity occurred. All pts were eligible for 2nd or 3rd line treatment. Results: In the 54 pts enrolled [54% M, 46% F; median age: 63 (range: 43–82); 22.2% stage III, 77.8% stage IV, ECOG PS=2], adenocarcinoma was the most frequent diagnosis (67%). Prior therapies included radiotherapy (74%) and EGFR inhibitors (28%). At the final analysis, the median PFS was 1.9 mos (95% CI: 1.7–1.9), and the PFS rate at 6 mos was 14% (95% CI: 4.4%–23.6%). The median OS was 9.9 mos (95% CI: 6.5–14.6). The OS rate at 12 mos was 46.3% (95% CI: 32.1%–60.5%). Nineteen pts (35%) had stable disease (SD); none had a complete or partial response. Ten (19%) pts were on-study for =6 cycles, 3 of whom continued for >10 months. The most common toxicity, fatigue (grade =2, n=15), occurred within 1 week of enrollment and was not reported in pts with SD. Grade =3 toxicities observed were ataxia (n=1), fatigue (n=2), thrombo-embolism (n=1), and anemia (n=1). Two pts discontinued due to fatigue and dizziness. Five pts died on-study and 4 within 30 days of discontinuation due to PD. Post-study chemotherapy (n=28) included bevacizumab, erlotinib, pemetrexed, gemcitabine, cisplatinum and paclitaxel. Conclusion: Although no objective tumor responses occurred, 14% of the pts were progression-free at 6 months. Based on encouraging survival and tolerability data, further evaluation of enzastaurin as a single agent or in combination, is warranted in NSCLC.

No significant financial relationships to disclose.

Phase II trial of docetaxel (D) plus gefitinib (G) in elderly (≥70 years) patients with advanced stage non-small cell lung cancer (ANSCLC)

7690

Background: Adding G to first-line doublet chemotherapy did not improve survival in comparison to doublet chemotherapy alone in phase III trials (INTACT 1 and INTACT2). We hypothesized that therapy with D and G will yield similar efficacy to doublet chemotherapy but with improved toxicity profile that would be especially meaningful for elderly patients. We report here the results of a completed phase II trial. Methods: Previously untreated elderly patients with ANSCLC with ECOG performance status (PS) of 0 or 1, were eligible. D was given at 75 mg/m2 IV on day1, Q 21 days. G given orally daily; starting day 1, at a dose of 250mg. D-G was given for 2 cycles beyond maximal response. G was continued until progression. Tumors were assessed every two cycles while on D-G and every two months while on G. The RECIST criteria were used to measure responses. Results: Forty-four eligible patients were enrolled from 07/2003 to 11/2005. Demographic characteristics were M/F = 25/19; Median age 75 years (range; 70 to 84 years); ECOG PS 0/1= 27/16; Stage IV/IIIB = 38/6; Never-smoker/smoker 8/36; Adenocarcinoma/non-adeno-NSCLC 30/14; Median number of D-G cycles administered is 4 (range; 1 to 6). Median duration on maintenance D was 5 months (range; 1 to 36) Overall response rate was 29% (CR- 2%; PR- 27%) with 48% stable disease. Median progression free survival (PFS) was 8 months (95% CI: 6.2–10.6), PFS at 12 months was 34%, and 24 months was 19%. Median Overall Survival (OS) was 12 months (95% CI: 5.6–17.5). OS at 12 months was 52% and 24 months was 20%. The most common hematologic and non- hematologic adverse events were lymphopenia/anemia, and fatigue/hyperglycemia (steroid-induced)/dyspnea, respectively. Three patients had febrile neutropenia (6.8%). Detailed toxicity analyses will be reported at the meeting. Conclusion: The combination of D and G demonstrates comparable efficacy to conventionally used doublet chemotherapy regimens. The relatively favorable toxicity profile warrants further development of this approach, especially in clinical situations or special populations where toxicities are an impediment to treatment.

No significant financial relationships to disclose.

Quality-of-life (QoL) outcome of standard chemotherapy for advanced non-small cell lung cancer (NSCLC): A comparison between cisplatin- and non-cisplatin-based regimens

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Background: Among standard chemotherapy regimens for NSCLC, cisplatin-based regimen is known to be associated with significant nausea and vomiting. QoL during treatment with cisplatin-based chemotherapy, when compared with others is unclear. Methods: We performed a MEDLINE search for all phase III randomized controlled trials of NSCLC that reported QoL outcomes and used standard chemotherapy regimens containing cisplatin in one arm and non-cisplatin in the other. Two reviewers independently extracted data and assess quality. QoL reporting criteria were priori hypothesis stated, rationale for instrument reported, psychometric properties reported, cultural validity verified, adequacy of domains covered, instrument administration reported, baseline compliance reported, timing of assessment documented, missing data documented, clinical significance addressed, and presentation of results (Efficace et al, JCO 2003). Results: Out of 893 potential titles, 9 studies were identified. Two did not meet the minimum QoL reporting criteria and were excluded. Of the 7 included studies (N=3439), only one measured QoL as a primary endpoint; only two satisfied all 11 quality criteria for QoL reporting. Due to the heterogeneity of the reporting formats, we were unable to pool data on QoL. Two of seven studies indicated that a cisplatin-containing regimen was associated with a significantly worse QoL when compared with a non-cisplatin regimen (Table). Among these selected studies, treatment-related death was higher with cisplatin-based regimens [reported from 8 studies, N=3290, RR=0.66;95%CI (0.46–0.95), p=0.03]. Grade 3 and 4 neutropenia and neutropenic fever were also more common in the cisplatin-based arms. Conclusion: We found a suboptimal quality of QoL reporting and a lack of standardization of QoL analysis method in these trials. This limits a comparison between studies and the usefulness of QoL endpoint for clinical decision-making.

[Table: see text]

No significant financial relationships to disclose.

A global genome damage score predictive of lung cancer patients outcome

Genome damage is a hallmark of human cancer. Efforts at assessing the impact of genome damage on tumor phenotype and patients outcome have focused on measurements of the relative DNA content in tumor cells compared to normal cells and the assessment of allelic loss at single or multiple selected loci that are thought to harbor genes important in cancer biology. We adapted a global, high-resolution genotyping method for determination of global and unbiased allelic loss. We generated a score, termed global genome damage score (GGDS), that is a continuous variable from zero to one and a measure of the extent of damaged DNA in individual tumors. In 71 patients with completely resected non-small-cell lung cancer, the GGDS ranged from 0.0006 to 0.5530 with a median value of 0.0401 indicating that between 0.06 and 55.3% of the genome has allelic loss. Patients with high scores (>0.04) had a significantly worse outcome than those with low scores (median overall survival time 35.5 vs >120.0 months, P=0.006 log-rank test; median disease-free survival 28.3 vs >120.0 months, P=0.003 log-rank test). This suggests that the clinical behavior of lung tumors with low GGDS is relatively benign whereas tumors with high GGDS are aggressive resulting in early death of patients.

Dose-dense pemetrexed (P) and gemcitabine (G) as neoadjuvant therapy in resectable non-small cell lung cancer (NSCLC)

7129

Background: Adjuvant chemotherapy is standard of care for NSCLC stage IB-III after complete resection. Neoadjuvant therapy has potential advantages. P and G are efficacious in NSCLC with low toxicity. In combination, they can be given dose-dense, which may result in better efficacy, lower toxicity, and higher patient acceptability than traditional platinum-based therapy. Methods: Patients with resectable IB-IIIA and selected IIIB, PS 0–1, w/o prior therapy were eligible. CT, PET, brain MRI, and mediastinoscopy were used for staging. P (500 mg/m2) and G (1,500 mg/m2) were given on d1, 15, 29, and 43. Imaging studies were repeated 7–14 days after treatment and response determined by RECIST. Patients had surgery 3–4 weeks after the last treatment. F/U was every 3 months for 2 years with imaging studies. The primary clinical endpoint is radiographic disease response rate. The secondary endpoints are overall and disease-free survival, pathologic response rate, treatment-related toxicity, and surgical respectability and outcome Results: From 4/04 to 12/05, 45 eligible patients were enrolled. The disease stages were IB in 17, IIA in 3, IIB in 10, IIIA in 12, and IIIB in 3 patient. 8 had adeno, 15 squamous, and 22 large cell or unspecified NSCLC on initial diagnosis. 27 had a PS of 0 and 18 PS 1. 3/45 had weight loss. 22 were women. The median age was 67 (range 42–83 years). 2 were never-smokers, 24 had quit, and 19 were active smokers. Disease response rates to PG were 3% CR, 34% PR, 55% SD, and 8% PD. An R0 resection was performed in 75% of patients, 15% had an incomplete resection, and 10% did not have a thoracotomy. There have been no deaths or unexpected morbidities related to surgery or chemotherapy. Conclusions: Dose-dense PG is well tolerated with acceptable side effects. It appears to be equally as efficacious as platinum-containing chemotherapy doublets in terms of radiographic response rates. Survival rates and the median survival time are forthcoming to allow for a better comparison of this regimen with platinum-containing doublets.

No significant financial relationships to disclose.

Evaluation of publicly-sponsored lung cancer trials in US: Are experimental treatments better than the control ones?

7157

Background: Lung cancer is one of the leading causes of cancer deaths in the US. A considerable number of these patients are treated in randomized clinical trials (RCTs). However, how often experimental lung treatments are superior to control treatments is not known. To accurately assess this, three factors have to be taken into consideration: publication rate, methodological quality of trials and the choice of the comparator intervention. Methods: All phase 3 RCTs that were completed to date by 3 National Cancer Institute cooperative groups (ECOG, NCCTG and RTOG) were eligible for the analysis. We identified 50 RCTs enrolling 11,631 lung cancer patients. The methodological quality of the trials was assessed for possible effects of bias and random error on the outcomes of the trials. The possible impact of the choice of a comparator intervention was also assessed. To evaluate the outcomes, we extracted data on survival (OS), disease free survival (DFS), response rate (RR) and treatment-related mortality (TRM). In addition, the final investigators’ preference about experimental or control interventions was used to assess whether experimental treatments were better than controls. Results: In terms of OS, DFS and RR experimental treatments were as likely as control treatments to be successful—Hazard ratio [HR]= 0.96 (99%CI 0.92–1.01)], [HR = 0.98 (99%CI 0.98–1.17)] and [RR = 1.11 (99%CI 0.84–1.46)], respectively. TRM was worse with experimental treatments [HR = 1.61 (99% CI 1.10–2.36)]. Investigators’ preferences for experimental vs. control treatments were 30% and 70%, respectively (p < 0.001). The quality of trials was high. We did not find any evidence that the methodological quality of trials/choice of comparator influenced the results. Conclusions: We found that there is no clear pattern that predicts which treatment will be better. In aggregate, there is about an equal chance for experimental and standard treatments to result in successful outcomes or that the outcomes may not differ between two types of the treatments, although TRM is slightly higher with experimental arms. This is a welcome finding because if one intervention (experimental or control) was consistently better, maintaining randomization will be difficult.

No significant financial relationships to disclose.

Prospective evaluation of RRM1 as a predictor of response to gemcitabine/carboplatin (GC) in non-small cell lung cancer (NSCLC)

7054

Background: RRM1 is the regulatory subunit of ribonucleotide reductase. It is a molecular target of G. RRM1 increases upon continuous exposure of cell lines to G. Preliminary data suggest improved survival for patients with low as opposed to high tumoral expression of RRM1 when treated with G-based chemotherapy. Methods: We determined the efficacy of G and C as induction therapy in patients with locally advanced NSCLC. Trial eligibility included measurable disease, no prior chemotherapy or RT, PS 0–1, and no weight loss. Patients were staged with CT, PET, and brain MRI. GC consisted of two 28-day cycles of G, 1,000 mg/m2 d1&8 and C, AUC 5 d 1. Unidimensional tumor measurements were obtained before and after GC. The study required tumor collection prior to therapy by core needle biopsy. Specimens were frozen in LN. Tumor cells were collected by LCM. Real-time quantitative RT-PCR gene analysis was performed in triplicate per sample for RRM1 and 18SrRNA. Results: Between 11/03 and 7/05, 30 eligible patients were enrolled, and the required tumor biopsies were obtained in all. In one patient, a pneumothorax developed that required chest tube placement. Disease response ranged from a 9% increase to a 100% decrease. 14/26 had SD, 11/26 PR, and 1/26 CR. The patients’ age was 47- 87 years; 12 were women; 13 had IIIA and 13 IIIB; 10 had sq, 7 ad, and 9 LC or NOS NSCLC. RRM1 expression ranged from 0.18 to 129.3. There was a significant (p = 0.014) inverse correlation (r = −0.474) between RRM1 expression and disease response. When grouping patients into those with response (CR/PR) and without response (SD), RRM1 expression was significantly (p = 0.027) associated with response. No significant association was found between RRM1 expression and other parameters. Conclusions: In a prospective clinical trial intratumoral RRM1 expression was significantly and inversely correlated with disease response to gemcitabine and carboplatin. These results strongly suggest that tumoral RRM1 expression is a major predictor of disease response to gemcitabine-based chemotherapy.

No significant financial relationships to disclose.

The benefits of a restaging PET scan after two cycles of neoadjuvant chemotherapy for resectable non-small cell lung cancer

17092

Background: Neoadjuvant chemotherapy can potentially improve the outlook of resectable non-small cell lung cancer (NSCLC). Whole-body 2-deoxy-2-[18F] fluoro-D-glucose (FDG)-PET is often used as an initial test to determine tumor resectability, but its role as a restaging test after neoadjuvant chemotherapy is unclear. Restaging PET after neoadjuvant chemoradiation helps identify unexpected distant metastasis and avoid unnecessary thoracotomy. We explored its benefits after neoadjuvant chemotherapy. Methods: Patients with stage IB-IIIA and selected IIIB resectable NSCLC received induction gemcitabine (1,000 mg/m2) and vinorelbine (25 mg/m2) on days 1, 8, 22, and 29. PET and CT scan were performed before enrollment and between day 43–50. Response from CT scan was defined by RECIST criteria; from PET, defined as >20% reduction in the SUVmax (a decrease of > 2 SD of spontaneous change in FDG uptake, previously validated). This abstract explores patients participated in a published prospective trial with available both pre- and post-treatment PET scans. Results: There were 19 patients: stage IB-7, stage IIB-2, and stage III-10. Median age was 67 years. Mean interval between staging and restaging PET scan was 59 days. By PET, 10 patients responded. By RECIST criteria, complete response occurred in 0, partial response in 6, and stable disease in 13 patients. Most successfully underwent a complete resection, but positive margins were present in 3; multi-station lymph node involvement was found intraoperatively in 1 patient. Overall median survival was 20.5 months. We found that restaging PET did not help identify any distant metastasis. Moreover, no survival difference was observed between PET responders and non-responders, though PET responders had more advanced stage than their counterparts: median survival 16 months vs. not reached (p = 0.08 adjusted for stage). PET response was correlated with RECIST response (p = 0.05) as well as the response as obtained by SUV max divided by the activity of contralateral lung or aorta ratio. Conclusion: Based on this small group of patients, a restaging PET scan obtained after two cycles of neoadjuvant chemotherapy among patients with resectable NSCLC did not appear to impact the decision on a planned thoracotomy.

No significant financial relationships to disclose.