Intergroup randomized phase III study of androgen deprivation therapy (ADT) plus radiation therapy (RT) in locally advanced prostate cancer (CaP) (NCIC-CTG, SWOG, MRC-UK, INT: T94-0110; NCT00002633)

CRA4504

Background: The impact of radiotherapy on overall survival (OS) in men with locally advanced CaP is unclear. The SPCG-7 trial recently showed a benefit to RT for CaP specific mortality. Our primary objective was to assess the effect of RT on OS when added to lifelong ADT in men with locally advanced CaP.

Methods: Patients with T3/T4 (1057) or T2, PSA > 40 μ g/l (119) or T2 PSA > 20 μ g/l and Gleason ≥ 8 (25) and N0 /NX, M0 prostate adenocarcinoma were randomized to lifelong ADT (bilateral orchiectomy or LHRH agonist) with or without RT (65-69 Gy to prostate ± seminal vesicles with or without 45Gy to pelvic nodes). The primary endpoint was OS and secondary endpoints included disease specific survival (DSS), time to disease progression and quality of life.

Results: 1205 patients were randomized from 1995 to 2005, 602 to ADT and 603 to ADT+RT (well balanced with respect to baseline characteristics). A protocol specified second interim analysis on OS was performed in Aug 2009 (data cut-off Dec 31 2008). The DSMC recommended release of the results to the Trial Committee for publication. The median follow-up is 6.0 years and 320 patients have died (175 ADT and 145 ADT+RT). 10% of patients had no follow-up data beyond 2006. The addition of RT to ADT significantly reduced the risk of death (hazard ratio [HR] 0.77, 95% CI 0.61-0.98, p=0.033). 140 patients died of disease and/or treatment (89 on ADT and 51 on ADT+RT) The disease specific survival HR was 0.57 (95% CI 0.41-0.81, p=0.001) favoring ADT+RT. The 10 year cumulative disease specific death rates were estimated at 15% with ADT+ RT and 23% with ADT alone. Grade ≥2 late GI toxicity rates were similar in both arms (proctitis, 1.3% ADT alone, 1.8% ADT+RT).

Conclusions: The trial results indicate a substantial overall survival and disease specific survival benefit for the combined modality approach (ADT+RT) in the management of patients with locally advanced prostate cancer with no significant increase in late treatment toxicity. In view of this data combined modality therapy (ADT+RT) should be the standard treatment approach for these patients. Supported by NCI-US Grant #5U10CA077202-12, CCSRI Grant #15469.

No significant financial relationships to disclose.

A phase III randomized, double-blind, placebo-controlled trial of the epidermal growth factor receptor inhibitor gefitinb in completely resected stage IB-IIIA non-small cell lung cancer (NSCLC): NCIC CTG BR.19

LBA7005

Background: In meta-analyses, platinum-based adjuvant (adj) chemotherapy (CT) in completely resected NSCLC increased cure rate by ∼5%. At BR.19 initiation, adj study results with third-generation agents were unavailable. Gefitinib, an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, showed activity in monotherapy trials. We report a trial of adj gefitinib versus placebo after complete resection of NSCLC.

Methods: Patients (pts) with stage IB-IIIA NSCLC were stratified by sex, stage, histology, post-op radiation, and after Jan 2003, adj CT. Pts were randomized to gefitinib 250 mg or placebo daily x 2 years. Study endpoints included overall survival (OS), disease free survival (DFS), toxicity, preplanned correlative studies. Study closed prematurely in Apr. 2005. Trial committee and NCIC CTG staff remained blinded to study drug.

Results: 503 pts randomized (Sep 2002-Apr 2005); median age 67, males 54%, PS 0 54%; stage IB 49%, II 38%, III 13%; adenocarcinoma 59%, squamous 28%; ever smokers 89%; adj CT 17%; lobectomy 82%. Commonest grade 3/4 toxicities = fatigue 5%, rash 4% and diarrhea 5%. grade 3+ pneumonitis in 7 (1.4%) pts and led to death in 1. Median follow-up is 4.7 yrs; median treatment time is 4.8 mos. For gefitinib versus placebo, median DFS is 4.2 yrs versus not yet reached (NYR) HR1.22 (95% C.I. 0.93-1.61), p=0.15 and median OS 5.1 yrs versus NYR HR 1.24 (95% C.I. 0.94-1.64), p=0.14. In multivariate analysis, tumor size >4cm was predictive of poor DFS (p<0.0001) and never smoking for better OS with gefitinib (p=0.02). Results for KRAS and EGFR copy are available on 350 and 348 pts respectively. KRAS mutations were neither prognostic HR 1.12 (95% C.I. 0.67-1.86), p=0.66 nor predictive of gefitinib benefit (p = 0.16) on OS. EGFRcopy whether low/high polysomy or amplification was neither prognostic (p=0.77) nor predictive of OS benefit from gefitinib.

Conclusions: Adjuvant gefitinib after complete resection of early stage NSCLC did not confer DFS or OS advantage in overall population. KRAS and EGFR copy were neither prognostic nor predictive of benefit from gefitinib. EGFR mutational analysis will be presented.

[Table: see text]

MI-63: a novel small-molecule inhibitor targets MDM2 and induces apoptosis in embryonal and alveolar rhabdomyosarcoma cells with wild-type p53

Background:

Interruption of the role of p53s as a tumour suppressor by MDM2 may be one of the mechanisms by which cancer cells evade current therapy. Blocking the inhibition of wild-type p53 by MDM2 in cancer cells should reactivate p53's tumour suppressor functions and enhance current cancer treatments. MI-63 is a novel non-peptide small molecule that has shown strong binding affinity (K_i=3 nM) for MDM2; however, its effects on paediatric cancer cells and the specific mechanism of tumour suppressor reactivation have not been evaluated.

Methods:

Rhabdomyosarcoma (RMS), the most common childhood soft tissue sarcoma, expresses either wild-type or mutant p53 protein. We examined the inhibitory effects of MI-63 in embryonal RMS (ERMS) and alveolar RMS (ARMS) cell lines expressing wild-type or mutated p53.

Results:

Treatment with MI-63 reduced cell viability by 13.4% and by <1%, respectively, at 72 h in both RH36 and RH18 cell lines expressing wild-type p53. In contrast, RH30 and RD2 cells expressing p53 mutants are resistant to MI-63 treatment. An increased expression of p53, p21^WAF1, and Bax protein was observed after treatment with MI-63 in RMS cells with wild-type p53, and apoptosis was confirmed by cleaved PARP and caspase-3 expression. However, RD2 and RH30 RMS cells, as well as human normal skeletal muscle cells, showed a minimal increase in p53 signalling and no induction of cleaved PARP and caspase-3. MI-63 was compared with Nutlin-3, a known MDM2 inhibitor, and was found to be more potent in the inhibition of cell proliferation/viability. Further, synergy was observed when MI-63 was used in combination with doxorubicin.

Conclusion:

These results indicate that MI-63 is a potent therapeutic agent for RMS cells expressing wild-type p53 protein.

Indoor air pollution from solid biomass fuels combustion in rural agricultural area of Tibet, China

In this study, we are trying to investigate the indoor air pollution and to estimate the residents' pollution exposure reduction of energy altering in rural Tibet. Daily PM(2.5) monitoring was conducted in indoor microenvironments like kitchen, living-room, bedroom, and yard in rural Tibet from December 2006 to March 2007. For kitchen air pollution, impact of two fuel types, methane and solid biomass fuels (SBFs), were compared. Questionnaire survey on the domestic energy pattern and residents' daily activity pattern was performed in Zha-nang County. Daily average PM(2.5) concentrations in kitchen, living-room, bedroom, and yard were 134.91 microg/m(3) (mean, n = 45, 95%CI 84.02, 185.80), 103.61 microg/m(3) (mean, n = 21, 95%CI 85.77, 121.45), 76.13 microg/m(3) (mean, n = 18, 95%CI 57.22, 95.04), and 78.33 microg/m(3) (mean, n = 34, 95%CI 60.00, 96.65) respectively. Using SBFs in kitchen resulted in higher indoor pollution than using methane. PM(2.5) concentrations in kitchen with dung cake, fuel wood and methane use were 117.41 microg/m(3) (mean, n = 18, 95%CI 71.03, 163.79), 271.11 microg/m(3) (mean, n = 12, 95%CI 104.74, 437.48), and 46.96 microg/m(3) (mean, n = 15, 95%CI 28.10, 65.82) respectively. Family income has significant influence on cooking energy choice, while the lack of commercial energy supply affects the energy choice for heating more. The effects of two countermeasures to improve indoor air quality were estimated in this research. One is to replace SBFs by clean energy like methane, the other is to separate the cooking place from other rooms and by applying these countermeasures, residents' exposure to particulate matters would reduce by 25-50% (methane) or 20-30% (separation) compared to the present situation.

PRACTICAL IMPLICATIONS

Indoor air pollution caused by solid biomass fuels is one of the most important burdens of disease in the developing countries, which attracts the attention of environment and public health researchers, as well as policy makers. This paper gives a pilot research on the indoor air pollution and estimated the effects of some intervention policies in Tibet of China, where the living habits of the residents are quite different from other parts of the world. This work would be an important supply to the indoor air pollution studies, and would be helpful in policy making.

Hypertension (HTN) in National Cancer Institute of Canada Clinical Trials Group study BR.24: A randomized, double-blind phase II trial of carboplatin (C) and paclitaxel (P) with either daily oral cediranib (CED), an inhibitor of vascular endothelial growth factor receptors, or placebo, in patients with advanced non-small cell lung cancer

3527

Background: CED 30 mg/d with C+P increased response rate (RR: 38 vs 16% p < 0.0001) and median progression free survival (PFS: 5.6 vs 5 m, hazard ratio [HR] 0.77) over C+P alone. HTN is a known effect of angiogenesis inhibitors (AI). For BR.24, we describe the incidence of HTN, effects on drug delivery, predictors of its development/worsening, and assess the predictive effect of HTN on efficacy. Methods: Pts received C+P plus either placebo (n =146) or CED (n = 148). HTN as an adverse event (HTN AE: defined as either new onset HTN, or worsening grade HTN in a previously hypertensive pt), was managed with a protocol-defined algorithm. Exploratory analyses characterized the relationship between HTN AE and baseline characteristics and treatment arm. Kaplan Meier curves summarized time to event outcomes and Cox regression models with time dependent covariates correlated HTN AE to outcomes. Results: Rate of pts with a history of HTN were similar: CED 26 %, placebo 33 %. CED pts had significantly higher HTN AE (any: 38 vs 12%, p < 0.0001; grade 3 or 4: 19 vs 2 %). With the treatment algorithm, HTN AE had minimal impact on drug delivery (1 pt interrupted C+P, 11 pts [3.7%] reduced /discontinued CED / placebo). Headache was the only other AE that correlated with HTN AE. Predictors of HTN AE included: CED arm (p < 0.0001), good ECOG (p = 0.02), female (p = 0.006), history of HTN (p = 0.06). CED pts with HTN AE had significantly higher RR (51.8 vs 32.6%, p = 0.025) and PFS (8.5 vs 5.1 m; HR 0.45, 95% CI 0.29 to 0.72, p = 0.0007); similar but not significant findings were observed with placebo (RR 35.3 vs 17.2%, p= 0.098; PFS 5.6 vs 4.9 m; HR 0.84, 95 % CI 0.45–1.54); the interaction term by treatment arm was not significant. Conclusions: CED pts had greater HTN AE, but this did not impact drug delivery. Certain baseline characteristics predicted HTN AE in all pts. Unexpectedly, development of on-study HTN predicted improved outcome in all pts, although to a greater extent for those on CED. Additional evaluation of the role of HTN AE as a predictor of efficacy of both AI and cytotoxics is warranted.

[Table: see text]

Updated survival analysis of JBR.10: A randomized phase III trial of vinorelbine/cisplatin versus observation in completely resected stage IB and II non-small cell lung cancer (NSCLC)

7501

Background: JBR.10 was one of a number of phase III trials that established adjuvant cisplatin based chemotherapy as a recommended treatment in completely resected NSCLC . Long-term follow-up of these trials is important to document persistent benefit and potential late toxicities of adjuvant therapy. We report the updated survival data for JBR.10 with more than 9 years median follow up. Methods: Patients with completely resected stage IB (T2N0) or II (T1–2N1) NSCLC were randomized to receive 4 cycles of vinorelbine/cisplatin or observation.. Kaplan-Meier curves were generated for overall (OS) and disease specific survival (DSS). Log-rank test was used to compare survival distribution and to test cause specific hazard. For the competing risk analysis, the Gray test was used to test the difference in cause specific incidences. All efficacy analyses were done on an ITT basis. Results: 482 patients were randomized. Data cut-off for this update was July 2008. Median follow-up is 9.3 years (3.2–13.8 y). 12 patients were lost to follow up, a median 4.9 years from randomization (1.5–12 years). 271 deaths have occurred, 73% due to lung cancer or its treatment. Survival analysis continues to show a benefit for chemotherapy: HR .78 (CI .61-.99, p=.04). The benefit appears to be confined to N1 patients: median OS 6.8 y versus 3.6 y, HR .68 (CI .5-.92, p=.01). N0 patients did not appear to benefit: HR 1.03 (CI .7–1.52, p=.87). Chemotherapy significantly prolonged DSS, HR.73 (CI .55-.97, p=.03) Competing risk analysis showed observation to be associated with significantly higher risk of death from lung cancer (p=.02) with no difference in incidences of death from other causes between arms (p=.62). Conclusions: Prolonged follow-up of patients in the JBR.10 trial continues to show a benefit in survival for adjuvant chemotherapy. This benefit appears to be confined to N1 patients. There was no increase in death from other causes in the chemotherapy arm.

[Table: see text]

The impact of brain metastases on overall survival (OS) in National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) clinical trials (CT) in advanced non-small cell lung cancer (NSCLC)

8075

Background: NSCLC patients (pts) with brain metastases (BMet) commonly are excluded from participating in clinical trials (CTs), based on perceptions of inferior outcomes. We evaluated the validity of this exclusion criterion, by investigating the OS of stage IV NSCLC pts with (BMet) and without (non-BMet) a prior history of BMet recruited to NCIC CTG CTs. Methods: This pooled analysis utilized data from BR.18 (paclitaxel/ carboplatin [PC] ± MMPI [BMS275291]), BR.21 (erlotinib vs. placebo), BR.24 (PC± VEGFR TKI [AZD2171]). Each trial permitted entry of pts with neurologically stable BMet, provided they had been treated and off corticosteroids (BR.24), or either treated or not but without corticosteroids (BR.18), or on a stable corticosteroid dose (BR.21). The primary end-point of these analyses was OS, evaluated in the pooled pt cohorts stratified by treatment arm, and in each trial individually. Results: Of 1,349 stage IV pts, 131 had a history of BMet. Of these, 103 (78%) pts had cranial radiation prior to randomization and 15 (11%) prior craniotomy. The median age of the BMet cohort was 56yrs vs. 61yrs for non-BMet cohort. There was no difference in baseline PS (BMet: PS 0–1 vs. 2 vs. 3 =74% vs. 21% vs.5%; non-BMet: 81% vs. 16% vs. 4%, p=0.16), weight loss (p=0.73) or hemoglobin (p=0.80) between the two cohorts. Female gender (41% vs. 33%, p=0.04) and adenocarcinoma (66% vs. 51%, p=0.005) was more common in the BMet cohort. There was no OS difference between the BMet and non-BMet cohort in the pooled analysis, stratified by trial (HR 1.05, 95%CI 0.85–1.28, stratified log-rank p=0.67), or in multivariate analysis adjusted for baseline covariates (AHR 1.12, 95%CI 0.91–1.37, p=0.31). There was also no OS difference between BMet and non-BMet pts when evaluated in each individual trial separately. Conclusions: Pts with a prior history of BMet have a similar OS to those pts without BMet in NSCLC in NCIC CTG CTs. In neurologically stable pts, BMet, should not be an exclusion criterion, while discontinuation or stable dose of corticosteroids appears a reasonable eligibility requirement.

No significant financial relationships to disclose.

TGF-α and amphiregulin levels in non-small cell lung cancer (NSCLC) patients (pts) treated with erlotinib/placebo in the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) BR.21

11023

Background: In BR.21, erlotinib prolonged survival of previously treated NSCLC pts. We examined the predictive/ prognostic effects of the EGFR ligands, TGFa and amphiregulin(Am). Methods: Plasma was collected prior to treatment in consenting pts. TGFa and Am were analyzed by ELISA (R&D Systems). Samples were blinded, measured in duplicate and ligand concentrations determined following interpolation of a standard curve generated from known quantities of recombinant proteins. Sensitivity was ∼3pg/ml. Cutoff points for TGFa were <10 (low) and ≥10 (high); for Am <1.5 (low) vs 1.5–10 (intermediate) vs >10 (high). Standard statistical methods were used to correlate biomarker data with baseline characteristics and outcomes. Results: In 731 randomized pts, 539 were evaluable for both markers; there was a significant interaction (p=0.03) between the evaluable and inevaluable cohorts (erlotinib benefit favoring the evaluable cohort); evaluable pts were more likely to be male, > 60 and to have EGFR amplification. Baseline high TGFa was associated with poorer ECOG PS (p=0.03) while high Am was associated with worse PS (p<0.0001), anemia (p<0.0001), non response to prior therapies (p=0.01) and no-prior platinum therapy (p=0.02). Although TGFa was not prognostic for OS (HR=1.0, p=0.99), high Am was (HR: Middle vs low: 0.94, 95% C.I 0.49 -1.81; high vs.low: 2.04, 95% C.I 1.43 - 2.91; p=0.0002). High TGFa was a poor prognostic factor for PFS (HR 1.4, p=0.07) as was elevated Am (HR: Middle vs low: 1.02, 95% C.I 0.56 -1.85; high vs. low: 1.67, 95% C.I 1.19 - 2.35, p=0.01). In multivariate analyses including both ligands, high Am remained prognostic, but neither ligand was predictive. Conclusions: High levels of baseline Am appears to be a poor prognostic factor, while low levels of TGFa showed a trend to predict benefit from erlotinib in univariate analyses. [Table: see text]

[Table: see text]

Defining the optimal treatment strategy for localized prostate cancer patients: a survey of ongoing studies at the National Cancer Institute of Canada Clinical Trials Group

The designation "clinically localized prostate cancer" comprises a group of biologically heterogeneous tumours with different growth rates and risks of relapse. Because prostate cancer is primarily a disease of older men, treatment selection must take into account the prognosis of the tumour, patient age, comorbidities, side effects of treatment, and patient preferences. Clinical trials must identify the various prognostic groups and test the appropriate treatment strategies within these subgroups.

The impact of anemia on outcome of chemoradiation for limited small-cell lung cancer: a combined analysis of studies of the National Cancer Institute of Canada Clinical Trials Group

BACKGROUND

Associations between anemia and outcomes of chemoradiation have been documented in several malignancies, but few data exist for limited small-cell lung cancer (LD-SCLC). This combined analysis of 652 patients in two randomized clinical trials in LD-SCLC carried out by the National Cancer Institute of Canada Clinical Trials Group was undertaken to explore the relationship between anemia at baseline and anemia arising during therapy, and outcomes of chemoradiation in this cancer.

PATIENTS AND METHODS

The relationships between overall survival and local control with hemoglobin levels at baseline and those arising during therapy (nadir hemoglobin (Hb) and maximum percentage drop from baseline values) were explored.

RESULTS

No Hb parameter was associated with either outcome. Baseline anemia was found in one-third of patients, was more common in males, in those with a poorer performance status and those with an elevated lactate dehydrogenase; all of these latter factors were associated with shorter survival. A trend towards improved local control in patients with the greatest drop in their Hb did not remain significant in a multivariate analysis.

CONCLUSIONS

Anemia is common in patients with LD-SCLC. Anemia at diagnosis may have a different prognostic implication than that arising during therapy, and correction of anemia may have no impact on outcomes.

Patterns of disease progression and outcomes in a randomized trial testing ABVD alone for patients with limited-stage Hodgkin lymphoma

BACKGROUND

In the National Cancer Institute of Canada Clinical Trials Group/Eastern Cooperative Oncology Group HD.6 trial, progression-free survival was better in patients randomized to therapy that included radiation, compared to doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (ABVD) alone. We now evaluate patterns of progression and subsequent outcomes of patients with progression.

PATIENTS AND METHODS

After a median of 4.2 years, 33 patients have progressed. Two radiation oncologists determined whether sites of progression were confined within radiation fields. Freedom from second progression (FF2P) and freedom from second progression or death (FF2P/D) were compared.

RESULTS

Reviewers agreed for the extended (kappa = 0.87) and involved field (kappa = 1.0) analyses. Progression after ABVD alone was more frequently confined within both the extended (20/23 vs. 3/10; P = 0.002) and involved fields (16/23 vs. 2/10; P = 0.02). There was no difference in FF2P between groups [5-year estimate 99% (radiation) versus 96% (ABVD alone)] [hazard ratio (HR) = 3.14, 95% confidence interval (CI) 0.63-15.6; P = 0.14]; the 5-year estimates of FF2P/D were 94% in each group (HR = 1.04, 95% CI 0.41-2.63; P = 0.93).

CONCLUSION

Treatment that includes radiation reduces the risk of progressive Hodgkin lymphoma in sites that receive this therapy, but we are unable to detect differences in FF2P or FF2P/D.

Fibrinogen controls human platelet fibronectin internalization and cell-surface retention

BACKGROUND

We recently demonstrated that platelet aggregation occurred in fibrinogen-deficient mice. In these animals, platelet fibronectin (Fn) content was increased 3-5 fold, suggesting that Fn may also be involved in platelet aggregation.

METHODS AND RESULTS

We compared platelet Fn content from a severe hypofibrinogenemic patient (with approximately 0.5% of normal fibrinogen levels) with his parents (heterozygous) and healthy donors. A significant increase in the patient's platelet Fn content was detected by immunoblot, flow cytometry, and immunoelectron microscopy (IEM). To examine the possible contribution of platelet Fn to platelet aggregation, we examined cell-surface Fn expression after thrombin treatment. Unexpectedly, IEM detected only trace amounts of Fn retained on the patient's platelet surface, and flow cytometry indicated that surface Fn was approximately 6-fold lower than that of his parents and tenfold lower than that of healthy donors. An ELISA further confirmed that the patient's platelet Fn was primarily released into the extracellular medium. To test whether retention of surface Fn was due to fibrin formation on the platelet surface, an antifibrin antibody (T2 G1) was employed. Fibrin was detected on platelets from healthy donors and from the father, but was negligible on the patient's platelets. Consistent with these data, when gel-filtered platelets of healthy donors were treated with thrombin receptor activation peptide (SFLLRN-NH(2); no conversion of fibrinogen to fibrin), little surface Fn was detected.

CONCLUSION

Fibrinogen not only competitively inhibits human platelet Fn internalization but also controls platelet-surface Fn retention via fibrin formation. The Fn-fibrin interaction is one possible mechanism to promote Fn interaction with platelets.

P53 protein over-expression but not p53 gene mutation is a poor prognostic marker and a predictive marker for survival benefit from adjuvant chemotherapy in non-small cell lung cancer (NSCLC) in the JBR.10 Trial

7577

Background: JBR.10, a phase III inter-group trial randomized 482 patients with resected stage IB & II NSCLC to receive 4 cycles of adjuvant cisplatin + vinorelbine or observation alone. Chemotherapy patients had an overall survival (OS) benefit (Hazard Ratio [HR] 0.69, p=0.04). P53 has important regulatory roles in cell cycle progression, apoptosis, gene transcription and DNA repair. We evaluated the prognostic and predictive value of p53 in JBR.10. Methods: P53 protein expression was evaluated by immunohistochemistry (IHC) on tissue micro-arrays (282 available blocks). We used the DO7 antibody, and defined ≥15% nuclear staining as the cutoff for over- expression. Mutations in exons 5–9 were determined by denaturing high performance liquid chromatography (446 available samples), followed by sequencing of aberrant PCR products. Results: Successful assays: p53 mutation, 403/446 patients; p53 IHC, 254/282 patients. P53 gene mutations were found in 126/403 (31%) patients. In the observation arm, mutations were not prognostic of poorer survival (HR = 1.18, 95% CI 0.77–1.81; p= 0.45). Adjuvant chemotherapy effect was not significantly different in p53 mutated and wild type patients (interaction p = 0.66), the estimated HR was 0.68 (95% CI 0.46–1, p=0.047) for patients with wild type p53, and 0.79 (95% CI 0.47–1.33, p=0.37) for mutated patients. P53 protein over-expression was found in 133/254 (52%) patients. Patients with over-expression in the observation arm had a higher risk of death than patients with low expression (HR 1.89, 95% CI 1.07–3.34, p=0.03). However, the adjuvant chemotherapy effect was significantly better in p53 over-expressing patients (interaction p= 0.018), with an estimated HR of 0.53 (95% C.I. 0.31–0.90, p=0.03) for p53 over-expressing patients, and 1.40 (95% C.I. 0.78–2.52, p=0.26) for low expressing patients. Conclusions: P53 protein overexpression but not p53 gene mutation is both a significant prognostic marker of poorer survival in the JBR 10 population and a significant predictive marker for the benefit of adjuvant chemotherapy.

[Table: see text]

Quality of life (QOL) impact of adjuvant chemotherapy for early stage non-small cell lung cancer (NSCLC): Final analysis of JBR.10 randomized trial

7585

Background: Adjuvant chemotherapy for early stage NSCLC is now standard of care, but its impact on QOL is not known. We report the final QOL analysis of JBR.10, a North American intergroup randomized trial of adjuvant cisplatin/vinorelbine compared to observation in patients (pts) with completely resected stage IB/II NSCLC (n=482). Methods: QOL, a secondary endpoint of JBR.10, was assessed using the EORTC QLQ-C30 and a trial-specific checklist at baseline, weeks 5 and 9 for those on chemotherapy, and at 3, 6, 9, 12, 18, 24, 30 and 36 months of follow up. A 10-point change in QOL scores from baseline was considered clinically significant. Results: QOL assessment was not mandatory for all pts; 186/242 (76.9%) pts randomized to chemotherapy completed the baseline QOL assessment, compared to 173/240 (72.1%) pts on the observation arm. The overall survival of pts contributing QOL data, and the effect of adjuvant chemotherapy, was not different from the entire study population. Baseline QOL in the two study arms was comparable, with low global QOL scores and a significant symptom burden, especially pain and fatigue, following thoracotomy. A significantly greater proportion of chemotherapy pts experienced worsening symptoms including fatigue (p=0.02), appetite, hair loss, nausea and vomiting. At 6 months, a higher proportion of pts on the observation arm reported improved QOL in the global (p = 0.002), physical (p=0.02) and functional domains, compared to pts on the chemotherapy arm. However, by the 9 month time-point, global QOL of patients on chemotherapy was comparable to QOL of patients on observation, as were the five functional domains. Numbness (change scores: 22 vs 6, p<0.01) and pins & needles in fingers/toes (change scores: 21 vs 5, p<0.01) were the only symptoms that persisted, up to 24 months. Conclusion: Patients on adjuvant chemotherapy experience an initial slower recovery of QOL after thoracotomy, but following completion of treatment reach levels comparable to patients treated with surgery alone, in most aspects of QOL.

[Table: see text]

Updated molecular analyses of exons 19 and 21 of the epidermal growth factor receptor (EGFR) gene and codons 12 and 13 of the KRAS gene in non-small cell lung cancer (NSCLC) patients treated with erlotinib in National Cancer Institute of Cancer

7571

Background: BR.21 demonstrated significant survival benefit from erlotinib for NSCLC patients (Shepherd, NEJM 2005). EGFR gene point mutations in exon 21 and deletions in exon 19 predict response to EGFR TKIs, but the predictive value of EGFR mutations (Mut) or high copy number (Amp) on survival remains unclear. Methods: The sensitivity of PCR-sequencing to detect EGFR mutations may be suboptimal. Thus, we re-analyzed all BR.21 samples with available material using a fluourescent-based PCR technique (Pan, JMD 2005;7:396) and ScorpionIM kits (DxS, Manchester, UK) as they may detect mutations in samples with only 5–10% tumor DNA. 204 samples were analyzed successfully for EGFR Mut, 206 for KRAS Mut and 159 by FISH for EGFR Amp. Results: Exon 19 deletion and/or exon 21 L858R Mut were identified in 34 patients (overall Mut rate 17%). EGFR high polysomy or true amplification was present in 61 patients (38%), and 30 patients (15%) had KRAS Mut. Overall response rates were EGFR wildtype (WT)/Mut: 7%/27%, p=0.03; KRAS WT/Mut: 10%/5%, p=0.69; No Amp/Amp: 5%/21%, p=0.02. Hazard ratios for survival benefit were EGFR WT: 0.74 (0.52–1.05, p=0.09), Mut: 0.55 (0.25–1.19, p=0.12); KRAS WT: 0.69 (0.9–0.97, p=0.03), Mut: 1.67 (0.62–4.50, p=0.31); no Amp: 0.80 (0.49–1.29, p=0.35), Amp: 0.43 0.23–0.78, p=0.004). The test for interaction was borderline for KRAS Mut (0.09) but was not significant for EGFR Mut (p=0.47) or EGFR Amp (0.12). It was significant only for non-smokers with EGFR Amp (p=0.04). In the multiple Cox regression model, including all markers, EGFR Amp was both prognostic for poorer survival (p=0.005) and predictive of a differential survival benefit from erlotinib (p=0.009). EGFR and KRAS Mut were not significant prognostic or predictive markers. Conclusion: EGFR genotype and copy number are predictive of objective response to erlotinib. In BR.21, EGFR gene copy number is the strongest molecular prognostic marker and the only significant molecular predictor of a differential survival benefit from treatment.

[Table: see text]

Randomized phase II study of maintenance vandetanib (ZD6474) in small cell lung cancer (SCLC) patients who have a complete or partial response to induction therapy: NCIC CTG BR.20

7522

Background: Vandetanib (V) is an inhibitor of vascular endothelial and epidermal growth factor receptors. This trial sought to determine whether maintenance V, given after standard chemotherapy (CT) and radiation (RT), prolonged progression-free survival (PFS) in responding patients with SCLC. Secondary endpoints: overall survival (OS) and toxicity. Methods: Phase II randomized, study of V 300 mg PO daily or placebo (P). Eligibility: complete (CR) or partial response (PR) to platinum-based CT, ECOG PS 0–2 and completion of RT (thoracic or prophylactic cranial). Statistics: 80% power to detect a 2.5 months improvement in median PFS (estimate for P of 4 months) using a 1-sided 10% level test (100 eligible patients; 77 events). Results: Between May 2003 and March 2006, 107 patients were accrued from 17 centres. Median follow up: 13.5 months. 46 had limited disease (LD); 61 extensive disease (ED). There were fewer PS 0 patients (11 vs. 20), and fewer had CR to initial CT (4 vs. 8) in the V arm. V patients were more likely to experience toxicity and require dose modification. The most frequent toxicities leading to dose modifications were gastrointestinal and rash. Clinically asymptomatic QTc prolongation was observed in 8 V patients. 83 of 107 patients developed progressive disease (43 on V; 40 on P). The median PFS for V was 2.7 months (80% C.I.: 1.1 –4.5) and 2.8 months for P (80% C.I.: 1.9 –5.6); estimated hazard ratio (HR) was 1.01 for V vs P (80% C.I.: 0.75 –1.36, 1-sided P-value = 0.51). Median OS for V was 10.6 months vs. 11.9 months for P; HR was 1.43 for V vs. P (80% C.I.: 1.00 –2.05, 1-sided P-value = 0.90). In a planned subgroup analysis, a significant interaction was noted (P-value = 0.01); with LD patients randomized to V having a longer OS (HR: 0.45, 1-sided P-value = 0.07), whereas ED patients randomized to V had a shorter OS compared to P (HR: 2.27, 1-sided P-value = 0.996). Conclusion: V failed to demonstrate efficacy as maintenance therapy for SCLC. Future targeted therapies should probably be explored concurrently with chemotherapy. This study was supported by the Canadian Cancer Society and AstraZeneca.

[Table: see text]

Adjuvant chemotherapy in elderly patients: An analysis of National Cancer Institute of Canada Clinical Trials Group and Intergroup BR.10

7009

Background: Recent trials have shown significant survival benefit from adjuvant chemotherapy after resection of NSCLC. Whether elderly patients tolerate platinum-based adjuvant chemotherapy and derive the same survival advantage is unknown. This retrospective study evaluated the influence of age on survival, chemotherapy delivery and toxicity in NCIC CTG BR.10. Methods: Pretreatment characteristics and survival benefit from treatment were compared for patients ≤65 & >65. Chemotherapy delivery and toxicity were compared for 213 treated patients. Results: There were 327 young and 155 elderly patients. Baseline prognostic factors by age were similar with the exception of histology (adeno 58% young, 43% elderly; squamous 32% young, 49% elderly; p=0.001) and PS (PS 0 53% young, 41% elderly; p=0.01). Overall survival by age showed a trend favoring the young in univariate (HR 0.77, CI 0.58–1.04, p=0.084) and multivariate analyses (HR 0.75, CI 0.56–1.01, p=0.059). Patients >75 years had significantly shorter survival than those aged 66–74 (HR 1.95, CI 1.11–3.41, p=0.02). Overall survival for patients >65 was significantly better with chemotherapy v observation (HR 0.61, CI 0.38–0.98, p=0.04). Chemotherapy administration and toxicity were evaluated in 63 elderly and 150 young patients. Mean dose intensities of vinorelbine (V) and cisplatin (C) were 13.2 and 18.0 in the young and 9.9 and 14.1 in the elderly (V p=0.0004; C p=0.001). The elderly received significantly fewer doses of V (p=0.014) and C (p=0.006). Fewer elderly patients completed treatment and more refused treatment compared to the young (p=0.03). There were no significant differences in toxicities, G-CSF use or hospitalization by age group, except for myalgias and mood alteration (more frequent among the young). Six of 126 deaths (4.8%) in the young were from non-malignant causes v 12 of 71 (16.9%) in the elderly (p=0.008). Conclusions: In spite of receiving less chemotherapy than young patients, adjuvant chemotherapy improves overall survival in patients aged >65 with acceptable toxicity. Adjuvant chemotherapy should not be withheld from elderly patients, although patients >75 years of age require further study.

No significant financial relationships to disclose.

Class III beta tubulin expression and benefit from adjuvant cisplatin/vinorelbine chemotherapy in operable non-small cell lung cancer: Analysis of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) study JBR.10

7051

Background: Biomarkers may be useful to select patients who will benefit from a particular chemotherapy regimen. High class III beta tubulin (bTubIII) expression in advanced NSCLC is known to correlate with reduced response rates and inferior survival with the anti-microtubule agents vinorelbine or paclitaxel. JBR.10 demonstrated a 12% and 15% improvement in 5-year recurrence-free (RFS) and overall survival (OS) respectively with the addition of cisplatin and vinorelbine following resection of stage IB-II NSCLC. We sought to determine the impact of bTubIII on patient outcome and benefit from adjuvant chemotherapy in the JBR.10 trial. Methods: We performed an immunohistochemical assay for bTubIII on primary tumor tissue available from 265 of the 482 patients in JBR.10. A validated, numerical bTubIII score was assigned by two observers based on the intensity and frequency of tumour cell staining. Tumours were classified as bTubIII “low” or “high” based on the median score. We examined the prognostic impact of bTubIII in patients treated with or without chemotherapy, and the survival benefit from chemotherapy in low versus high bTubIII subgroups. Results: High bTubIII expression was associated with poorer RFS (HR = 1.9, p = 0.01) in patients treated with surgery alone, but not in patients treated with adjuvant chemotherapy (HR = 1.1, p = .75). In the low bTubIII subgroup, the improvement in RFS with chemotherapy was non-significant (HR = 0.78, p = 0.4), while the improvement in RFS with chemotherapy was significant in the high bTubIII subgroup (HR = 0.45, p = 0.002). With Cox regression, the interaction between bTubIII status and chemotherapy treatment in predicting RFS did not reach statistical significance (p = 0.15). Results for OS were similar. Conclusions: Chemotherapy appeared to overcome the negative prognostic impact of high bTubIII expression. Greater benefit from adjuvant chemotherapy was seen in patients with high bTubIII expression. This is contrary to what has been seen in the setting of advanced disease; possible reasons for this difference are being explored.

No significant financial relationships to disclose.

Are age and comorbidity independent prognostic factors in the treatment of metastatic NSCLC? A review of prospectively randomized national cancer institute of Canada Clinical Trials Group (NCIC CTG) trials

7117

Background: This study analyzed all patients enrolled in two large prospectively randomized trials of systemic chemotherapy to determine whether age and/or co-morbidity are independent predictors of outcome. Methods: Baseline information was recorded, including ongoing medical problems and current medications. This information was extracted and scored using the validated Charlson co-morbidity scale. Scores were then correlated with other clinical data, which included age, gender, race, performance status, histology, stage, weight, LDH, chemotherapy (type, total dose, dose intensity), response and survival. Results: A total of 1,255 patients (481 in BR10 and 774 in BR18) were included in this analysis, the median age was 61.2 years (range 34.2 to 88.7), 827 were less than 65yrs, and 428 65yrs or older. 391 had other medical conditions besides the primary disease of lung cancer, 310 with a Charlson co-morbidity score of 1, and 81 with a cumulative score of 2 or higher. There were more male patients with co-morbidity (35% vs. 21%, p < 0.0001); fewer patients with histologic subtype of adeno with co-morbidity (26% vs. 35%, p = 0.001); and more older patients with co-morbidity (42% vs. 26%, p < 0.001). There was no difference in overall survival in the elderly (≥65) as compared to the younger patients (<65). In contrast, patients with co-morbidity were associated with a shorter survival (p = 0.01). A cumulative Charlson score of 1 was associated with a hazard ratio of 1.28 (95% CI 1.09–1.5; p =0.003), and a cumulative score of 2+ was associated with a hazard ratio of 1.09 (95% C.I. 0.83 -1.44, p = 0.52). Conclusions: From these two large randomized NCIC CTG trials, one observes that age over 65 is not associated with a worse outcome. However, the presence of co-morbidity does appear to be a negative prognostic factor and co-morbity is more common in older patients.

No significant financial relationships to disclose.

Identifying patients with non-small cell lung cancer (NSCLC) unlikely to benefit from erlotinib: An exploratory analysis of National Cancer of Institute of Canada Clinical Trials Group BR.21

7161

Background: Despite a 9% response rate, BR.21 demonstrated significant survival benefit for patients receiving erlotinib as 2nd/3rd line therapy for NSCLC. We undertook to characterize, by exploratory subset analysis, patients less likely to benefit from erlotinib. To identify factors for consideration, we first identified baseline characteristics associated with early progression by eight wks and early death by 3 mos. Methods: Using stratification factors and potential prognostic factors from BR.21, the Cox regression model with stepwise selection was used to establish a prognostic model to separate erlotinib patients into 4 risk categories based on the 10th, 50th & 90th percentiles of prognostic index scores. 7 variables (smoking history, PS, weight loss, anemia, high LDH, response to prior chemo and time from diagnosis to randomization) were used in the final model. The hypothesis was that the characteristics of the treated patients in the highest risk group would also be predictive of lack of benefit from erlotinib when erlotinib and placebo patients with the same characteristics were compared. Results: Factors associated with PD by 8 wks were: PS2–3 (p = 0.009), weight loss (p = 0.0004), anemia (p = 0.008), PD to prior chemo (p = 0.006), non-Asian (p = 0.047), EGFR IHC-negative (p = 0.005), Factors associated with survival < 3 mos were: PS2–3 (p < 0.0001), weight loss (p < 0.0001), anemia (p < 0.0001), PD to prior chemo (p < 0.0001), non-Asian (p = 0.008), high LDH (p < 0.0001), time to randomization <12 mos (p = 0.0003). Comparison of overall survival for the 4 risk groups derived from prognostic index score as follows: high benefit (HR = 0.41, p = 0.007), 2 intermediate benefit (HR 0.79, p = 0.09; HR 0.80; p = 0.09); no benefit (HR 1.23; p = 0.42). Median survivals for erlotinib (placebo) patients in each group were 17.3 (8.3), 9.7 (7.5), 4.1 (3.7), 1.9 (2.7) mos. Conclusions: By establishing a prognostic model, we identified a small group of patients who are unlikely to benefit from 2nd/3rd line erlotinib therapy. This model requires prospective validation to confirm that it is both prognostic and predictive of outcome from treatment.

[Table: see text]

An analysis of the prognostic and predictive importance of K-ras mutation status in the National Cancer Institute of Canada Clinical Trials Group BR.21 study of erlotinib versus placebo in the treatment of non-small cell lung cancer

7005

Background: BR.21 demonstrated a significant survival benefit for patients with advanced non-small cell lung cancer (NSCLC) who received erlotinib vs. placebo (hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.58–0.85, p<0.001). Tyrosine kinase (TK) domain mutations and high EGFR gene copy number by fluorescent in situ hybridization (FISH) have been associated with significantly higher response rates to erlotinib, while high gene copy number is a better predictor of survival benefit than mutations. K-ras mutation has been associated with non-responsiveness to EGFR TK inhibitors and poorer outcome for patients treated with erlotinib and chemotherapy. The survival impact of K-ras mutation on single agent erlotinib therapy in NSCLC patients remains unknown. Methods: 731 patients were randomized to BR.21 (488 erlotinib, 243 placebo). K-ras mutation analysis was conducted by sequencing in 246 patient samples. Results: K-ras analysis was successful in 206 patients; 30 (14.6%) demonstrated oncogenic mis-sense mutations on codon 12 or 13 (22 on the erlotinib arm and 8 on the placebo arm). For all 206 patients with known K-ras genotype, the HR for erlotinib was 0.77 (95% CI 0.57–1.06, p=0.06). For the 176 K-ras wild type patients, the univariate HR for erlotinib was 0.69 (95% CI 0.49–0.97, p=0.03). In contrast, the HR for the thirty K-ras mutant patients was 1.67 (95% CI 0.62–4.5, p=0.31), with an interaction p value of 0.09. Overall response rates were 5% (1/20) in K-ras mutant patients, and 10.2% (10/98) in K-ras wild type patients. In patients with K-ras genotype known, the multivariate Cox regression model showed that K-ras mutation was significantly associated with shorter survival (HR 1.63, 95% CI 1.06–2.51, p=0.03). Conclusion: In BR.21, patients with K-ras mutation do not appear to derive any survival benefit from erlotinib therapy. However, the numbers of patients are small and results need to be confirmed in other studies. (Supported by the Canadian Cancer Society, Ontario Cancer Research Network, the Jacqueline Seroussi Memorial Foundation for Cancer Research and OSI Pharmaceuticals).

[Table: see text]

Reducing the expression of glutathione transferase D mRNA in Drosophila melanogaster exposed to phenol and aniline

Phenol and aniline are toxic to animals. The purpose of the present study was to examine the expression of glutathione transferase D mRNA in fruit flies altered by long-term exposure to phenol and aniline. Changes in the amount of mRNA were measured by a semiquantitative reverse-transcription polymerase chain reaction assay. The level of each glutathione transferase D mRNA expressed in the phenol-treated and aniline-treated strains of adult fruit flies differed after chemical treatment. Aniline was more potent than phenol in suppressing the expression of cytosolic glutathione transferase D mRNA. Aniline reduced the level of glutathione transferase mRNA expressed in the aniline-treated strain to less than a 0.5 fraction as compared to that measured in the wild-type strain. But phenol was only able to suppress the GstD7 and GstD4 mRNAs expressed in the phenol-treated strain. Neither aniline nor phenol reduced the expression of microsomal glutathione transferase mRNA in fruit flies.

Gemcitabine, dexamethasone and cisplatin is an active and non-toxic chemotherapy regimen in relapsed or refractory Hodgkin's disease: a phase II study by the National Cancer Institute of Canada Clinical Trials Group

BACKGROUND

Gemcitabine (difluorodeoxycytidine) is active as a single agent in Hodgkin's disease and has been used successfully in combination with cisplatin to treat a variety of solid tumors.

PATIENTS AND METHODS

We evaluated the combination of gemcitabine/dexamethasone/cisplatin (GDP) as salvage chemotherapy in 23 patients with relapsed or refractory Hodgkin's disease (median age 36 years, range 19-57). Treatment consisted of gemcitabine 1000 mg/m(2) intravenously on days 1 and 8, dexamethasone 40 mg orally days 1-4 and cisplatin 75 mg/m(2) on day 1, every 21 days as an outpatient. Response was assessed following two cycles of treatment.

RESULTS

There were four complete responses and 12 partial responses for a response rate of 69.5% (95% confidence interval 52% to 87%); the remaining seven patients had stable disease and no patient progressed on treatment. All patients had successful stem cell mobilization and underwent transplantation with a median 10.6 x 10(6) CD34+ cells/kg. Hematological toxicity from GDP was mild (grade 3 neutropenia 8.6%, grade 3 thrombocytopenia 13%).

CONCLUSIONS

In summary, GDP is an active regimen for patients with relapsed or refractory Hodgkin's disease. The response rate is similar to the rates of other current salvage regimens, it can be given to outpatients with tolerable toxicity and it does not inhibit the mobilization of autologous stem cells.

Randomized, double-blind, controlled trial of mitoxantrone/prednisone and clodronate versus mitoxantrone/prednisone and placebo in patients with hormone-refractory prostate cancer and pain

PURPOSE

To compare the incidence of palliative response in patients with hormone-resistant prostate cancer (HRPC) treated with mitoxantrone and prednisone (MP) plus clodronate with that of patients treated with MP plus placebo.

MATERIALS AND METHODS

Men with HRPC, bone metastases, and bone pain were randomly assigned to receive clodronate 1,500 mg administered intravenously (IV) or placebo every 3 weeks, in combination with mitoxantrone 12 mg/m2 IV every 3 weeks and prednisone 5 mg orally bid. Patients completed the present pain intensity (PPI) index and Prostate Cancer-Specific Quality-of-Life Instrument at each treatment visit and used a diary to record analgesic use on a daily basis. The primary end point was a reduction to zero or of two points in the PPI or a decrease of 50% in analgesic intake, without increase in either.

RESULTS

The study accrued 209 eligible patients over 44 months. One hundred sixty patients (77%) had mild PPI scores (1 or 2), and 49 (24%) had moderate PPI scores (3 or 4). The primary end point of palliative response was achieved in 46 (46%) of 104 patients on the clodronate arm and in 41 (39%) of 105 patients on the placebo arm (P =.54). The median duration of response, symptomatic disease progression-free survival, overall survival, and overall quality of life were similar between the arms. Subgroup analysis suggested possible benefit in patients with more severe pain.

CONCLUSION

MP provides useful palliation in symptomatic men with HRPC. Clodronate does not increase the rate of palliative response or overall quality of life. Clodronate may be beneficial to patients who have moderate pain, but this requires further confirmation.