Predictors of outcome and treatment decisions of older patients with stage III non-small cell lung cancer

19574

Background: In treating Stage III non-small cell lung cancer in the elderly, oncologists often empirically adjust treatment without clear guidelines. Identifying patient characteristics that impact prognosis will aid in creating better treatment algorithms in this patient population. Methods: A retrospective analysis was done on older patients (age > 70) treated for Stage III NSCLC (excluding “wet” IIIB) at the H. Lee Moffitt Cancer. Cox multivariate analysis identified variables impacting progression free survival, overall survival, treatment chosen, treatment interruptions, and hospitalizations. Correlation and regression tree analysis (CART) was performed to create potential decision making models. Results: 213 patients were evaluable. Multivariate analysis identified ECOG performance status (hazard ratio = 1.52, p = 0.005) and nodal status (HR = 1.36, p = 0.001) as negatively associated with PFS while BMI (HR = 0.96, p = 0.02) was positively associated. ECOG performance status (HR = 2.26, p < 0.0001), nodal status (HR = 1.18, p = 0.08), and CIRS3 (having a comorbidity classified as severity 3; HR = 1.33, p = 0.02) were negatively associated with OS. BMI (HR = 0.95, p = 0.002) and CIRSmean (mean CIRS-G severity score; HR 0.61, p = 0.01) were positively associated with OS. These variables were also identified as the most significant splitters, along with smoking status and pulmonary function, in CART analyses. Trees using PFS and OS as outcomes were created with receiver operating curves (ROC) ranging from 0.64–0.75. A CART analysis targeting treatment modality chosen had ROCs ranging from 0.49–0.78. Conclusions: Our multivariate analysis found ECOG performance status, nodal status, and severe medical comorbidity as negatively associated with survival. Unexpectedly, BMI (at initial treatment), independent of weight loss, was found to be positively associated. Also, the splitter variables identified by CART analysis were very similar to the general multivariate model, but the weights differed in the various analyses and subgroups of patients. The CART analyses suggest that we can create decision making models with a range of applicability comparable to those commonly considered useful for clinical guidelines, i.e. about 60% of straightforward application.

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.

Health-related quality of life in older people using benzodiazepines: a cross-sectional study

Aim of this study is to investigate the QoL older people making regular use of BDZ. All subjects aged 65-84 years attending their General Practitioners were invited to fill in a questionnaire about their consumption of BDZ and all the subjects consuming BDZ to fill in the Medical Outcome Measures Short Form-36 (MOS SF-36) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaires. A total of 2,246 subjects used BDZ and 1,109 (49.4%) of them filled in the MOS SF-36 questionnaire. 1,005 of these participants also completed the PRIME-MD questionnaire (90.6%). The presence of sleep disorders and the characteristics of the BDZ used were not associated with any score in the MOS SF-36 questionnaire, whereas the Prime diagnosis was the most important predictor, since subjects with depression and/or anxiety had a lower mean score on each scale than subjects without disorders. Among a sample of Italian seniors taking BDZ, QoL was associated with the presence of anxiety and/or depression. Age, gender, education and the presence of cardiovascular diseases or stroke were associated with specific aspects of QoL, when anxiety and depression were controlled for.

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.

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.

Hyper-Raman scattering from vitreous boron oxide: coherent enhancement of the boson peak

Hyper-Raman scattering spectra of vitreous B(2)O(3) are compared to Raman scattering ones. Particular attention is given to the low-frequency boson peak which relates to out-of-plane rigid librations of planar structural units, mostly boroxols. While the Raman strength can be accounted for by the motions of single units, the hyper-Raman signal exhibits a unequaled enhancement due to coherent librations of several boroxols. This important distinction is explained by the different symmetry properties of the polarizability and hyperpolarizability tensors of the structural units.

[MRI of arthritis with the USPIO SH U 555 C: optimization of T1 enhancement]

PURPOSE

To optimize contrast agent dose and pulse sequence parameters in order to achieve a maximal T1 enhancement in arthritic knee joints with ultra small superparamagnetic iron oxides (USPIO)-enhanced MRI.

MATERIALS AND METHODS

Antigen-mediated arthritis was induced in the right knee of nine Sprague Dawley rats. The arthritic knee joint as well as the contralateral normal knee were investigated in a 2 Tesla MR scanner before as well as in short intervals up to 2 h after USPIO injection, using T1-weighted gradient echo (GE) sequences. Three rats each received intravenous injections of the new USPIO SHU 555 C (SH U 555 C, Schering AG, Berlin) at doses of 40, 100 and 200 micromol Fe/kg. Pulse sequence parameters of the GE-sequence were optimized by varying flip angles (alpha) and echo times (TE). Changes in signal intensities (SI) of the arthritic knee and contralateral normal knee were quantified as DeltaSI (%) = /([SIpost - SIpre] / SIpre) x 100 %/ and compared with histopathology.

RESULTS

Histology of the arthritic knees demonstrated a marked inflammatory proliferation of the synovium. The USPIO SH U 555 C caused a significant increase in signal intensity of the arthritic joints on T1-weighted MR images (p < 0.05). This effect was optimized using a flip angle of 60-70 degrees, a minimal TE and a dose of 200 micromol Fe/kg. Visually the contralateral normal knee did not show any USPIO enhancement.

CONCLUSION

Inflammation can be depicted with marked T1 enhancement by the USPIO SH U 555 C using high contrast agent doses and optimized MR pulse sequence parameters.

Clinical Depression and Risk of Out-of-Hospital Cardiac Arrest

BACKGROUND

The association of depression with coronary heart disease-related mortality has been widely recognized. This finding may partly reflect an association between depression and sudden death, in part because the imbalance between sympathetic and parasympathetic tone is altered in depressed subjects. We, thus, investigated whether the presence and severity of clinical depression was associated with a higher risk of sudden cardiac death.

METHODS

We used data from a population-based case-control study of risk factors for incident out-of-hospital cardiac arrest (CA) conducted among enrollees of a health maintenance organization in western Washington State. Cases (n = 2228) were aged 40 to 79 years and experienced CA between January 1, 1980, and December 31, 1994. Controls (n = 4164) were a stratified random sample of enrollees defined by calendar year, age, sex, and prior heart disease. Clinical depression was defined as physician diagnosis of depression or use of antidepressant treatment within the year before the event. Referral to mental health clinics or hospitalization for depression defined severe depression.

RESULTS

Clinically depressed patients had a higher odds ratio (OR) of CA (1.88; 95% confidence interval [CI], 1.59-2.23), which persisted after adjustment for confounders (OR, 1.43; 95% CI, 1.18-1.73). The association was observed in both sexes, in various age groups, and in subjects with prior physician-diagnosed heart disease (OR, 1.27; 95% CI, 1.01-1.60) and without prior physician-diagnosed heart disease (OR, 1.71; 95% CI, 1.22-2.41) (P = .13 for the interaction). Compared with nondepressed subjects, the risk of CA was increased in less severely depressed subjects (OR, 1.30; 95% CI, 1.04-1.63) and further increased in severely depressed subjects (OR, 1.77; 95% CI, 1.28-2.45) (P<.001 for trend).

CONCLUSION

Clinical depression may be associated with a higher risk of CA independently of established coronary heart disease risk factors.

Detection of hepatocellular carcinoma: comparison of Gd-DTPA- and ferumoxides-enhanced MR imaging

The aim was to compare the diagnostic performance of dynamic Gd-DTPA- and ferumoxides-enhanced MRI for hepatocellular carcinoma (HCC). Twenty-five patients with chronic hepatitis or liver cirrhosis underwent both dynamic gadopentetate- and ferumoxides-enhanced MRI studies of the liver for HCC detection on the same day. MR data of both studies were retrospectively and independently analyzed. Two observers determined in consensus the grade of diffuse fibrotic liver changes (mild, moderate or severe) and the number of focal lesions. HCCs were confirmed by histology (n=22) and/or follow-up studies for at least six months (n=64). Differences in results obtained from both MR data sets were tested for significance with the McNemar's test (p<0.05). Ferumoxides-enhanced MR images detected 84 of 99 hepatic lesions, including 82 of 86 HCCs and 2 false positive, nonmalignant lesions, while Gd-DTPA-enhanced MR images detected 92 of 99 hepatic lesions, including 81 of 86 HCCs and 11 false positive, nonmalignant lesions. Sensitivity of MRI for detection of HCCs was not significantly different between ferumoxides-enhanced (95.3%; p>0.05) and Gd-DTPA-enhanced scans (94.2%). Gd-DTPA- and ferumoxides-enhanced MRI perform equally well for HCC detection. The majority of small hypervascular hepatic lesions, detected on dynamic Gd-DTPA-enhanced MRI but not on ferumoxides-enhanced MRI, represent no HCCs.