Randomized, double-blind, dose-ranging trial of the oral neurokinin-1 receptor antagonist casopitant mesylate for the prevention of cisplatin-induced nausea and vomiting

BACKGROUND

Casopitant mesylate is a novel, oral neurokinin-1 receptor antagonist with demonstrated antiemetic efficacy. We conducted a randomized, double-blind, controlled phase II trial to evaluate three casopitant doses as part of a triple-therapy regimen for the prevention of nausea and vomiting associated with high-dose cisplatin. The aim of the study was to detect a dose response.

PATIENTS AND METHODS

A total of 493 patients with solid tumors receiving a first cycle of cisplatin > or =70 mg/m(2) were randomly assigned among six treatment arms. The primary analysis compared a control arm [ondansetron/dexamethasone (Ond/Dex)] with three investigational treatments (Ond/Dex plus oral casopitant 50, 100, or 150 mg administered daily for 3 days). Two exploratory arms were included: one evaluating a single oral casopitant dose of 150 mg added to standard Ond/Dex and another with 3-day oral aprepitant-based therapy (Ond/Dex plus aprepitant 125 mg day 1, 80 mg days 2-3).

RESULTS

The complete response (CR) rate (defined as no vomiting, retching, rescue therapy, or premature discontinuation) was significantly increased in each casopitant arm relative to control over the 120-h evaluation period: 76% (50 mg), 86% (100 mg), 77% (150 mg), and 60% with control (P = 0.0036). The CR rate for the single oral dose regimen was similar to the CR rate reported for the 3-day regimens. No differences were observed in the incidence of nausea or significant nausea among groups in the primary analysis. The most common adverse events related to treatment included headache (n = 10) and hiccups (n = 14).

CONCLUSION

All doses of oral casopitant as a 3-day regimen (and likely as a 150-mg single oral dose) in combination with Ond/Dex provided significant improvement in the prevention of cisplatin-induced emesis.

Tyrosine kinase inhibitors in non-small cell lung and pancreatic cancer: the emerging role of erlotinib

During the last years, molecular targeted agents generated a small revolution within the various treatment options for malignant tumors. Preclinical data showed that activation of the epidermal growth factor receptor (EGFR)-depending downstream pathways, plays a major role in tumor growth and development. Small molecules, like the tyrosine kinase inhibitors (TKIs), proved their capacity to inhibit the trigger event of this oncogenic activation. Of paramount importance was the fact that this effect has been efficiently translated from preclinical models into clinical practice. Erlotinib is a major representative of this category of drugs. This review will address the current status of the treatment with erlotinib and other TKIs in pancreatic and non-small cell lung cancer (NSCLC), along with the most debated issues regarding the clinical and molecular criteria for patient selection for this kind of targeted therapy.

Compliance with adjuvant chemotherapy in non-small cell lung cancer. The experience of a single institution evaluating a cohort of 356 patients

PURPOSE

To evaluate the patient compliance with adjuvant chemotherapy (CT) following radical surgery for non-small cell lung cancer (NSCLC), and to identify the potential confounding factors affecting this particular aspect.

PATIENTS AND METHODS

We retrospectively evaluated a series of 356 consecutively treated NSCLC patients at a single institution during 1994-2003. All patients had macroscopic and microscopic radical resection of the primary tumor, with or without mediastinal node dissection or sampling, had received at least one adjuvant CT cycle, with or without postoperative irradiation (RT). CT was planned to be believed for 6 cycles. The following schedules were used: cisplatin (CDDP) 60 mg/m(2), cyclophosphamide 600 mg/m(2) and epirubicin 60 mg/m(2) on day 1 every 21 days (16%);etoposide 120 mg/m(2) and CDDP 30 mg/m(2), on days 1-3, every 21 days (68%); other platinum-based doublets (16%). A multivariate analysis, for a target of 4 and 6 cycles was performed in order to evaluate the potential impact on the patient compliance of the following categories: age, sex (male vs. female), extent of surgery (pneumectomy vs. lesser resection), stage (I,II vs. III), RT(delivered or not) and patient residence (local vs. remote).

RESULTS

One hundred and seventy-nine (50%) patients completed all 6 cycles, while 299 (84%) received at least 4 cycles. The median number of administered cycles was 5. For a target of 4 cycles none of the investigated variables had any significant impact. A significant impact on compliance for 6 cycles was recorded for age (OR 0.97, 95% CI 0.95-0.99, p=0.01) and extent of surgery (OR 0.54, 95% CI 0.33-0.87, p=0.01)

CONCLUSION

Using the above mentioned combinations, the patient compliance with adjuvant CT was good, with 84% receiving at least 4 and 50% all 6 cycles. The median number of cycles was 5. For a target of 4 cycles none of the investigated variables had a significant impact. For a longer CT duration, age and extent of surgery were correlated with a lower compliance.

Randomized phase II trial of the neurokinin-1 receptor antagonist (NK-1 RA) casopitant mesylate with ondansetron (ond)/dexamethasone (dex) for chemotherapy-induced nausea/vomiting (CINV) in patients (pts) receiving highly emetogenic chemotherapy (HEC)

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Background: A combination of a 5-HT3 receptor antagonist (5-HT3 RA) + dex is standard for prevention of CINV due to HEC. However, NK-1 RAs are now also of interest. The current trial evaluated casopitant mesylate, a potent, oral, selective NK-1 RA, in a triple therapy regimen with a 5-HT3 RA and dex in pts receiving HEC. Methods: In this multicenter, randomized, double-blind, placebo-controlled, dose-ranging, parallel group study, pts receiving HEC were stratified by gender and randomized among six arms. HEC consisted of regimens including cisplatin ≥ 70 mg/m2 IV over 1–4 hours (h) day 1 (D1). All pts received ond 32mg IV D1 and dex PO D1–4 with either placebo control, casopitant 50mg QD D1–3, casopitant 100mg QD D1–3, or casopitant 150mg QD D1–3. Pts on exploratory arms received ond/dex plus either casopitant 150 mg D1 only or aprepitant 125mg D1 and 80mg D2–3. The primary endpoint was complete response (CR) rate (no vomiting, retching, rescue medications or premature withdrawals) during the first 120 h following initiation of HEC. Target intent-to-treat (ITT) group enrollment was 82 pts per arm. Results: 493 enrolled patients comprised the ITT group. CR rate was 60% in the control arm; 76% for casopitant 50mg; 86% for 100mg; and 77% for 150mg (p=.0036, Cochran-Armitage trend test). CR rate was 75% with casopitant 150 mg D1 and 72% for 3-day aprepitant. CR rates at 24 h were similar in all groups (86%-96%). Casopitant prolonged time to emesis (p=.0029) and increased the proportion of pts without vomiting (p=.0122) relative to control. There were no differences in rates of nausea or use of rescue medication among groups. Adverse events were similar across all arms, with neutropenia, nausea, and hiccups (≤ 17%) as most common. All casopitant doses were generally well tolerated. Conclusions: The addition of casopitant to ond/dex at all doses tested and in 1- or 3-day administration regimens was well tolerated and significantly reduced CINV rates over a 5-day period in pts receiving HEC. The results of the exploratory 1-day regimen are of particular interest for future evaluation.

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Erlotinib in previously treated non-small-cell lung cancer

BACKGROUND

We conducted a randomized, placebo-controlled, double-blind trial to determine whether the epidermal growth factor receptor inhibitor erlotinib prolongs survival in non-small-cell lung cancer after the failure of first-line or second-line chemotherapy.

METHODS

Patients with stage IIIB or IV non-small-cell lung cancer, with performance status from 0 to 3, were eligible if they had received one or two prior chemotherapy regimens. The patients were stratified according to center, performance status, response to prior chemotherapy, number of prior regimens, and prior platinum-based therapy and were randomly assigned in a 2:1 ratio to receive oral erlotinib, at a dose of 150 mg daily, or placebo.

RESULTS

The median age of the 731 patients who underwent randomization was 61.4 years; 49 percent had received two prior chemotherapy regimens, and 93 percent had received platinum-based chemotherapy. The response rate was 8.9 percent in the erlotinib group and less than 1 percent in the placebo group (P<0.001); the median duration of the response was 7.9 months and 3.7 months, respectively. Progression-free survival was 2.2 months and 1.8 months, respectively (hazard ratio, 0.61, adjusted for stratification categories; P<0.001). Overall survival was 6.7 months and 4.7 months, respectively (hazard ratio, 0.70; P<0.001), in favor of erlotinib. Five percent of patients discontinued erlotinib because of toxic effects.

CONCLUSIONS

Erlotinib can prolong survival in patients with non-small-cell lung cancer after first-line or second-line chemotherapy.

Anthracycline pretreated patients: who is who in the chemotherapy choice of relapsed breast cancer?

During the last years, a strong trend towards excluding anthracyclines from the first-line chemotherapy (CT) of relapsed breast cancer (RBC) has been noticed. This trend is based on the concept of previous exposure of the tumor on the same drugs in the adjuvant setting. Consequently, some guidelines and experts recommend the avoidance of using these compounds for RBC under those circumstances, while the taxanes became the first treatment option. This article gives detailed references about the lack of correlation between the type of adjuvant chemotherapy (including anthracyclines), and the clinical outcome of patients treated with front-line anthracyclines for RBC. It also addresses the weakness of this rationale based on recent translational research data and comments on the fact that anthracyclines could represent the best treatment option for some subcategories of patients with RBC. Concluding, this new trend seems more empirical than evidence-based, and clarification of this issue is warranted.

Adjuvant chemotherapy for radically resected non-small cell lung cancer

BACKGROUND

The impact of adjuvant chemotherapy (CT) in the management of resectable non-small cell lung cancer (NSCLC) is highly debated. The aim of the study was to evaluate the outcome of this category of patients, treated at the Military Hospital Bucharest (surgery) and Institute of Oncology Bucharest (CT).

PATIENTS AND METHODS

We retrospectively analyzed the survival data according to various patients' characteristics, the corresponding pattern of relapses, along with the data concerning the CT program.

RESULTS

A number of 311 consecutively treated patients (pts.), between January 1994 and October 2002, were evaluated. All patients were radically resected and received adjuvant CT. Chemotherapy was planned to be cisplatin-based and to be delivered for six cycles. In addition, 141 pts. (45%) received post-operative irradiation (RT). demographics: sex, M 252 (81%)/F 59 (19%) and median age: 58 (range 31-75). Stage: I 55 (17%), II 71 (23%), III A 140 (45%) and III B 45 (15%). After a median follow-up of 46 months, the overall median survival (MS), considering all the patients, was 42 months and the 5-year survival rate (5-year SR) was 44%. According to stage, MS and 5-year SR were as follows: Stage I = not reached/94%; Stage II = 54 months/59%; Stage III A = 28 months/37% and Stage III B= 18 months/27%. According to lymph node status, the MS was not reached for pN-negative pts. and 26 months for pN-positive pts. (P = 0.0002), while the 5-year SR was 75% versus 35%, respectively. Platinum-based CT was delivered in 295 pts. (95%). The medium number of cycles was five. A number of 86 (28%) relapses were recorded, of which 50 (16%) were distant, 25 (8%) local and 11 (4%) distant and local. The sites of the 50 distant relapses were BRA 24 (48%), OSS 10 (20%), PUL 6 (12%) and OTH 10 (20%).

CONCLUSION

Our analysis shows good long-term survival data for adjuvant CT following surgery in NSCLC, which looks comparatively superior to those communicated for surgery-only series. Pathologic invasion of the lymph nodes has a strong adverse effect on patients' outcome. The positive impact of CT in this setting is indirectly sustained by the pattern of relapses, which place the brain sanctuary on the first rank. Overall, the patients' compliance was good and we delivered a medium of five cycles of adjuvant platinum-based CT.

Split course radiation with concurrent vinorelbine and cisplatin in locally advanced non-small cell lung cancer. A phase II study

PURPOSE

Recent results coming from large randomized trials suggest that for locally advanced non-small cell lung cancer (NSCLC), integration of chemotherapy (CT) with irradiation (RT) should be concurrent rather than sequential. This study aimed at evaluating the actually delivered RT and CT dose intensities (DI), along with the toxicity and efficacy of a split course RT program with concurrent CT.

PATIENTS AND METHODS

From October 2000 to September 2002, 24 patients with histologically or cytologically documented NSCLC were included. Patients' characteristics were as follows: males/females=22/2, median age=59 years, stage IIIB/IIIA=22/2 patients, ECOG PS 0-1=15 (62%) and PS 2=9 (38%).

HISTOLOGY

adenocarcinoma/ squamous cell/large cell/unclassified 10/6/1/7, respectively. Four cycles of vinorelbine (VNB) 25 mg/m(2) and cisplatin (CDDP) 40 mg/m(2) on days 1+8 were administered (days 1,8,22,29,57,64,78,85). Concurrent with the second CT cycle, RT (2 courses of 30 Gy separated by a 2-week break) was delivered, with a plan to achieve a total dose of 60 Gy, with a fractionation schedule of 2 Gy/day/5 days weekly.

RESULTS

The intended RT dose was delivered to 21 (88%) patients with a relative DI of 0.93. Nineteen (79%) patients received more than 3 CT cycles. The relative DI for VNB and CDDP were 0.88 and 0.83, respectively. During treatment 3 (13%) patients experienced WHO grade 3-4 hematologic toxicity while ECOG grade 3 esophagitis was recorded also in 3 patients. At the end of treatment 14 (58%) patients achieved an objective response (2 complete - CR and 12 partial response - PR), while 8 (33%) patients had stable disease (SD) and 2 (8%) progressive disease (PD). After a median follow up of 15 months (range 3-26), 15 (62%) patients relapsed. There were 8 (33%) patients with local relapse and 7 (29%) with distant metastases. The median progression free (PFS) and overall survival (OS) were 10 (range 2-24) and 15 (range 5-24) months, respectively, with an estimated 1 and 2-year survival rates of 55% and 10%, respectively.

CONCLUSION

Our concurrent schedule allows for good CT and RT DI, with low associated toxicities. The efficacy data are considered promising, taking into account the high proportion of stage IIIB patients evaluated.