Effects of CERA (continuous erythropoietin receptor activator) in patients with advanced non-small-cell lung cancer (NSCLC) receiving chemotherapy: results of a phase II study

BACKGROUND

Continuous erythropoietin receptor activator (CERA; methoxy polyethylene glycol-epoetin beta) is a new erythropoiesis-stimulating agent with a prolonged half-life. The objective of this study was to select a starting dose of CERA for the treatment of anemia in non-small-cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

The study was an open-label randomized phase II trial containing four treatment groups of patients with anemia and stage IIIB or IV NSCLC. The fourth treatment group was a reference group of patients treated with darbepoetin alfa administered at either 6.75 μg/kg s.c. every 3 weeks or 2.25 μg/kg weekly. Due to observed imbalances in death across treatment arms, this study was prematurely terminated.

RESULTS

The primary efficacy parameter of the mean hemoglobin (Hb) change from baseline during weeks 5-13 was +0.03 g/dl, +0.50 g/dl, and -0.02 g/dl in the CERA 6.3, 9, and 12 μg/kg dose groups, respectively, and +0.26 g/dl in the darbepoetin alfa dose group (P value not significant for all three study arms). Eight (21%), 12 (32%), 9 (24%), and 4 (10%) patients in the CERA 6.3, 9, and 12 μg/kg and darbepoetin groups, respectively, died.

CONCLUSION

In this phase II study in patients with stage IIIB or IV NSCLC receiving chemotherapy, none of the four treatment arms showed an adequate increase in mean Hb level.

Development of a new G-CSF product based on biosimilarity assessment

BACKGROUND

Zarzio, a new recombinant human granulocyte colony-stimulating factor (filgrastim), was evaluated in healthy volunteers and neutropenic patients in phase I and III studies.

PATIENTS AND METHODS

Healthy volunteers in randomized, two-period crossover studies received single- and multiple-dose s.c. injections of 1 microg/kg (n = 24), 2.5 microg/kg (n = 28), 5 microg/kg (n = 28), or 10 microg/kg (n = 40), as well as single-dose i.v. infusions of 5 microg/kg (n = 26), of Zarzio or the reference product (Neupogen). Filgrastim serum levels were monitored; pharmacodynamic parameters were absolute neutrophil count (all studies) and CD34(+) cells (multiple-dose studies). Supportive efficacy and safety data were obtained from an open phase III study in 170 breast cancer patients undergoing four cycles of doxorubicin and docetaxel (Taxotere) chemotherapy, receiving Zarzio (300 or 480 microg) as primary prophylaxis of severe neutropenia.

RESULTS

The results of the studies in healthy volunteers confirm the comparability of the test and reference products with respect to their pharmacodynamics and pharmacokinetics. Confidence intervals were within the predefined equivalence boundaries. In the phase III study in breast cancer patients, the administration of Zarzio was efficacious and safe, triggering no immunogenicity.

CONCLUSION

The results of these studies demonstrate the biosimilarity of Zarzio with its reference product Neupogen.

Phase II trial of short-term neoadjuvant docetaxel and complete androgen blockade in high-risk prostate cancer

BACKGROUND

The low probability of curing high-risk prostate cancer (PC) with local therapy suggests the need to study modality of therapeutic approaches. To this end, a prospective phase II trial of neoadjuvant docetaxel (D) and complete androgen blockade (CAB) was carried out in high-risk PC patients. The primary end point was to detect at least 10% of pCRs after chemohormonal treatment.

METHODS

Patients with T1c-T2 clinical stage with prostate-specific antigen (PSA) >20 ng ml(-1) and/or Gleason score >or=7 (4+3) and T3 were included. Treatment consisted of three cycles of D 36 mg m(-2) on days 1, 8 and 15 every 28 days concomitant with CAB, followed by radical prostatectomy (RP).

RESULTS

A total of 57 patients were included. Clinical stage was T1c, 11 patients (19.3%); T2, 30 (52.6%) and T3, 16 (28%) patients. Gleason score was >or=7 (4+3) in 44 (77%) patients and PSA >20 ng ml(-1) in 15 (26%) patients. Treatment was well tolerated with 51 (89.9%) patients completing neoadjuvant therapy together with RP. The rate of pCR was 6% (three patients). Three (6%) additional patients had microscopic residual tumour (near pCR) in prostate specimen. With a median follow-up of 35 months, 18 (31.6%) patients presented PSA relapse.

CONCLUSION

Short-term neoadjuvant D and CAB induced a 6% pCR rate, which is close to what would be expected with ADT alone. The combination was generally well tolerated.

Correlation of serum interleukin-6 (IL-6) levels and clinical outcome in hormone-independent (HI) prostate cancer (PC) patients (PTS) treated with docetaxel

e16044

Background: IL-6 acts as an autocrine and paracrine growth factor in PC, linked to HI progression. We previously reported preliminary data on the correlation of serum IL-6 and D response in metastatic HI PC pts. We present here a larger group of pts tested to asses the clinical relevance of IL-6 in these pts. Methods: Pts with HIPC treated with D were prospectively tested for IL-6 levels by ELISA before D. Prostate-specific antigen (PSA) response, time to PSA progression, overall survival (OS) and PC specific survival (SpS) were analyzed. Evaluated variables were age, performance status, PSA, Gleason, number (n) of D cycles, time to HI progression, presence of visceral metastasis, n of bone metastasis, hemoglobin, lactate deshydrogenase and alkaline phosphatase. Results: Seventy-two pts were included. At the time of the analysis 5 pts had died from non-PC related causes, two from treatment toxicity and 29 (40%) from PC. Mean of age was 69 ± 7 years. Median baseline IL-6 level was 14 pg/ml (range 0.1–1100). Thirty-five pts (49 %) had IL-6 levels > 14 pg/ml. IL-6 > 14 pg/ml correlated with lower D response (13 % vs 40%, p= 0.039); lower time to PSA progression (4 months vs 6, p=0.023); lower OS (10 months vs 25, p= 0.001) and lower PC SpS (12 months vs 26, p= 0.001), in contrast to pts with IL-6 ≤ 14pg/ml. In the multivariate analysis, serum IL-6 (p=0.002), n of bone metastasis (p=0.008) and n of D cycles (p=0.002), were independent prognostic factor for OS and PC SpS. Conclusions: High serum IL-6 correlates with an adverse clinical outcome of pts with HIPC treated with D. IL-6 determination may be a potential tool to select patients for D-based or targeted therapies. FIS ( PI070388 )

No significant financial relationships to disclose.

Bortezomib/docetaxel combination therapy in patients with anthracycline-pretreated advanced/metastatic breast cancer: a phase I/II dose-escalation study

The aim of this study was to determine the dose-limiting toxicities (DLTs) and maximum tolerated dose (MTD) of bortezomib plus docetaxel in patients with anthracycline-pretreated advanced/metastatic breast cancer. Forty-eight patients received up to eight 21-day cycles of docetaxel (60-100 mg m(-2) on day 1) plus bortezomib (1.0-1.5 mg m(-2) on days 1, 4, 8, and 11). Pharmacodynamic and pharmacokinetic analyses were performed in a subset of patients. Five patients experienced DLTs: grade 3 bone pain (n=1) and febrile neutropenia (n=4). The MTD was bortezomib 1.5 mg m(-2) plus docetaxel 75 mg m(-2). All 48 patients were assessable for safety and efficacy. The most common adverse events were diarrhoea, nausea, alopecia, asthenia, and vomiting. The most common grade 3/4 toxicities were neutropenia (44%), and febrile neutropenia and diarrhoea (each 19%). Overall patient response rate was 29%. Median time to progression was 5.4 months. In patients with confirmed response, median time to response was 1.3 months and median duration of response was 3.2 months. At the MTD, response rate was 38%. Pharmacokinetic characteristics of bortezomib/docetaxel were comparable with single-agent data. Addition of docetaxel appeared not to affect bortezomib inhibition of 20S proteasome activity. Mean alpha-1 acid glycoprotein concentrations increased from baseline at nearly all time points across different bortezomib dose levels. Bortezomib plus docetaxel is an active combination for anthracycline-pretreated advanced/metastatic breast cancer. The safety profile is manageable and consistent with the side effects of the individual agents.

Correlation of serum interleukin-6 (IL-6) levels with immunohistochemical p65/nuclear factor-κB (NF-κB) expression and prediction of the clinical outcome of hormone-independent prostate cancer patients (HIPC) treated with docetaxel (D)

5075

Background: We have recently reported that NF-κB/IL-6 was linked to D response in human prostate cancer cells. In this study we investigated the clinical significance of IL-6 serum levels in HIPC pts treated with D and the correlation between serum IL-6 levels and p65/NF-κB tissue expression. Methods: Pts with HIPC treated with D were prospectively tested for IL-6 levels by ELISA before chemotherapy. In patients with available specimens of hormone-independent tumor p65/NF-κB was determined by immunohistochemistry. PSA response to D, time to progression and survival were analyzed. Results: Sixty pts were included. Median follow-up time was 29.3 (5.3–55.47) months. Median time to D progression was 4.2 (0,6–15.1) months and median survival was 10.1 (1.6- 47.1) months. Median baseline IL-6 were 16 pg/ml (range 0–156). Pts that responded to D had median IL-6 of 15.1±3.9 pg/ml and patients that did not respond had median IL-6 of 34.7±6.5 (p=0.009). IL-6 correlated with the number of bone metastasis (r=0.39, p=0.002), LDH levels (r=0.53, p<0.0001) and inversely with time to PSA progression (r=-0.65, p<0.0001) and survival (r=-0.61, p<0.0001). In the multivariate analysis IL-6 were an independent prognostic factor for time to PSA progression HR 1.026 (CI95% 1.013–1.046) and survival IL-6 levels HR 1.022 (CI 95% 1.006- 1.038, p=0.008). HIPC tissue samples from 12 pts were assessed for p65/NF-κB expression. All tissue samples showed cytoplasmatic and nuclear staining. Median percentage of nuclear p65/NF-κB stained cells was 15% (range 5–45%). P65/NF-κB nuclear staining showed correlation with serum IL-6 levels (r=0.719, p=0.009). Patients with low serum IL-6 levels (= 16 pg/ml) had a median % of nuclear p65/NF-κB staining of 5.4±2.5% and patients with high IL-6 levels had a median % of nuclear p65/NF-κB staining of 30.2±4.9% (p=0.001). Conclusions: High IL-6 serum levels were associated to a worse survival in HIPC pts treated with D. Our data suggest that the determination of serum IL-6 levels may serve as a surrogate marker of NF-κB activity in hormone-independent prostate cancer tumor and may be useful to select patients for NF-κB targeted therapy.

No significant financial relationships to disclose.

The development of a prediction tool for chemotherapy-induced anemia in patients with advanced non-small cell lung cancer (NSCLC) palliative receiving chemotherapy

8600

Background: Anemia remains a common complication in patients with advanced NSCLC on palliative chemotherapy. Many oncologists believe that anemia is unpredictable, acting on a low hemoglobin value once the patient is anemic (i.e. reactively). However, patient care could be substantially improved if severe anemia could be accurately predicted by validated mathematical models. The development and validation of our cycle-based prediction model for severe anemia (hemoglobin ≤ 100 g/L) is described. Methods: Data on 536 European patients receiving palliative chemotherapy was prospectively collected as part of the European Cancer Anemia Survey (Ludwig et al, 2004), including information on clinical and biochemistry parameters that could potentially be associated with anemia. The sample was randomly divided into a 2/3 model derivation and 1/3 validation sample. Multivariable logistic regression techniques were applied for the initial model. A risk scoring system based on regression parameters was created, from 0 to 15. Finally a receiver operating characteristic curve (ROC) analysis was undertaken to measure predictive accuracy of the validation sample. Results: Precycle hemoglobin, low body surface area, advanced age, poor performance status, recurrent/persistent disease and platinum or gemcitabine-based chemotherapy were identified as being important predictors for severe anemia. The ROC analysis on the derivation and internal validation datasets had areas under the ROC curve of 0.80 (95%CI: 0.74 - 0.85) and 0.86 (95%CI: 0.83 - 0.89). A risk score of ≥ 8 to < 10 was identified as being the optimal cut-off to maximize sensitivity (83.1%) and specificity (67.8%) of the prediction tool. Patients with a score of ≥ 8 would be considered at high risk for developing severe anemia following a particular cycle of chemotherapy. Conclusions: This study outlines the development of an accurate anemia prediction tool for NSCLC patients receiving chemotherapy. The application and planned continued refinement of this prediction tool will be an important source of patient specific risk information for the practicing oncologist and can enhance patient care by utilizing anemia therapies earlier and pro-actively.

[Table: see text]

Serum c-erbB-2 ectodomain (ECD) correlates with immunohistochemical c-erbB-2 expression and predicts an aggressive clinical outcome in hormone-independent prostate cancer (HIPC) patients (pts) treated with docetaxel (D)

4632

Background: The overexpression of c-erbB-2 has been described as a common event associated to the hormone-independent progression in prostate cancer. The clinical implications of c-erbB-2 expression in HIPC pts are not fully established. In this study we investigated the clinical significance of c-erbB-2 serum levels in HIPC pts treated with D and the correlation between serum c-erbB-2 ECD and c-erbB-2 tissue expression. Methods: Pts with HIPC treated with D were tested for serum c-erbB-2 ECD levels by immunoassay before chemotherapy. In pts with available biopsy specimens of hormone-independent tumor, c-erbB-2expression was determined by immunohistochemistry in paraffin-embedded tissue sections. PSA response to D, time to PSA progression and survival were analyzed. Results: Forty-one pts were included in the study. Median follow-up time was 23.3 (3.7–43.1) months. Median time to D progression was 4.1 (0,4–15.1) months and median survival was 11.3 (1,6–43.1). Serum c-erbB-2 correlated with PSA (r=0.351, p=0.025), inversely with time to PSA progression (r = −0.338, p = 0.033) and inversely with survival (r = −0.305, p = 0.05). Median time to PSA progression in pts with high serum c-erbB-2 (≥15 ng/ml) was 1.5 months compared to 4.6 months in pts with low levels (p = 0.0003). Survival in pts with high c-erbB-2 was 11 months and in pts with low c-erbB-2 was 15 months (p = 0.053). HIPC tissue samples from 10 pts were assessed for c-erbB-2 expression. Immunohistochemical c-erbB-2 positive staining (score +2 and +3) was detected in 4 (40%). C-erbB-2 staining showed correlation with serum c-erbB2 levels. Pts with positive staining had 19.1 ± 1.78 ng/ml and negative pts 8.8 ± 2.6 ng/ml (p = 0.001).The 4 pts with tissue c-erbB-2 overexpression had serum c-erbB-2 levels >15 ng/ml, while pts with no c-erbB-2 overexpression in tissue had also low c-erbB-2 levels in serum. Conclusions: High c-erbB-2 ECD in serum is associated with a worse clinical outcome of HIPC. Our data suggest that the determination of c-erbB-2 ECD in serum translates the c-erbB-2 status in the hormone-independent tumor and may be useful to select pts for c-erbB-2-targeted therapy.

No significant financial relationships to disclose.

Role of metalloproteinase-7 in oxaliplatin acquired resistance in colorectal cancer cell lines

20042

Background: Mechanisms responsible for acquired resistance in colorectal cancer (CRC) tumors are not well understood. Anticancer drugs have been shown to enhance FASL expression by NF-kB induction. Additionally Metalloproteinase (MMP)-7 is over-expressed in CRC and has been shown to inhibit apoptosis by cleavage of FASL. We have previously shown in vivo that, sFASL increment was associated with acquired chemoresistance. Therefore we speculate that inhibition of MMP-7 or NF-kB can reverse chemoresistance in CRC cell lines. Methods: We generated an oxaliplatin-resistant cells (HT29R) from a p53 mutated (HT29) cell line. Both cell lines were cultured for 72h with different concentrations of oxaliplatin, BAY11–7085 (inhibitor of NF-kB activation), 0.01 mM of the MMP-7 inhibitor 1,10-Phenanthroline monohydrate (1,10-PM) and 100 ng/ml of DX2 monoclonal antibody. Different drug combinations were performed. Citotoxicity was determined by the MTS method, and cell cycle was analysed at 72h. Cell lines were characterized for MMP-7 expression (ELISA), NF-KB (Western-Blot), Fas expression (immunohistochemistry) and FasL expression (Western-Blot). Results: FAS was down-expressed in HT29R compared to HT29. The HT29R cells showed a IC50 for oxaliplatin 2-fold higher than normal cells. Treatment with 1,10-PM decrease MMP-7 levels (p < 0.005) compared with untreated cells. Additionally, inhibition of MMP-7, restore IC50 values after oxaliplatin treatment in HT29R without changes in NF-KB expression. This oxaliplatin-resistant cell line, presents also sensibility for BAY11–7085, without affecting MMP-7 levels. Finally the addition of oxaliplatin to the MMP-7 inhibitor, increase FAS-mediated apoptosis (induced by DX2 antibody), suggesting that FASL cleavage is responsable of sensitivity. Conclusions: Reversal of oxaliplatin chemo-resistance can be obtained either by MMP-7 or NF-kB inhibition. Both drugs induced sFASL decrement, by inhibiting cleavage or expression, respectively.

No significant financial relationships to disclose.

Prevalence of anemia in cancer patients not receiving antineoplastic treatment (ANT): Data from the European Cancer Anaemia Survey (ECAS)

8565

Background: Cancer-associated anemia occurs frequently in patients receiving ANT. Patients not receiving ANT may also have low hemoglobin (Hb) levels that may compromise optimal disease management and patient outcomes. Methods: Patients enrolled in ECAS (Ludwig et al, Eur J Cancer 2004;40:2293–2306) and not receiving ANT (chemotherapy, radiotherapy, or hormonal treatment) at enrollment were evaluated for prevalence of anemia (Hb <12.0 g/dL), effect of anemia on performance according to WHO score (0 to 4), and anemia treatment. Disease status at enrollment was catagorized as newly diagnosed (ND), persistent/recurrent (P/R), or in remission. Results: Of 15,367 enrolled patients, 7947 (53%) were not receiving ANT: 60% ND; 28% P/R disease; 12% in remission. Anemia was present in 32% of patients, with Hb levels 10.0–11.9 g/dL in 24%, and <10.0 g/dL in 8%. Anemia rates were P/R, 38%; ND, 30%; in remission, 25%. Poor performance scores correlated positively with lower Hb levels; for patients with Hb <8.0 g/dL, 8.0–9.9 g/dL, 10.0–11.9 g/dL, and ≥12.0 g/dL, worse WHO scores of 2–4 were recorded for 43%, 41%, 25%, and 15%, respectively. During ECAS 1168 patients with data after enrollment never received ANT, and 40% were anemic at some time (at enrollment and/or at follow-up). Hb nadirs were approximately evenly distributed: 11.0–11.9 g/dL, 37%; 10.0–10.9 g/dL, 29%, and <9.0–9.9 g/dL, 34%. Anemia was infrequently treated with only 31.4% of patients receiving anemia treatment at any time. Anemia treatments administered and mean Hb at initiation were 14% epoetin alone ± transfusion ± iron (9.8 g/dL); 9% transfusion ± iron (8.4 g/dL); 8% iron (11.7 g/dL). Conclusions: Almost one-third of cancer patients who are not actively receiving ANT are anemic, including 25% of patients considered to be in remission. Anemia has a negative effect on performance, with worse WHO scores related to lower Hb levels. Anemia appears to be undertreated, with less than one-third of anemic patients receiving anemia treatment, and then only when Hb nadirs are <10.0 g/dL. To insure optimal management of cancer patients, all should be screened for anemia and receive the most effective anemia treatment.

[Table: see text]

Activation of nuclear factor-kappa B is linked to resistance to neoadjuvant chemotherapy in breast cancer patients

The nuclear factor (NF)-kappaB system is a promising anticancer target due to its role in oncogenesis and chemoresistance in preclinical models. To provide evidence in a clinical setting on the role of NF-kappaB in breast cancer, we aimed to study the value of basal NF-kappaB/p65 in predicting resistance to neoadjuvant chemotherapy, and to characterise the pharmacodynamic changes in NF-kappaB/p65 expression following chemotherapy in patients with locally advanced breast cancer. Pre- and post-chemotherapy tumour specimens from 51 breast cancer patients treated with anthracycline- and/or taxane-containing neoadjuvant chemotherapy were assayed by immunohistochemistry for NF-kappaB/p65 subcellular expression. We studied NF-kappaB/p65, a well-characterised member of the NF-kappaB family that undergoes nuclear translocation when NF-kappaB is activated. Activation of NF-kappaB (i.e. nuclear NF-kappaB/p65 staining in pre-therapy specimens) was linked to chemoresistance. Patients with NF-kappaB/p65 nuclear staining in pre-treatment samples had a 20% clinical response rate, while patients with undetected nuclear staining had a 91% response rate to chemotherapy (P = 0.002). Notably, four patients achieved a complete histological response and none of them had pre-treatment NF-kappaB/p65 nuclear staining. Moreover, the number of patients with NF-kappaB/p65 activation increased after chemotherapy exposure. It is concluded that NF-kappaB/p65 activation assayed by immunohistochemistry is a predictive factor of resistance to neoadjuvant chemotherapy in breast cancer patients. Moreover, NF-kappaB activation was inducible following chemotherapy in a proportion of breast cancer patients. These novel clinical findings strengthen the rationale for the use of NF-kappaB inhibitors to prevent or overcome chemoresistance in breast cancer.

Activation of nuclear factor-kappaB in human prostate carcinogenesis and association to biochemical relapse

Nuclear factor (NF)-κB/p65 regulates the transcription of a wide variety of genes involved in cell survival, invasion and metastasis. We characterised by immunohistochemistry the expression of NF-κB/p65 protein in six histologically normal prostate, 13 high-grade prostatic intraepithelial neoplasia (PIN) and 86 prostate adenocarcinoma specimens. Nuclear localisation of p65 was used as a measure of NF-κB active state. Nuclear localisation of NF-κB was only seen in scattered basal cells in normal prostate glands. Prostatic intraepithelial neoplasias exhibited diffuse and strong cytoplasmic staining but no nuclear staining. In prostate adenocarcinomas, cytoplasmic NF-κB was detected in 57 (66.3%) specimens, and nuclear NF-κB (activated) in 47 (54.7%). Nuclear and cytoplasmic NF-κB staining was not correlated (P=0.19). By univariate analysis, nuclear localisation of NF-κB was associated with biochemical relapse (P=0.0009; log-rank test) while cytoplasmic expression did not. On multivariate analysis, serum preoperative prostate specific antigen (P=0.02), Gleason score (P=0.03) and nuclear NF-κB (P=0.002) were independent predictors of biochemical relapse. These results provide novel evidence for NF-κB/p65 nuclear translocation in the transition from PIN to prostate cancer. Our findings also indicate that nuclear localisation of NF-κB is an independent prognostic factor of biochemical relapse in prostate cancer.

Serum Protein S-100 Predicts Clinical Outcome in Patients with Melanoma Treated with Adjuvant Interferon – Comparison with Tyrosinase RT-PCR

OBJECTIVE

To study the clinical value of the determination of serum S-100 protein as a single tumor marker or in combination with tyrosinase RT-PCR in patients with melanoma receiving adjuvant interferon.

PATIENTS AND METHODS

Patients were tested for serum S-100 protein luminoimmunometric assay and for blood tyrosinase mRNA (RT-PCR), before starting interferon and every 2-3 months thereafter.

RESULTS

One hundred and six patients (stage IIA, 27; IIB, 19; III, 49; and IV, 11) were included in the study. Median follow-up was 51 months (range 2-76). In the univariate analysis, under treatment S-100 > or =0.15 microg/l and a positive RT-PCR correlated with a lower disease-free survival and overall survival (OS). In the multivariate analysis, clinical stage, under therapy positive RT-PCR and S-100 levels > or =0.15 mug/ml, were independent prognostic factors for OS. The hazard ratio for OS was 3.9 (95% CI, 1.67-9.15; p = 0.004) and 2.2 (95% CI, 1.05-4.6; p = 0.016) for S-100 > or =0.15 microg/l and positive RT-PCR, respectively. When both techniques where combined, a positive RT-PCR indicated a poorer clinical outcome only in patients with S-100 <0.15 microg/l.

CONCLUSIONS

S-100 > or =0.15 microg/l and a positive RT-PCR during adjuvant interferon therapy indicate a high risk of death in resected melanoma patients. S-100 determination has a higher positive predictive value than RT-PCR, while tyrosinase RT-PCR adds prognostic information in patients with S-100 <0.15 microg/l.