Erlotinib for the treatment of relapsed non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of erlotinib for the treatment of relapsed non-small cell lung cancer (NSCLC), according to its licensed indication, based upon the evidence submission from Roche Products to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence includes one randomised controlled trial (RCT) (BR21) investigating the effect of erlotinib versus placebo, which demonstrates that erlotinib significantly increases median overall survival, progression-free survival and response rate compared with placebo. The majority of patients in the trial experienced non-haematological drug-related adverse effects. Currently there are no trials that directly compare erlotinib with any other second-line chemotherapy agent. For the purposes of indirect comparison, the manufacturer’s submission provides a narrative discussion of data from 11 RCTs investigating the use of docetaxel. From these data the manufacturer concludes that erlotinib has similar clinical efficacy levels to docetaxel but results in fewer serious haematological adverse events; however, it is difficult to compare the results of BR21 with those of the docetaxel trials or with current UK clinical practice because, for example, the BR21 patient population is younger than that expected to present in UK clinical practice and almost half of the BR21 participants received erlotinib as third-line chemotherapy, with third-line chemotherapy being rare in the UK. The manufacturer’s submission included a three-state model comparing erlotinib with docetaxel, reporting an incremental cost-effectiveness ratio (ICER) of –£1764 per quality-adjusted life-year (QALY) gained for erlotinib compared with docetaxel. Rerunning the manufacturer’s economic model with varied parameters and assumptions increases the ICER to in excess of £52,000 per QALY gained. There is still a large amount of unquantifiable uncertainty in the model and it is unlikely that erlotinib could be considered to be cost-effective compared with docetaxel at a willingness to pay of £30,000 and there may even be the potential for docetaxel to dominate erlotinib. Because of the limitations of the indirect analysis undertaken by the manufacturer and the subsequent economic modelling exercise there is a need for a head-to-head trial comparing erlotinib with docetaxel. The guidance issued by NICE in February 2007 as a result of the STA states that erlotinib is not recommended for the treatment of locally advanced or metastatic NSCLC.

A phase II trial of first-line bevacizumab in combination with pemetrexed and carboplatin in advanced nonsquamous non-small cell lung cancer (NSCLC)

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Background: Combining bevacizumab (Bev) with platinum doublet yields a survival benefit in previously untreated patients with advanced nonsquamous non-small cell lung cancer. Carboplatin with pemetrexed is an efficient combination that is potentially less toxic. This phase II trial evaluates the efficacy and the safety of adding bevacizumab to carboplatin and pemetrexed in advanced non-small cell lung cancer. Methods: This is a single arm, open-label phase II trial. Eligibility stipulated enrollment of patients with stage IIIB/IV non-squamous non-small cell lung cancer with an ECOG PS 0–1 and no other contraindications to Bev. Treatment consisted of pemetrexed 500 mg/m2, carbo AUC 6 and Bev 15mg/kg on day 1, repeated every 3 weeks. If clinical benefit was proven, patients received Bev maintenance until progression. The response was evaluated every two cycles. The primary endpoint was time to progression (TTP); secondary endpoints included overall survival, response rate (RR) and grade 3–4 toxicities. Results: As of September 2008, 27 out of 42 projected patients were enrolled of which, 14 were males and 13 females; median age 68 (72% older than 60); IIIB/IV 5/22; median number of cycles 9 (range 2–33). At the time of analysis, 25 patients were evaluable. Preliminary results show a median time to progression of 7.25 months (95% CI, 6.4 to 8.2). 23 patients (92%) had disease control (95%, CI 82–96%) with an overall response rate of 36% (95%, CI 25–47%).14 patients had stable disease (56%), 8 had partial response (32%) and one achieved a complete response (4 %). Median survival has not yet been reached. Grade 3/4 adverse events include: Cerebral ischemic event (N=1), Anorexia (Gr 3: N= 5/ Gr 4: N= 4), gastrointestinal fistula (N=1), hypertension (Gr3: N=3), epistaxis (Gr 3 N=1), vomiting (Gr 3; N= 3), fever (Gr 4: N=1) and neuropathy (Gr 3: N=2). Conclusion: The addition of bevacizumab to carboplatin and pemetrexed appears to be an active first line treatment with a high disease control rate and an acceptable toxicity profile in the setting of advanced non-small cell lung cancer.

No significant financial relationships to disclose.

Clinical outcomes of elective nodal irradiation (ENI) compared with involved field radiotherapy (IFRT) in NSCLC

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Background: Local failure rates in patients treated with definitive radiotherapy for non-small cell lung cancer (NSCLC) remain high. IFRT allows higher radiation doses to the primary tumor with the goal of reducing local failure rates while minimizing toxicity. This approach, however, raises concern for increased nodal failures. Our retrospective analysis evaluates clinical outcomes of patients treated at our institution with ENI or IFRT. Methods: We assessed all patients (pts) with stage III locally advanced or stage IV oligometastatic NSCLC treated with definitive radiotherapy (RT) from January 1, 2003 to August 21, 2008. The decision to treat with ENI vs. IFRT was based on physician treatment philosophy. We compared baseline demographics in each group as well as toxicities and therapeutic outcomes. Involved nodal failures (INF) were defined as radiographic progression in lymph nodes that were initially involved at the time of treatment. Elective nodal failures (ENF) were defined as progression in initially uninvolved lymph nodes. Results: A total of 104 consecutive pts (56 ENI vs. 48 IFRT) were assessed. Pts in both groups had similar characteristics with respect to age, baseline KPS, and percentage receiving chemotherapy. The average RT dose was 6,345 cGy in the ENI group and 6988 cGy in the IFRT group. The median follow-up time was 8.4 mos (0.3–43.4) for all pts and 9.7 mos (1.5–40.1) for survivors. The results follow in the table below. Conclusions: Our data suggest that IFRT does not result in increased nodal failures or decreased survival compared to ENI, and may result in increased local control. The majority of patients who experienced a local failure also experienced nodal failure, suggesting that local relapse may be linked to subsequent nodal failure. This may explain the increased nodal failure rates in patients treated with ENI. Decreased esophagitis rates in patients treated with IFRT may allow the integration of concurrent, full dose systemic therapy in a greater proportion of patients, as well as higher RT doses.

[Table: see text]

No significant financial relationships to disclose.

Reading and communication skills after universal newborn screening for permanent childhood hearing impairment

BACKGROUND

Birth in periods with universal newborn screening (UNS) for permanent childhood hearing impairment (PCHI) and early confirmation of PCHI have been associated with superior subsequent language ability in children with PCHI. However their effects on reading and communication skills have not been addressed in a population-based study.

METHODS

In a follow-up study of a large birth cohort in southern England, we measured reading by direct assessment and communication skills by parent report in 120 children with bilateral moderate, severe or profound PCHI aged 5.4-11.7 years, of whom 61 had been born in periods with UNS, and in a comparison group of 63 children with normal hearing.

RESULTS

Compared with birth during periods without UNS, birth during periods with UNS was associated with better reading scores (inter-group difference 0.39 SDs, 95% CI 0.02 to 0.76, p = 0.042) and communication skills scores (difference 0.51 SDs, 95% CI 0.06 to 0.95, p = 0.026). Compared with later confirmation, confirmation of PCHI by age 9 months was also associated with better reading (difference 0.51 SDs, 95% CI 0.15 to 0.87, p = 0.006) and communication skills (difference 0.56 SDs, 95% CI 0.12 to 1.00, p = 0.013). In the children with PCHI, reading, communication and language ability were highly correlated (r = 0.62-0.84, p<0.001).

CONCLUSION

Birth during periods with UNS and early confirmation of PCHI predict better reading and communication abilities at primary school age. These benefits represent functional gains of sufficient magnitude to be important in children with PCHI.

Trends in multidrug-resistant tuberculosis in Scotland, 2000-7

Overall numbers of multidrug-resistant (MDR) tuberculosis (TB) rose sharply in the United Kingdom and Scotland in 2007. Risk factors associated with MDR TB in the United Kingdom have been identified but there has been no previous report on risk factors associated with MDR TB in Scotland. Enhanced Surveillance of Mycobacterial Infections (ESMI) data were used to examine demographic and clinical characteristics and treatment outcome of MDR TB cases notified in Scotland between 2000-7. There was a total of 11 culture-positive cases of MDR TB, five of which were notified in 2007. The majority of patients were female, 15-44 years old and unemployed. All were born outside the United Kingdom and most had arrived within the past year from or frequently travelled to their home countries in China, the Indian subcontinent or Africa. Except for one individual, our patients did not self report a history of previous diagnosis of TB which was previously identified as a risk factor for MDR TB in the United Kingdom. Only three patients received directly observed treatment (DOT). Only two patients had completed treatment at 12 months, partially due to the inadequate length of follow-up under the current ESMI system. Our results suggest that most patients had primary resistance due to transmission of MDR TB in high incidence countries and thus point to the importance of international efforts to control MDR TB in these countries. In Scotland, national efforts should be made to increase the number of MDR TB patients receiving DOT and to extend follow-up to improve monitoring of treatment outcome. It is important to identify high risk groups for MDR TB infection in order to deliver effective community-based disease control measures.

Trends in multidrug-resistant tuberculosis in Scotland, 2000-7

Overall numbers of multidrug-resistant (MDR) tuberculosis (TB) rose sharply in the United Kingdom and Scotland in 2007. Risk factors associated with MDR TB in the United Kingdom have been identified but there has been no previous report on risk factors associated with MDR TB in Scotland. Enhanced Surveillance of Mycobacterial Infections (ESMI) data were used to examine demographic and clinical characteristics and treatment outcome of MDR TB cases notified in Scotland between 2000-7. There was a total of 11 culture-positive cases of MDR TB, five of which were notified in 2007. The majority of patients were female, 15-44 years old and unemployed. All were born outside the United Kingdom and most had arrived within the past year from or frequently travelled to their home countries in China, the Indian subcontinent or Africa. Except for one individual, our patients did not self report a history of previous diagnosis of TB which was previously identified as a risk factor for MDR TB in the United Kingdom. Only three patients received directly observed treatment (DOT). Only two patients had completed treatment at 12 months, partially due to the inadequate length of follow-up under the current ESMI system. Our results suggest that most patients had primary resistance due to transmission of MDR TB in high incidence countries and thus point to the importance of international efforts to control MDR TB in these countries. In Scotland, national efforts should be made to increase the number of MDR TB patients receiving DOT and to extend follow-up to improve monitoring of treatment outcome. It is important to identify high risk groups for MDR TB infection in order to deliver effective community-based disease control measures.

Tract-based spatial statistics of diffusion tensor imaging in adults with dyslexia

BACKGROUND AND PURPOSE

Diffusion tensor imaging is a tool that can be used to study white matter microstructure in dyslexia. We tested the hypothesis that dyslexics have a white matter structural change (as measured by directional diffusion of water, which can be affected by disruption in white matter tracts) between brain regions that previous functional connectivity studies showed were associated with phonologic processing.

MATERIALS AND METHODS

Diffusion tensor imaging (DTI) scans were acquired from 7 healthy adult normal readers and from 14 adults with dyslexia on a 1.5T scanner. Voxelwise statistical analysis of the fractional anisotropy data were carried out by using Tract-Based Spatial Statistics to compare dyslexic subjects versus control subjects in white matter tracts.

RESULTS

Significant group difference map clusters (comparing adults with and without dyslexia) occurred in specific bilateral white matter tracts within the frontal lobe, temporal lobe, occipital lobe, and parietal lobe.

CONCLUSION

The DTI fractional anisotropy results in the bilateral white matter showing higher fractional anisotropy in adult control subjects compared with adults with dyslexia (relating to white matter fiber tract integrity) are consistent with our previous functional connectivity results from seed points in the bilateral inferior frontal gyrus.

Temperament: a consideration of concepts and methods

This paper discusses conceptual issues and begins with a consideration of definitions of temperament. It is suggested that the purposes for which temperament has been studied have, to some degree, dictated methods used and inferences drawn. Those psychopathologists interested in the relationship between temperament and psychiatric disorder, or emotional and behavioural disturbance, have tended to use different methods from those more concerned with delineating the structure of personality. Some issues and problems are common to both approaches, e.g. the definition of behaviour reflecting temperament in terms of style rather than content. Other issues, such as the difficulty involved in drawing a clear distinction between temperamental attributes and mental disorders, are restricted to one approach. The relative contribution of gentic and environmental effects is of interest to both psychopathologists (who wish to examine this issue in relation to the development of the individual), and to psychologists (who are usually more concerned with populations or aggregate effects). The application of biometric genetic models might clarify this issue, and various suggestions are made regarding steps that need to be taken if such models are to be successfully applied.

Toxicity and persistence of sodium fluoroacetate (1080) in the land crab (Gecarcinus lagostoma) on Ascension Island

An eradication program for introduced feral cats, using sodium fluoroacetate (1080) bait, was planned on Ascension Island to help breeding seabird populations to recover. We investigated the likelihood of mortality and the occurrence of residual 1080 in the ‘non-target’ Ascension land crab (Gecarcinus lagostoma) through simulating ‘realistic’ and ‘worst case’ exposure to 1080 bait. Crabs feeding on 1080 baits ingested an estimated maximum of 9–56 mg 1080 (kg bodyweight)–1 and although two of 32 treatment crabs died, this mortality was not attributed to 1080 poisoning but to other, unknown, causes. Our results suggest that G. lagostoma has relatively low susceptibility to acute toxic effects of 1080. Most residual 1080 was eliminated rapidly from crab tissue, with concentrations of 0.006–0.070 mg (kg bodyweight)–1 measured in crab claw/leg tissue 9–11 days after exposure. Concentrations of 0.200 and 0.650 mg (kg bodyweight)–1 were measured in the claw tissue of two crabs that died from other causes on the third day of exposure to 1080, indicating potential for secondary exposure of sensitive scavengers or predators of 1080-exposed crabs. We recommend a moratorium on human consumption of all crabmeat for a withholding period following the eradication program. The withdrawal period should be defined by further research on the longevity of 1080 in crab tissues, and be confirmed by monitoring of residues in crabs after baiting.

Phase II trial of bevacizumab plus pemetrexed and carboplatin in previously untreated advanced nonsquamous non-small cell lung cancer

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Background: A randomized phase III trial has demonstrated the efficacy and safety of high dose bevacizumab (15 mg/kg) with carboplatin and paclitaxel in previously untreated advanced nonsquamous NSCLC (Sandler et al, NEJM 2006). Pemetrexed has also shown significant activity in advanced NSCLC. Clinical investigation of combination bevacizumab (BEV), pemetrexed (PEM) and carboplatin (CARBO) is therefore of interest in this population. Methods: Phase II, open label study in stage IIIB/IV NSCLC: eligible patients have non- squamous histology and no prior chemotherapy, brain metastasis, gross hemoptysis, tumor proximity to major vessels, uncontrolled hypertension or anticoagulation. All patients receive PEM (500 mg/m2), CARBO (AUC 6) and BEV (15 mg/kg) every 21 days. Patients are pretreated with vitamin B12 1,000 mcg every 9 weeks and folic acid 1 mg daily. Responses are assessed every 2 cycles. Patients with CR, PR or SD receive maximum of 6 cycles followed by BEV (15 mg/kg) maintenance. Our primary objective is to determine time to progression and secondary objectives include response rate, overall survival, and safety of the combination. Results: 14 patients (9 female/ 5 male; median age 62 years; range 34–77; 2 stage IIIB/12 stage IV, all ECOG PS 0 or 1) have been entered. Median number of cycles received is 5.5 (range 2 - 15). 12 patients are evaluable for response. 9 patients continued to have disease control at a median duration of 20.2 weeks (range 5–52) with 6 PRs and 3 SDs (response rate 60%; disease control rate 75%). 5 patients proceeded to BEV maintenance with 2 still ongoing. Overall survival data is immature to date. Toxicity data is available for all patients. Grade 3/4 toxicities have included neutropenia (4), nausea/vomiting (2), BEV related allergic reaction (1) and epistaxis (1). Conclusions: Combination BEV, PEM and CARBO is safe, well tolerated and shows promising activity to date. The regimen is not associated with alopecia, neuropathy or arthralgias/myalgias, and is conveniently administered. Enrollment continues and updated results will be presented.

No significant financial relationships to disclose.

The occurrence of congenital heart defects in an inbred herd of pigs in Australia

OBJECTIVE

To report on the first case of congenital heart defects in pigs in Australia.

DESIGN

Retrospective analysis of case records from an inbred herd of "Westran" pigs at the University of Sydney, between January 2001 and December 2004. Detailed gross and histological examination of 15 hearts from pigs that had died or were euthanased in 2004.

CASE DETAILS

The necropsy records from a population of 471 pigs that had died (106 pigs) or were euthanased for research purposes (365 pigs) were analysed and the incidence of heart defects recorded, together with basic demographic data. No attempts were made to diagnose the condition in live pigs.

RESULTS

Congenital heart defects were diagnosed in 6.4% of pigs but this is likely to be an underestimate of the incidence of the deformity. Eighteen pigs died on the farm as a result of the defect, and 12 pigs were diagnosed with the defect as an incidental finding. The most common abnormality seen at necropsy was a sac-like dilatation on the right lateral surface of the right atrium. This was associated with secondary deformity and hypoplasia of the adjacent left ventricle, interventricular region and part of the right ventricle. All hearts showed atrial septal defects of varying size.

CONCLUSION

This is the first reported case of congenital heart defects in pigs in Australia, and one of less than five reported cases of atrial septal defects in pigs in the world. The authors conclude that there may be an element of genetic predisposition to the malformation, since it has only been reported in this inbred line of pigs.

Attention deficit hyperactivity disorder with reading disabilities: preliminary genetic findings on the involvement of the ADRA2A gene

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) and reading disability (RD) tend to co-occur and quantitative genetic studies have shown this to arise primarily through shared genetic influences. However, molecular genetic studies have shown different genes to be associated with each of these conditions. Neurobiological studies have implicated noradrenergic function in the aetiology of ADHD that is comorbid with RD. This paper examines the neurobiological evidence and presents preliminary testing of the hypothesis that the ADRA2A receptor gene is contributing to ADHD and comorbid RD.

METHODS

One hundred and fifty-two children (140 boys, 12 girls) of British Caucasian origin, aged between 6 and 13 years and with a diagnosis of ADHD, were recruited. The children's reading ability was tested. Children were identified as having ADHD or ADHD plus RD (n=82). DNA was available for 110 parent child trios and 42 parent child duos. Genotyping was undertaken for an ADRA2A polymorphism.

RESULTS

For those with ADHD plus RD there was evidence of association with the alpha 2A adrenergic receptor (ADRA2A) polymorphism with the G allele being preferentially transmitted.

CONCLUSIONS

The preliminary evidence together with other neurobiological research findings suggests that the ADRA2A gene may contribute to comorbid ADHD and RD and needs to be properly examined.

Randomized trial of effects of estradiol in combination with either norethisterone acetate or trimegestone on lipids and lipoproteins in postmenopausal women

OBJECTIVE

This double-blind, randomized, multicenter study was designed to compare the blood lipid profiles in postmenopausal women after treatment with either a combined formulation containing estradiol (2 mg) and trimegestone (TMG 0.25 or 0.5 mg) or a standard hormone therapy (HT) containing estradiol and norethisterone acetate.

METHOD

The serum concentrations of several lipids and lipoproteins were measured in this study, which was conducted over 13 cycles, each of 28 days. A total of 487 subjects were included, 349 of whom completed the study.

RESULTS

The circulating concentrations of high density lipoprotein (HDL) cholesterol, HDL2 cholesterol and apolipoprotein (apo) AI increased from baseline in both estradiol/trimegestone groups, whilst levels of HDL3 cholesterol were unchanged. In contrast, in the estradiol/norethisterone acetate group, HDL cholesterol, HDL3 cholesterol and apo AI concentrations were reduced from baseline, while HDL2 cholesterol remained unchanged. Total cholesterol, low density lipoprotein (LDL) cholesterol, lipoprotein(a) and apo-B concentrations were reduced in all treatment groups. The concentration of triglycerides was elevated after treatment with the estradiol/trimegestone combinations but was unchanged after treatment with the estradiol/norethisterone acetate combination. The differences in the lipid pattern between the groups may be explained by the different pharmacological properties of the two progestogens: norethisterone exerts an androgenic effect and opposes the estrogen-induced increase in HDL cholesterol, whilst trimegestone has no androgenic effect and does not oppose the estrogenic effect.

CONCLUSION

Overall, the results of this study suggest that the use of trimegestone in combination with estradiol may be preferable to norethisterone acetate because of the more favorable HDL and apo AI profile.

Mothers' expressed emotion towards children with and without intellectual disabilities

OBJECTIVES

To identify factors associated with maternal expressed emotion (EE) towards their child with intellectual disability (ID).

DESIGN AND METHOD

A total of 33 mothers who had a child with ID and at least one child without disabilities between the ages of 4 and 14 years participated in the study. Mothers completed self-assessment questionnaires which addressed their sense of parenting competence, beliefs about child-rearing practices, and their reports of behavioural and emotional problems of their child with ID. Telephone interviews were conducted to assess maternal EE towards the child with ID and towards a sibling using the Five Minute Speech Sample (FMSS; Magana et al. 1986), and also to assess the adaptive behaviour of the child with ID using the Vineland Adaptive Behaviour Scale (VABS; Sparrow et al. 1984).

RESULTS

Mothers with high EE towards their child with ID were more satisfied with their parenting ability, and their children had more behaviour problems. Analysis of differential maternal parenting, through comparisons of EE towards their two children, showed that mothers were more negative towards their child with ID for all domains of the FMSS except dissatisfaction.

CONCLUSIONS

A small number of factors associated with maternal EE towards children with ID were identified. Differences in maternal EE towards their child with ID and their other child suggest that EE is child-driven rather than a general maternal characteristic. Implications of the data for future research are discussed.

Outbreak of chickenpox in a Scottish prison

An outbreak of chickenpox occurred in a Scottish prison in April 2003. Three clinical cases (one virologically confirmed) were identified, two prisoners and one staff member. All were male and aged between 30 and 45 years. A further six possible cases were identified. The source of the outbreak was likely to have been a prisoner's child who visited the prison with a chickenpox rash. The outbreak was point source in nature, and no secondary spread of infection occurred within the prison despite the crowded conditions, possibly reflecting high levels of natural immunity. The outbreak serves as a reminder of the prison environment and the vulnerability of the prison population to infectious disease, both because of the prison environment and the clinical characteristics of the prison population.