A phase II trial of gemcitabine in patients with 5-FU-refractory pancreas cancer

Gemcitabine combined with docetaxel for the treatment of unresectable pancreatic carcinoma

PURPOSE

To assess the efficacy and toxicity of combination therapy with gemcitabine and docetaxel in patients with unresectable pancreatic carcinoma.

PATIENTS AND METHODS

Thirty-four patients with unresectable stage III, IVA, and IVB pancreatic carcinoma were eligible for this study. The first 18 patients received gemcitabine 800 mg/m2 intravenously (i.v.) on days 1, 8, and 15 and docetaxel 75 mg/m2 i.v. on day 1, repeated every 28 days. Due to a high incidence of myelosuppression in this first group, the treatment schedule was modified in the remaining patients to gemcitabine 1,000 mg/m2 i.v. and docetaxel 40 mg/m2 i.v. on days 1 and 8 of a 21-day schedule. The primary study endpoints were objective response rate and duration of survival.

RESULTS

Ten of 33 evaluable patients achieved a partial response, for an overall response rate of 30.3% (95% CI, 16.21%-48.87%). Partial responses noted in the pancreas and a variety of metastatic sites were maintained for 4 to 12 months (median 6 months). Twelve additional patients (36%) experienced stable disease. The median time to progression was 6 months, and median survival was 10.5 months. The toxicity profile of the modified gemcitabine/docetaxel schedule was more favorable than that associated with the initial regimen, particularly with respect to hematologic toxicity.

CONCLUSION

The response and survival data reported here for combination therapy with gemcitabine and docetaxel are encouraging given the poor prognosis associated with unresectable pancreatic cancer. These data suggest that gemcitabine plus docetaxel may be more effective than either agent alone in the treatment of pancreatic cancer and warrants further study.

Modern management of pancreatic carcinoma

Pancreatic cancer remains a fearsome disease. New insights into the molecular pathogenesis may influence choice of treatment modalities and provide avenues for novel therapeutic strategies for testing in the clinic. The survival rate of patients with all stages of disease is poor and clinical trials are appropriate alternatives for treatment and should be considered. Surgical resection, when possible, remains the primary treatment modality and can result in long-term cure. Less invasive techniques such as laparoscopy may reduce the rate of unnecessary laparotomies. The role of adjuvant therapy is re-emerging. Patients with unresectable and metastatic disease are incurable and optimal palliation is the goal. These patients may benefit from palliative bypass of biliary or duodenal obstruction if symptomatic. Pain associated with local tumour infiltration may be palliated with radiation, with or without chemotherapy, or with coeliac nerve blocks or local neurosurgical procedures. Chemotherapy with gemcitabine has modest objective response rates but has been shown to improve symptoms.

Cancer in the elderly: pancreatic cancer

Pancreatic cancer remains a devastating and difficult disease to diagnose and successfully treat. Its incidence increases with age, with 60% of patients being over the age of 65 at presentation. Due to the insidious nature and asymptomatic onset of pancreatic cancer approximately 85% of patients present with disseminated or locally advanced disease resulting in a very poor prognosis. In the past the elderly patient, who may be felt to be too frail for operative procedures or further therapy, may have missed out on optimal treatment. In this article we review the investigation and treatment of pancreatic cancer and examine current evidence with regard to pancreatic cancer in the elderly. The evidence suggests that surgical resection can be performed safely in patients who are fit for surgery in specialist centres but may require more intensive post-operative rehabilitation.

Neoadjuvant induction chemotherapy followed by chemoradiation: a phase I trial of gemcitabine, cisplatin, and 5-fluorouracil for advanced pancreatic/gastrointestinal malignancies

The authors developed a strategy that includes a novel approach of induction full-dose chemotherapy followed by traditional chemoradiation as a neoadjuvant therapy for pancreatic cancer. Here they report the results of a phase I/II trial of gemcitabine, cisplatin, and 5-FU for patients with advanced gastrointestinal malignancies.

Phase I-II trial of twice-weekly gemcitabine and concomitant irradiation in patients undergoing pancreaticoduodenectomy with extended lymphadenectomy for locally advanced pancreatic cancer

PURPOSE

Define the maximum tolerated dose (MTD), tolerability, and efficacy of gemcitabine given concomitantly with radiotherapy in patients with locally advanced pancreatic cancer.

METHODS AND MATERIALS

Patients were required to have locally advanced T1-T3 resectable pancreatic cancer. Gemcitabine, given twice weekly before irradiation as a 30-min infusion, was tested at 3 dose levels: 20, 50, and 100 mg/m(2). The radiation dose was 50.4 Gy (ICRU) in 28 fractions. The targeted irradiation volume included the tumor, edema, and a 1-cm margin.

RESULTS

Twenty-eight of 34 patients was eligible for analysis of the treatment. The median age was 67 years (range 38-82). Six patients had T1, 9 had T2, and 19 had T3 diseases (AJCC). Dose-limiting toxicities were Grade 4, fatigue and nausea; Grade 3, thrombocytopenia, diarrhea, and infection. The MTD established was at the 50-mg/m(2) gemcitabine dose. A total of 21 of 28 patients underwent surgery: 18 had pancreaticoduodenectomy, 2 had total pancreatectomy, and 1 for palliative surgery. At the time of analysis, 13 of 28 (46%) were disease-free. The estimated median survival was 25 months and overall survival rate at 2 years (Kaplan-Meier) was 55%.

CONCLUSION

Gemcitabine 50 mg/m(2) given twice weekly with concomitant irradiation induces acceptable and manageable toxicity and might prolong survival.

Selenoprotein P, as a predictor for evaluating gemcitabine resistance in human pancreatic cancer cells

Gemcitabine is a new standard chemotherapeutic agent used in the treatment of pancreatic cancer, but the mechanisms of gemcitabine sensitivity are still controversial. In our study to determine a mechanism that regulates gemcitabine sensitivity, we carried out molecular analysis on the susceptibility of the pancreatic cancer cells. Using a gemcitabine-sensitive pancreatic cancer cell line KLM1, we established a resistant cell line KLM1-R exhibiting a 20-fold IC50-value (the concentration of gemcitabine causing 50% growth inhibition). Microarray analysis of genes showed specific expression of selenoprotein P, one of the anti-oxidants, in the KLM1-R cell line but not in the KLM1 cell line. Administration of selenoprotein P inhibited the gemcitabine-induced cytotoxicity in the pancreatic cell lines. The levels of intracellular reactive oxygen species (ROS) were increased in the KLM1 cells by gemcitabine, but selenoprotein P suppressed the gemcitabine-induced ROS levels. Furthermore interferon-gamma suppressed the expression of selenoprotein P mRNA and increased intracellular ROS level, leading to the recovery of the gemcitabine sensitivity in KLM1-R. These results suggest a novel mechanism that selenoprotein P reduces the intracellular ROS levels, resulting in the insusceptibility to gemcitabine.

Effect of chemoradiotherapy with gemcitabine and cisplatin on locoregional control in patients with primary inoperable pancreatic cancer

Gemcitabine sensitizes tumor cells to radiation and cisplatin and thereby enhances the cytotoxic effect of gemcitabine. Here we report the efficacy and toxicity of concurrent chemoradiation with gemcitabine and cisplatin in the treatment of patients with locally advanced, unresectable pancreatic cancer. A total of 47 patients (29 men, 18 women; median age 61 years) with histologically proven advanced pancreatic carcinoma were included in the study. They underwent chemotherapy with gemcitabine 300 mg/m2 and cisplatin 30 mg/m2 on days 1, 8, 22, and 29; concurrent radiation (45-50 Gy) was applied to the tumor and regional lymph nodes (1.8-2.0 Gy/fraction 5 days per week). Subsequent to chemoradiotherapy, treatment was continued with more two cycles of gemcitabine (1000 mg/m2) and cisplatin (50 mg/m2) applied on days 1 and 15 of a 4-week cycle. After completion of chemoradiotherapy, 9 patients (19.1%) achieved a complete response and 23 patients (48.9%) a partial response, for an overall response rate of 68%. The lesions were considered resectable in 27 patients, and 25 of the 27 patients underwent laparotomy. The other 20 patients underwent a definitive pancreatic resection. Altogether, 13 patients had negative surgical margins. With a median follow-up of 25.7 months (range 12.7-38.7 months) after completion of chemoradiation, distant metastasis had occurred in 23 patients and local recurrence in only 4 of 44 patients (8.5%). the median progression-free survival was 7.8 months (range 6.2-9.4 months). The median survival amounted to 10.7 months (range 8.4-13.0 months) for all patients, whereas it was prolonged to 24.2 months (range 6.8-41.7 months) for those undergoing R0 resection. The main toxicities associated with chemoradiation included grade 3/4 leukopenia (68% of patients) and thrombocytopenia (61%). Episodes of cholangitis were observed in 11 patients. We concluded that gemcitabine and cisplatin can safely be combined with external beam radiation. This preoperative treatment approach is highly effective and appears to improve survival in patients whose tumors are rendered completely resectable.

The evolving role of postoperative adjuvant radiation therapy for pancreatic cancer

The benefit of postoperative adjuvant chemoradiation in the treatment of resected pancreatic cancers was first established by a randomized trial conducted by the Gastrointestinal Tumor Study Group in 1974. During the past 3 decades, treatment has evolved toward more dose-intensive regimens of chemoradiation. Historical split-course conventional radiation therapy has been replaced by continuous-course radiotherapy to higher doses, and gemcitabine is being actively investigated as a potentially more effective agent than 5-fluorouracil. This article critically examines the results of important randomized multi-institutional trials and reviews the evolution toward dose-intensive adjuvant treatment regimens. Implications of the recently completed intergroup study are discussed, modern radiation therapy delivery techniques are reviewed, and suggestions for future trials are made.

Cetuximab, a monoclonal antibody targeting the epidermal growth factor receptor, in combination with gemcitabine for advanced pancreatic cancer: a multicenter phase II Trial

PURPOSE

To determine the response rate, time to disease progression, survival duration and rate, and toxicity with the combination of cetuximab and gemcitabine in patients with epidermal growth factor receptor (EGFR)-expressing advanced pancreatic cancer.

PATIENTS AND METHODS

Patients with measurable locally advanced or metastatic pancreatic cancer who had never received chemotherapy for their advanced disease and had immunohistochemical evidence of EGFR expression were eligible for the multicenter phase II trial. Patients were treated with cetuximab at an initial dose of 400 mg/m(2), followed by 250 mg/m(2) weekly for 7 weeks. Gemcitabine was administered at 1,000 mg/m(2) for 7 weeks, followed by 1 week of rest. In subsequent cycles, cetuximab was administered weekly, and gemcitabine was administered weekly for 3 weeks every 4 weeks.

RESULTS

Sixty-one patients were screened for EGFR expression, 58 patients (95%) had at least 1+ staining, and 41 were enrolled onto the trial. Five patients (12.2%) achieved a partial response, and 26 (63.4%) had stable disease. The median time to disease progression was 3.8 months, and the median overall survival duration was 7.1 months. One-year progression-free survival and overall survival rates were 12% and 31.7%, respectively. The most frequently reported grade 3 or 4 adverse events were neutropenia (39.0%), asthenia (22.0%), abdominal pain (22.0%), and thrombocytopenia (17.1%).

CONCLUSION

Cetuximab in combination with gemcitabine showed promising activity against advanced pancreatic cancer. Further clinical investigation is warranted.

New chemotherapeutic advances in pancreatic, colorectal, and gastric cancers

Pancreatic, gastric, and colorectal cancers are major causes of morbidity and mortality worldwide. When curative surgical resection is not an option, these malignancies tend to respond very poorly to chemotherapy and carry a dismal prognosis. There is, therefore, an urgent need for novel treatment strategies for these cancers. Great strides have been made in colon cancer treatment with the recent introduction of several novel agents, including capecitabine, irinotecan, and oxaliplatin either alone or in combination regimens. Treatment of advanced colon cancer, however, remains essentially palliative, and treatment-related toxicity remains a significant problem. The treatment of advanced gastric and pancreatic cancer has also seen the introduction of new agents, such as gemcitabine and irinotecan; however, the impact of these agents on survival has been small, and toxicity continues to be a major obstacle. The search for new chemotherapeutic agents and treatment strategies will need to focus on improving outcomes and safety and tolerability profiles. To date, several new agents have shown promise, including pemetrexed, G17DT, bevacizumab, and other targeted agents. Further research into their optimal use either alone or in combination regimens should be a priority.

Phase II study of leucovorin, 5-fluorouracil and gemcitabine for locally advanced and metastatic pancreatic cancer (FOLFUGEM 2)

AIM

FOLFUGEM 1 (leucovorin 400 mg/m2 combined with 5-flurorouracil (FU) bolus 400 mg/m2 then 5-FU 2-3 g/m2/46 hours and gemcitabine 1000 mg/m2 in 30 min) in patients with locally-advanced and metastatic pancreatic adenocarcinoma appeared to be toxic (neutropenia and alopecia). The aims of this phase II multicentric study were to evaluate the response rate, clinical benefit and tolerance of a new scheme of combined leucovorin, 5-FU and gemcitabine (FOLFUGEM 2).

PATIENTS AND METHODS

FOLFUGEM 2 associated leucovorin 400 mg/m2 in 2 hours followed by 5-FU 1000 mg/m2 in 22 hours, then gemcitabine 800 mg/m2 (10 mg/m2/min) with cycles every 14 days. Gemcitabine dose could be increased (1000 then 1250 mg/m2) when NCI/CTC toxicity was < or = grade 2.

RESULTS

Fifty-eight patients were included (locally-advanced tumor: N = 13 and metastatic: N = 45). Among the 39 patients with measurable disease, 11 had partial response (28.2%, 95% confidence interval: 14-42%) and 11 had stable disease (28.2%). On an intent-to-treat analysis, the objective response rate was 19% (95% confidence interval: 9-29%). Clinical benefit rate was 46%. Median progression-free survival and median overall survival were 3.1 and 7.2 months, respectively. There were 13% grade 3-4 neutropenia and 36% complete alopecia.

CONCLUSION

FOLFUGEM 2 schema has an antitumoral effect in advanced pancreatic cancer and has an acceptable toxicity which appears to be less than that of FOLFUGEM 1.

Pilot study of celecoxib and infusional 5-fluorouracil as second-line treatment for advanced pancreatic carcinoma

BACKGROUND

Cyclooxygenase-2 (COX-2) is up-regulated frequently and may constitute a promising therapeutic target in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Patients with advanced PDAC who had progressive disease after gemcitabine-based chemotherapy were eligible for this pilot study. Treatment was comprised of oral celecoxib (400 mg twice daily) and protracted intravenous (i.v.) infusion 5-fluorouracil (5-FU) (200 mg/m(2) per day), both given continuously for a maximum of 9 treatment months, in the absence of disease progression or unacceptable toxicity. Patients were examined weekly for toxicity and were restaged every 6-8 weeks for tumor assessment.

RESULTS

Seventeen patients entered the study. Asymptomatic transaminase elevation was the most common toxicity and reached NCI-CTC (version 3.0) Grade 3-4 in 4 of 133 treatment weeks. No other hematologic or nonhematologic toxicity > Grade 2 was observed. Four patients discontinued celecoxib due to upper gastrointestinal tract toxicity. Two confirmed partial responses (durations of 23 weeks and 68 weeks, respectively) and 2 patients with stable disease (durations of 10 weeks and 13 weeks, respectively) were observed for an overall response rate of 12% (95% confidence interval, 0-27%) in the intent-to-treat population. A significant decrease (> or = 50%) in serum CA 19.9 levels was observed in 3 of 9 evaluable patients. The median time to disease progression was 8 weeks, and the median overall survival was 15 weeks.

CONCLUSIONS

The combination of oral celecoxib and 5-FU by protracted i.v. infusion was found to be feasible and well tolerated, and was capable of inducing durable objective responses, even in patients with far advanced, gemcitabine-resistant/refractory PDAC. Further exploration of COX-2 inhibitor/fluropyrimidine combinations is warranted.

Severe Pulmonary Toxicity in Patients With Advanced-Stage Hodgkin's Disease Treated With a Modified Bleomycin, Doxorubicin, Cyclophosphamide, Vincristine, Procarbazine, Prednisone, and Gemcitabine (BEACOPP) Regimen Is Probably Related to the Combination of Gemcitabine and Bleomycin: A Report of the German Hodgkin's Lymphoma Study Group

Purpose

To investigate a new effective, nonleukemogenic polychemotherapy regimen, BAGCOPP (bleomycin, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone, gemcitabine) in a phase I/II dose-escalation study in patients with advanced-stage Hodgkin's disease (HD).

Patients and Methods

Patients in clinical stages IIB with risk factors III and IV were enrolled in this nonrandomized, multicenter trial aimed at defining the maximum-tolerated dose of gemcitabine within a modified escalated BEACOPP regimen. Gemcitabine was given at a starting dose of 800 mg/m2 on days 1 and 4 of each cycle.

Results

Twenty-seven patients (eight female, 19 male) were enrolled with a median age of 33 years (range, 19 to 65 years). Due to a higher than expected hematotoxicity, the day-4 application of gemcitabine was omitted after 14 patients were included and 59 cycles were given. A total of eight patients developed lung toxicity, mainly pneumonitis (six of eight), which led to the termination of the study. With a median follow-up of 27 months, 25 patients are in continuing complete remission.

Conclusion

The substitution of etoposide by gemcitabine in the escalated BEACOPP schema is not feasible and leads to severe pulmonary toxicity. This toxicity is probably related to the concomittant application of gemcitabine and bleomycin.

Phase III trial of radiosensitizer PR-350 combined with intraoperative radiotherapy for the treatment of locally advanced pancreatic cancer

A randomized, controlled trial was conducted to clarify the effect of novel radiosensitizer, PR-350, accompanied by intraoperative radiology (IOR) on locally advanced pancreatic cancer. Between July 1999 and March 2002, 48 patients were enrolled in this clinical trial and received either PR-350 or placebo. Any differences between the PR-350 group (n = 22) and control group (n = 25) were not statically significant. All patients were evaluated, and none of them showed toxicity, with the exception of 1 patient from the control group, and the PR-350 compound was considered to be safe. The efficacy of IOR with PR-350 was evaluated using CT examination. The committee responsible for evaluating efficacy reported that 47.4% of the PR-350 group showed the effective response, compared with 21.7% of the control group (P = 0.1067, Fisher analysis). At 6 months following treatment, the tumor mass reduction rate in the PR-350 group was significantly improved (P = 0.0274). By the time of the last follow-up in July 2003, 17 PR-350 patients and 24 control patients group had died of the disease. The median survival period of the PR-350 group was thus 318.5 days and that of the control group is 303.0 days. One-year survival rates of the PR-350 group and control group were 36.4% and 32.0%, respectively. Although the PR-350 group did not demonstrate significantly better survival than the control group, 4 of 22 PR-350 patients were still living more than 2 years after the end of the trial, compared with only 1 of 25 patients from the control group. The mechanism of this increased therapeutic response to radiotherapy using PR-350 must be clarified to establish more effective strategy for pancreatic cancer treatment.

Pancreatic cancer

Pancreatic cancer remains a major unsolved health problem, with conventional cancer treatments having little impact on disease course. Almost all patients who have pancreatic cancer develop metastases and die. The main risk factors are smoking, age, and some genetic disorders, although the primary causes are poorly understood. Advances in molecular biology have, however, greatly improved understanding of the pathogenesis of pancreatic cancer. Many patients have mutations of the K-ras oncogene, and various tumour-suppressor genes are also inactivated. Growth factors also play an important part. However, disease prognosis is extremely poor. Around 15-20% of patients have resectable disease, but only around 20% of these survive to 5 years. For locally advanced, unresectable, and metastatic disease, treatment is palliative, although fluorouracil chemoradiation for locally advanced and gemcitabine chemotherapy for metastatic disease can provide palliative benefits. Despite pancreatic cancer's resistance to currently available treatments, new methods are being investigated. Preoperative chemoradiation is being advocated, with seemingly sound reasoning, and a wider role for gemcitabine is being explored. However, new therapeutic strategies based on the molecular biology of pancreatic cancer seem to hold the greatest promise.

Is Reporting of Recurrence Data Important in Pancreatic Cancer?

BACKGROUND

Therapeutic approaches to patients with pancreatic cancer have undergone a paradigm shift in recent years. However, little is known about the outcome of patients with recurrent pancreatic cancer who undergo treatment. The purpose of this study was to identify patients with recurrent pancreatic cancer and to determine whether treatment after recurrence had any effect on outcome.

METHODS

A review of all patients undergoing surgical resection with curative intent revealed 70 patients with documented recurrence and complete medical records. Patients were grouped into three categories: group 1 included those who received treatment after recurrence (n = 45), group 2 included those who were not offered treatment (n = 9), and group 3 included those with poor performance status who received no treatment (n = 16).

RESULTS

The median overall survival for the three groups was 26, 18, and 14.5 months for groups 1, 2, and 3, respectively (P <.00001). The median survival after recurrence was 10 months, 6 months, and 1 month, respectively, for the three groups (P <.0001).

CONCLUSIONS

This is the first series we are aware of that compares the outcomes of patients who received treatment after recurrence of pancreatic cancer with the outcomes of those who received no treatment. In this series, it seems that patients who were well enough to tolerate additional therapy had a longer survival than those who received supportive care only. This may be important in the analysis of adjuvant therapy trials of pancreatic cancer with survival as an end point.

Concurrent chemoradiotherapy with gemcitabine and cisplatin after incomplete (R1) resection of locally advanced pancreatic carcinoma

PURPOSE

To analyze, in a prospective clinical trial, the efficacy and toxicity of concurrent radiotherapy and chemotherapy with gemcitabine and cisplatin in patients with incompletely (R1) resected pancreatic cancer.

METHODS AND MATERIALS

Between 2000 and 2002, a total of 30 pancreatic cancer patients were treated. Radiotherapy was performed in 15 patients up to a total dose of 45.0 Gy. An additional 15 patients received a total dose of 50.0 Gy according to the International Commission on Radiation Units and Measurements (ICRU) Report 50 reference point (equivalent to 45.0 Gy at the isodose, including 90% covering the former tumor area and local lymph nodes). Concurrent with radiotherapy, four applications of gemcitabine (300 mg/m(2)) and cisplatin (30 mg/m(2)) were administered. After chemoradiotherapy, patients received four additional courses of gemcitabine (1000 mg/m(2)) and cisplatin (50 mg/m(2)) on Days 1 and 15 in a 4-week cycle.

RESULTS

The median progression-free survival was 10.6 months, and the median overall survival was 22.8 months. The 1-, 2-, and 3-year survival rate was 81%, 43%, and 26%, respectively. After completion of chemoradiotherapy, distant metastasis was observed in 14 patients during a median follow-up of 15.0 months (range, 4.6-30.0). One patient developed both local recurrence and distant metastases. Hematologic toxicities were the most prominent side effects (leukopenia Grade 3 and 4 in 53% and 7% and thrombocytopenia Grade 3 and 4 in 33% and 7% of patients, respectively). Grade 3 and 4 GI toxicity was not observed.

CONCLUSION

Postoperative chemoradiotherapy with gemcitabine and cisplatin after incomplete (R1) resection of pancreatic carcinoma is safe and feasible. A prolonged progression-free survival suggests high local efficacy, translating into a benefit of overall survival. On the basis of the favorable outcome of patients receiving gemcitabine/cisplatin-based chemoradiotherapy, testing this combined treatment strategy appears warranted in a comparative trial.

Phase II study of cisplatin, gemcitabine and 5-fluorouracil in advanced pancreatic cancer

BACKGROUND

The aim of this study was to determine the activity of the combination of cisplatin, gemcitabine and 5-fluorouracil (5-FU) as therapy for metastatic or locally advanced inoperable pancreatic adenocarcinoma.

PATIENTS AND METHODS

Patients with histologically proven advanced or metastatic pancreatic adenocarcinoma received first-line chemotherapy comprising cisplatin (20 mg/m2 on days 1, 8, 15, 22, 29 and 36), gemcitabine (1000 mg/m2 on days 1, 8, 29 and 36) and 5-FU (200 mg/m2 as continuous infusion on days 1-42) every 56 days.

RESULTS

A total of 34 patients were studied. Eighty courses were administered (median two courses per patient). Among 32 patients evaluable for response, two patients had a complete response and four a partial response for an overall response rate of 19% (95% confidence interval 7% to 36%). Thirteen patients had stable disease (40%) and 13 progressed. Median progression-free survival was 4.7 months, median survival 9.0 months and 26% of patients achieved 1-year survival. Ten of 25 patients (40%) with pain at presentation had a sustained reduction of analgesic consumption. The principal grade 3/4 toxicities were neutropenia, thrombocytopenia, anaemia and mucositis, occurring in 24%, 21%, 9% and 3% of patients.

CONCLUSION

This schedule seems well tolerated and active in pancreatic cancer and worthwhile of further evaluation.

Mistletoe and gemcitabine in patients with advanced cancer: a model for the phase I study of botanicals and botanical-drug interactions in cancer therapy

Plant extracts of the European mistletoe (MTE), Viscum album, the most widely used cancer treatment in Germany, have been used in European countries as sole intervention or as adjunct to conventional cancer therapies for more than 80 years. Preclinical data suggest immunostimulatory and cytotoxic effects of MTE. While the clinical efficacy of MTE in cancer is being investigated, toxicity and potential interactions of MTE with standard chemotherapeutic agents are unknown. Gemcitabine is an approved antimetabolite chemotherapeutic agent effective as single agent in patients with solid tumors (ST). The documented metabolism and pharmacokinetics of gemcitabine make this agent well suited for the study of botanical-chemotherapy drug interactions (BDIA) in cancer. Based on reports of altered drug metabolism associated with botanical preparations, research into BDIA has intensified. The phase I, 2-stage, dose-escalation study outlined here will test MTE with gemcitabine as a paradigm for the phase I investigation of botanical-drug combination treatments in patients with advanced ST. The protocol including the following components has been reviewed and approved by the National Cancer Institute Institutional Review Board (IRB), the National Naval Medical Center IRB, and the Navy Clinical Investigation Program (study 02-074): (1) use of a standardized MTE, approved by the Food and Drug Administration for investigational use; (2) independent verification of key MTE components considered biologically active; (3) identification of contaminants and adulterants; (4) pharmacokinetics of gemcitabine and its principal metabolites before and upon exposure to MTE; (5) safety and toxicity data collection; (6) assays of plasma ML antibody production in vivo; and (7) pharmacodynamic studies of the botanical-drug combination.

Gemcitabine-related radiation recall preferentially involves internal tissue and organs

Radiation recall refers to inflammatory reactions triggered by cytotoxic agents and develops in previously irradiated areas. Most reactions develop cutaneously. The most common chemotherapeutic agents implicated are anthracyclines and taxanes. Gemcitabine, a nucleotide analog, recently was implicated in several cases. The authors performed a literature search using PubMed and the search terms "gemcitabine" and "radiation recall" to find prior cases of radiation recall attributed to gemcitabine. These cases were compared with those attributed to anthracyclines and taxanes. The literature search found 12 cases of radiation recall caused by gemcitabine. The authors also determined that their case of myositis developing in the rectus abdominus muscle of a patient with pancreatic adenocarcinoma was the manifestation of radiation recall, thereby bringing the number of patients who developed radiation recall to gemcitabine and were discussed in the current study to 13. Approximately 70% of the cases manifested as inflammation of internal organs or tissues and 30% manifested as a dermatitis or mucositis. This finding differs from other common agents, in which 63% of the radiation recall events are reported to manifest as a dermatitis. Compared with anthracyclines and taxanes, the interval from the completion of radiation therapy to the initiation of chemotherapy is less for gemcitabine (median time of 56 days for gemcitabine, compared with 218 days for the taxanes and 646 days for doxorubicin). The majority of radiation recall reactions attributed to gemcitabine are reported to affect internal tissue or organs. In contrast, other common agents for the most part trigger cutaneous inflammation. The development of internal tissue inflammation is reportedly correlated with a shorter interval from the time of completion of radiation therapy to the initiation of chemotherapy.

Chemoradiotherapy in the Treatment of Regional Pancreatic Carcinoma

In locally advanced pancreatic cancer, the utilization of chemotherapy and radiotherapy is increasing, although in view of the reported long-term results of several contemporary trials, further improvements are certainly needed. Encouraging results using the combination of cisplatin, cytarabine, caffeine, and continuous infusion (CI) 5-fluorouracil (5-FU) (PACE) for the treatment of advanced pancreatic carcinoma prompted a phase II study using PACE followed by external beam radiotherapy with CI of 5-FU (PACE-RT) for localized disease. Forty-one patients were treated with PACE-RT as adjuvant therapy after surgical resection (21 patients), or as primary therapy for locally advanced, unresectable disease (20 patients), with reevaluation for resection after completion of treatment. PACE consisted of cisplatin 100 mg/m2 IV on day 1, cytarabine 2 g/m2 IV every 12 hours x 2 doses, and caffeine 400 mg/m2 subcutaneously after each cytarabine dose; and days 3 to 21, 5-FU 250 mg/m2/d given by CI. Cycles were repeated every 28 days. After 2 cycles of PACE, radiation therapy was given concurrently with 5-FU at 200 mg/m2/d. In the adjuvant setting, the tumor bed and the draining lymph node basin received 50.4 Gy and 45 Gy, respectively. In the neoadjuvant setting, the primary and regional lymph nodes were to receive 39.6 Gy followed by a neutron boost of 8 NGy to the gross tumor volume. Photon therapy was delivered at 1.8 Gy per fraction and neutron therapy at 0.8 NGy per fraction, 5 days a week. All patients were evaluable for toxicity and survival. The most common toxicity was myelosuppression, with grade III to IV neutropenia occurring in 59% of the patients. The median survival times in the locally advanced and adjuvant patients were 13.4 and 18.1 months, with 1-year survival rates of 52% and 65%, respectively. Nine of 20 patients receiving PACE-RT for unresectable carcinoma had sufficient tumor regression to meet clinical criteria for exploration; three were resected with curative intent. The survival of these three patients undergoing resection after neo-adjuvant therapy was 22.4, 24.3 and 40 months. The treatment program was active, but only moderately well tolerated. Modification of this regimen with newer, less toxic drugs may provide better results and reduced toxicity.

Review article: chemotherapy for pancreatic cancer

Pancreatic cancer is a common, highly lethal disease that is rising in incidence. Chemotherapy based on 5-fluorouracil (5-FU) has been shown to prolong survival in advanced pancreatic cancer. Gemcitabine improves major symptoms and survival outcomes compared with bolus 5-FU. Many novel small molecules are being widely and actively researched. These compounds are based on classical mechanisms of action as well as biological therapies targeting novel cellular survival pathways, and include fluoropyrimidines, nucleoside cytidine analogues, platinum analogues, topoisomerase-inhibitors, antimicrotubule agents, proteasome inhibitors, vitamin D analogues, arachidonic acid pathway inhibitors, histone deacytylator inhibitors, farnesyltransferase inhibitors and epidermal growth factor receptor therapies. Adjuvant chemotherapy has also demonstrated the best survival outcomes following resection compared to other adjuvant or neo-adjuvant strategies such as radiation-based treatments. These benefits are superimposed on the dramatic increase in resectability rates and reduction in post-operative mortality achieved by centralisation of treatment in high-volume speciality centres. Newer 'small-molecule' drugs as well as the latest 'large-molecule' biological agents hold considerable promise for the future. Real advances are anticipated over the next five years but are dependent on large randomised controlled trials for success.

Prognostic value of CA 19-9 levels in patients with inoperable adenocarcinoma of the pancreas treated with gemcitabine

Serum carbohydrate antigen 19-9 (CA 19-9) has been identified as a useful tumour marker for diagnosis of exocrine pancreatic carcinoma, but its value for evaluating the response to chemotherapy with gemcitabine is not clear. Tumour regression in pancreatic carcinoma is hard to determine due to massive desmoplastic tissue. Furthermore, objective tumour response does not automatically transcribe into better survival. Therefore, clinical benefit response, a composed parameter consisting of factors like performance status, pain, and body weight was integrated in evaluating tumour response. The aim of this prospective study was to evaluate the usefulness of serial CA 19-9 measurements as a biochemical response marker and an outcome prognostic parameter in patients with advanced pancreatic cancer receiving gemcitabine treatment. A total of 46 consecutive patients (median age 66 years) suffering from histologically proven locally advanced or metastatic adenocarcinoma of the exocrine pancreas were analysed. Gemcitabine was applied for a median of 23 courses (range 6-76). Two patients achieved an objective complete remission, five an objective partial remission (overall response, OR=15.2%), while objective stable disease was documented in 19 and objective progressive disease in 20 patients. Patients with a decrease of >20% of the baseline CA 19-9 level after 8 weeks of chemotherapy had a significantly better median survival than patients with a rise or a decline <20%. The response of CA 19-9 >20% during chemotherapy was the only independent predictor of survival in a multivariate analyses. In contrast, neither objective tumour response nor clinical benefit response showed this level of significance. In conclusion, kinetics of CA19-9 serum concentration serves as an early indicator of response to gemcitabine chemotherapy in advanced pancreatic cancer.

Surrogate end points of quality of life assessment: have we really found what we are looking for?

Outcome research is a new interesting field in medical research. Some years ago, a document of the American Society of Clinical Oncology distinguished the outcomes of a treatment into patient-outcomes (overall survival and quality of life) and cancer-outcomes (response rate), giving higher priority to patient outcomes. This document is one of the best structured instruments to evaluate and classify the outcomes in clinical oncology. Nevertheless, although overall survival and quality of life represent the main patient outcomes in clinical oncology, in the last years many researchers tried to overcome these recommendations, creating new surrogate end points to assess overall survival and quality of life. Surrogate end points can be useful tools when they are used to achieve preliminary data that anticipate the evaluation of the final outcome, but the use of surrogate end points instead of the main outcomes is quite dangerous, as it can provide wrong answers to clinical questions. The use (or abuse) of surrogate end points of quality of life has recently favoured some questionable decisions of the main regulator organs, such as the approval by the Food and Drugs Administration of the use of gemcitabine in advanced chemotherapy-naive pancreatic cancer, or mitoxantrone in the palliative treatment of hormone-resistant pancreatic cancer, based on the improvement in clinical benefit (a non-validated instrument to evaluate the outcome of palliative chemotherapy) besides a minimal and questionable overall survival, or pain control (evaluated with a non-validated instrument). A correct use of surrogate end points of quality of life within and not instead of quality of life assessment should be the engagement of our further efforts in quality of life research.

A phase II irinotecan-cisplatin combination in advanced pancreatic cancer

We report a cisplatin and irinotecan combination in patients with biopsy-proven advanced pancreatic adenocarcinoma. Patients were selected from a specialist centre and required good performance status (KPS>70%), measurable disease on CT scan, and biochemical and haematological parameters within normal limits. Based on a two-stage phase II design, we aimed to treat 22 patients initially. The study was stopped because of the death of the 19th patient during the first treatment cycle, with neutropenic sepsis and multiorgan failure. A total of 89 treatments were administered to 17 patients. Serious grade 3/4 toxicities were haematological (neutropenia) 6%, diarrhoea 6%, nausea 7% and vomiting 6%. Using the clinical benefit response (CBR) criteria, no patients had an overall CBR. For responses confirmed by CT examination, there was one partial response (5%), three stable diseases lasting greater than 6 weeks (16%), with an overall 22% with disease control (PR+SD). The median progression-free and overall survival was 3.1 months (95% CI: 1.3-3.7) and 5.0 (95% CI: 3.9-10.1) months, respectively. Although this synergistic combination has improved the response rates and survival of other solid tumours, we recommend caution when using this combination in the palliation of advanced pancreatic cancer, because of unexpected toxicity.

The role of oxaliplatin in the management of upper gastrointestinal tract malignancies

Following the successful introduction of oxaliplatin into the management of advanced colorectal cancer, its clinical utility is currently being investigated in a variety of other malignancies, including cancers of the upper gastrointestinal tract. In advanced pancreatic cancer, oxaliplatin has been found to be clinically effective in phase II trials in which it was combined with either 5-fluorouracil (5-FU) or gemcitabine, the current standard chemotherapy for this disease. In a phase II trial involving 67 patients, the combination of oxaliplatin and 5-FU in a high dose infusional regimen (n = 31) achieved an objective response rate of 9.7%, stable disease for at least three cycles in 48.4% of patients, tumour growth control in 58% of patients, a median time to progression of 4.9 months and median overall survival reaching 9.2 months. In combination with gemcitabine in a phase II trial involving 64 patients with metastatic (n = 34) or locally advanced (n = 30) pancreatic cancer, there was an objective response rate of 30.6%, treatment benefit in 39.7%, a median progression-free survival of 5.3 months and again a median overall survival of 9.2 months. Response rates and survival times did not differ between locally advanced and metastatic disease. On the basis of these encouraging results, phase III studies of oxaliplatin in advanced pancreatic cancer are now in progress in Europe and the United States. In metastatic gastric cancer, a phase II study investigated the combined use of oxaliplatin and 5-FU using the FOLFOX6 regimen in 53 patients, of whom 49 were evaluable for efficacy. The objective response rate was 44.9% and the median duration of response was 7.9 months. Large phase III trials of oxaliplatin-based treatment for advanced gastric cancer are now in progress. Oxaliplatin is also being investigated in oesophageal cancer and several other gastrointestinal tumours. In summary, oxaliplatin is emerging as an effective and highly promising chemotherapeutic agent for the treatment of upper gastrointestinal malignancies.

Symptom control

Symptom control has become increasingly recognized as an important goal in patient care. In this article, advances in symptom assessment, and various definitions of symptom improvement are reviewed. Theoretical concepts underlying symptom control and clinically significant change are presented, as well as the role of symptom control as an endpoint in clinical trials. Symptom control is then surveyed in two broad categories for selected symptoms. The first area is therapy related symptoms, secondary to chemotherapy, radiation, hormonal therapy, and surgery. Symptoms reviewed include chemotherapy related mucositis, emesis, fatigue; hot flashes; and radiation related dermatitis, xerostomia, and mucositis. The second area is palliative oncologic approaches to disease-related symptoms. Results in palliative chemotherapy, palliative radiation therapy, cancer pain, and lack of appetite are summarized. Areas requiring further research are noted. Findings are presented in both a clinical and research context to help guide the reader with interpreting symptom control studies.

The medical management of pancreatic cancer: a review

Pancreatic carcinoma is a commonly occurring cancer that tends to present late in its course when potentially curative surgical treatment is not possible. The majority of patients are, therefore, candidates for systemic therapy. We review the patient and disease-related factors that contribute to the difficulties in the medical management of this condition and discuss new methods of assessing response to treatment, including the introduction of more clinically relevant novel end points such as clinical benefit response. We review the current trial literature examining the use of conventional cytotoxic agents in this disease, both as single agents and in combination. We also review the use of more novel targeted agents and examine their potential utility in this disease. The use of the farnesyl transferase inhibitors, matrix metalloproteinase inhibitors, epidermal growth factor receptor antagonists, and angiogenesis inhibitors is discussed.

A phase II study of cisplatin, etoposide and gemcitabine in an unfavourable group of patients with carcinoma of unknown primary site

BACKGROUND

The aim of this phase II study was to determine toxicity, response rate, time to progression, and overall survival of cisplatin, etoposide and gemcitabine in patients with carcinoma of unknown primary tumour site.

PATIENTS AND METHODS

Thirty patients with no previous chemotherapy and not belonging to a treatable group were treated with cisplatin 70 mg/m(2) on day 1, etoposide 70 mg/m(2) on days 1 and 2, and gemcitabine 700 mg m(2) on days 1 and 8, administered every 3 weeks. Stable or responding patients received a maximum of eight cycles. Twenty patients (67%) had more than three affected sites, and 25 patients (84%) had adenocarcinomas.

RESULTS

Overall response rate was 36.6% (11 patients), including four complete responses (13.3%) and seven partial responses (23.3%), with a 95% confidence interval of 19.9-56. Median survival was 7.21 months and eight patients remained alive for >1 year. Myelosuppression was the most important toxicity, with grade 3-4 neutropenia in 18 patients (60%) in 32% of the cycles: eight patients had neutropenic fever and 10 patients had thrombopenia in 11% of cycles. No non-haematological grade 4 toxicity occurred.

CONCLUSIONS

Cisplatin, etoposide and gemcitabine is an active combination, inducing objective responses in a subset of heavily advanced disease patients with carcinoma of unknown primary site. The role of adding gemcitabine to cisplatin and etoposide remains to be resolved as to the best schedule to diminish toxicity for the three-drug combination.

Surgical resection following radiation therapy with concurrent gemcitabine in patients with previously unresectable adenocarcinoma of the pancreas

The combination of gemcitabine with concurrent radiation therapy (Gem/RT) is a promising new approach that is being investigated in patients with unresectable pancreatic cancer. However, substantial toxicity with this combination has also been observed. This review was conducted to determine whether Gem/RT could be safely delivered in the neoadjuvant setting, based on our experience with this combined therapy in a cohort of patients with previously unresectable pancreatic cancer, who subsequently underwent surgical resection. Between July 1996 and June 2001, a total of 67 patients with locally unresectable pancreatic cancer, without distant metastatic disease, received Gem/RT at our institution. Seventeen patients (25%) underwent exploratory surgery following Gem/RT, and nine underwent standard Whipple resection. Thus 9 (52%) of 17 patients who had exploratory operations or 9 (13%) of 67 patients, underwent surgical resection. Thirty-day mortality after resection was 0%, and there were no major surgical complications. Median length of hospital stay was 14 days (range 11 to 19 days). With a median follow-up of 32 months, median survival for the resected patients was 17.6 months (95% confidence interval 12.6 to 37.3 months). Median survival for the remaining 58 patients was 11.9 months (95% confidence interval 9.6 to 14.7 months, P=0.013). We conclude that surgical resection may be safely performed after Gem/RT in a select group of patients initially considered to have unresectable pancreatic cancer. The use of Gem/RT in a neoadjuvant setting is currently being investigated in a multi-institutional phase II trial.

Adjuvant therapy for pancreatic adenocarcinoma: what have we learned since 1985?

To review developments relevant to pancreatic adjuvant therapy since the publication of the Gastrointestinal Tumor Study Group (GITSG) trial of adjuvant therapy for pancreatic cancer in 1985. Our understanding of the pathology, surgical management, clinical and pathologic prognostic factors, potential importance of adjuvant therapy, and optimal design of adjuvant therapies have all undergone major evolution. Available data suggest: (1) the morbidity of pancreaticoduodenectomy has been reduced substantially, especially in major referral centers; (2) physicians, patients, and families recognize the importance of clinical trials and substantial numbers of patients are available for such trials; (3) factors such as tumor size, margin status, nodal involvement, histologic differentiation, and blood loss at surgery have an impact on postoperative outcomes; (4) the use of gemcitabine and patient-specific, anatomic planning for conformal radiotherapy has the potential to radically alter the adjuvant paradigm; (5) vaccine therapies have completed Phase I testing and are being incorporated into Phase II trials; and (6) careful application of relevant statistical principles is necessary to avoid the execution of ambiguous or uninterpretable trials. The need for effective adjuvant therapy is undisputed, because surgery alone is inadequate. Increasing numbers of patients are undergoing and recovering from surgery who are willing to consider clinical trials. Major cooperative group and single-institution efforts recently completed, ongoing, or currently planned using improved stratification for prognostic subsets, translational approaches based on molecular biology and/or genetic engineering, and newer chemoradiotherapeutic regimens are rapidly changing the landscape of this clinical arena into one of promise and possibility.

Clinical research in pancreatic cancer: the Radiation Therapy Oncology Group trials

To summarize the clinical research activities of the Radiation Therapy Oncology Group program in the treatment of patients with locally advanced, as well as resected, pancreatic cancer. Phase II and III clinical trials are underway, examining novel cytotoxic and targeted agents with irradiation (RT) for patients with locally advanced and resected pancreatic cancer.A Phase II study incorporating concurrent paclitaxel with external beam radiotherapy in the locally advanced setting has been completed and recently analyzed. This experience has served as the foundation of a Phase II study using concurrent paclitaxel and gemcitabine with RT followed by R115777, a farnesyltransferase inhibitor, as maintenance therapy. In the adjuvant treatment of pancreatic cancer, an Intergroup Phase III trial has compared "conventional" postoperative chemoirradiation (5-fluorouracil before, after, and during RT) and gemcitabine before and after RT (with 5-fluorouracil during RT). This study has recently closed, meeting its accrual goal. The successor study will evaluate the use of gemcitabine given concurrently with RT, as well as in a maintenance schedule. This report summarizes current and future Radiation Therapy Oncology Group clinical trials in the treatment of patients with localized pancreatic cancer.

Chemotherapy for advanced pancreatic cancer

Achieving substantial and meaningful improvements in the response and survival rates for advanced pancreatic cancer has proved to be an elusive goal for many years. 5-Fluorouracil (5-FU)-based chemotherapy has typically produced discouraging response rates or improved clinical benefit for patients, and attempts to improve these results by altering 5-FU dosages, administration schedules, or using a variety of drugs in combination with 5-FU have been unrewarding. A clinical benefit, however, was identified when gemcitabine first generated improvements in symptom control in patients with advanced disease. In a subsequent randomized trial, gemcitabine demonstrated superiority to 5-FU with respect to response rate, time to progression, and median survival. These improvements were also associated with improvement in clinical benefit. The findings of subsequent randomized Phase III trials have suggested a survival benefit for gemcitabine compared with several single agents or combinations. Gemcitabine has thus become the de facto standard of care for advanced pancreatic cancer, and current efforts are directed toward finding strategies that can capitalize on and extend these clinical benefits.

Gemcitabine combination chemotherapy of ovarian cancer

OBJECTIVE

Used alone, gemcitabine has shown modest, albeit significant, activity in patients with ovarian cancer. The response rate is usually greater when it is used in combination with other agents, and many combinations of gemcitabine show promise. This review summarizes the results of clinical trials where gemcitabine has been used in combination with other cytotoxic agents for the treatment of ovarian cancer in both newly diagnosed patients and those whose disease recurred despite heavy prior treatment.

METHODS

The results of several clinical trials in which gemcitabine was used in combination with platinum compounds, paclitaxel, or other chemotherapeutic agents as either first-line or salvage therapy of ovarian cancer were reviewed.

RESULTS

Gemcitabine appears to act synergistically when combined with a platinum compound, producing response rates as high as 71% in previously untreated patients. The addition of paclitaxel to this combination was even more effective for first-line therapy. When used in the salvage setting, combinations of gemcitabine with cisplatin or carboplatin and/or other cytotoxic agents were also effective and well tolerated.

CONCLUSIONS

Combinations of gemcitabine with platinum compounds and/or other chemotherapeutic agents have significant activity with acceptable toxicity in patients with ovarian cancer, whether used as first-line therapy or in the salvage setting. The exact dosing and different mechanism of action of gemcitabine make it attractive for these combinations.

Phase II study of gemcitabine, cisplatin, and infusional fluorouracil in advanced pancreatic cancer

PURPOSE

This phase II study was undertaken to determine the efficacy of adding infusional fluorouracil (FU) to the chemotherapy doublet of gemcitabine and cisplatin in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

The eligibility criteria included histologically or cytologically confirmed adenocarcinoma of the pancreas that was either unresectable or metastatic. No prior gemcitabine therapy was allowed. Patients received a combination of gemcitabine 1000 mg/m2 intravenously (IV) on days 1, 8, and 15; cisplatin 50 mg/m2 IV on days 1 and 15; and FU 175 mg/m2/d from days 1 to 15 by continuous IV infusion. Cycles were repeated every 28 days. Objective tumor response and toxicity were evaluated according to the World Health Organization criteria.

RESULTS

A total of 47 patients (median age, 57 years; males, 59%) were enrolled. Sixteen patients had locally advanced (LA) disease, and 31 patients had metastatic disease. A total of 183 cycles of chemotherapy were administered. In patients with metastatic disease (n = 31), the probability of survival at 6 and 12 months was 66% and 34%, respectively. Objective partial response or stable disease was observed in 26% (90% confidence interval [CI], 0.14 to 0.41) and 61% (90% CI, 0.45 to 0.74) of patients, respectively. In patients with LA disease (n = 16), there were three partial responses (19%; 90 CI, 0.07 to 0.39). One patient in this group was successfully resected after FU-based radiotherapy. The most common grade 3 to 4 toxicities were neutropenia (60%), thrombocytopenia (42%), and anemia (26%). Thirteen patients were hospitalized for treatment-related complications.

CONCLUSION

The combination of gemcitabine, cisplatin, and infusional FU has significant activity in patients with advanced pancreatic cancer.

The cost of treating pancreatic cancer--a cohort study based on patients' records from four hospitals in Sweden

An estimate of the average cost of treatment (COT) was assessed for 53 patients with pancreatic cancer treated between 1997 and 1999 in four hospitals in southern Sweden. Average COT was estimated to Euro18 947, 55% of which was attributable to hospitalization (including surgical procedures), 20% to long-term care and 11% to chemotherapy. Diagnostics and radiotherapy accounted for 9% and 4%, respectively. Median survival was 5.6 months (mean 6.3 months). Treatment costs per patient were negatively correlated with age but were higher for patients receiving chemo/radiotherapy and surgical treatment than for patients receiving only standard supportive care. Disease stage and type of hospital (university versus regional/local hospitals) were not significant predictors of COT per se. Assuming that our estimate of the average cost is representative for Sweden, the total healthcare cost for pancreatic cancer was Euro16 million (dollar14 million), i.e about 2-3% of the COT for all cancer diseases in Sweden. In the USA the cost of pancreatic cancer accounted for the same proportion. However, our estimated cost per patient was about half the amount of the US estimate. The distribution of costs between the different types of treatment services did not differ greatly between Sweden and the USA.

Superiority of oxaliplatin and fluorouracil-leucovorin compared with either therapy alone in patients with progressive colorectal cancer after irinotecan and fluorouracil-leucovorin: interim results of a phase III trial

PURPOSE

In North America, no effective therapy has been available for patients with progressive metastatic colorectal cancer after front-line treatment with irinotecan, bolus fluorouracil (FU), and leucovorin (IFL).

PATIENTS AND METHODS

Patients with metastatic colorectal cancer who progressed after IFL therapy were randomly assigned to bolus and infusional FU and leucovorin (LV5FU2), single-agent oxaliplatin, or the combination (FOLFOX4). This planned interim analysis evaluated objective response rate (RR), time to tumor progression (TTP), and alleviation of tumor-related symptoms (TRS) in an initial cohort of patients.

RESULTS

Between November 2000 and September 2001, 463 patients from 120 sites in North America were randomly assigned to treatment. FOLFOX4 proved superior to LV5FU2 in all measures of clinical efficacy. Objective RRs determined by an independent radiology panel were 9.9% for FOLFOX4 versus 0% for LV5FU2 (Fisher's exact test, P <.0001). Median TTP was 4.6 months for FOLFOX4 versus 2.7 months for LV5FU2 (two-sided, stratified log-rank test, P <.0001). Relief of TRS occurred in 33% of patients treated with FOLFOX4 versus 12% of patients treated with LVFU2 (chi2 test, P <.001). Single-agent oxaliplatin was not superior to LV5FU2 in any measure of efficacy. Patients treated with FOLFOX4 experienced a higher incidence of clinically significant toxicities than patients treated with LV5FU2, but these toxicities were predictable and did not result in a higher rate of treatment discontinuation or 60-day mortality rate.

CONCLUSION

For patients with metastatic colorectal cancer, second-line treatment with FOLFOX4 is superior to treatment with LVFU2 in terms of RR, TTP, and relief of TRS.

Systemic capillary leak syndrome resulting from gemcitabine treatment in renal cell carcinoma: a case report

In a few cases, gemcitabine (GCB) has been shown to result in systemic capillary leak syndrome (SCLS) in the treatment of non-small cell lung, pancreatic, and ovarian carcinomas. SCLS is a life-threatening condition characterized by increased capillary permeability resulting in manifest pulmonary and peripheral edema. Usually SCLS responds successfully to corticosteroid therapy and diuretics. We present a case where GCB treatment likely resulted in SCLS in a male patient with metastatic renal cell carcinoma (RCC) in the absence of predisposing cardiac, pleural, or pulmonary disease.

Recent developments in the pharmacological treatment of advanced pancreatic cancer

Metastatic pancreatic cancer is one of the leading causes of cancer-related death in North America and Europe. The high mortality rate associated with pancreatic cancer is related to the fact that the vast majority of patients develop incurable, metastatic disease. Such patients have, in the past, had few treatment options. In recent years, however, the systemic administration of gemcitabine has been accepted as a standard first-line treatment for patients with advanced pancreatic cancer. While treatment with gemcitabine has been shown to result in both clinical benefit and in prolongation of survival, objective tumour responses following therapy with gemcitabine are relatively uncommon and median survival times remain short. Current efforts have, therefore, focused on evaluating chemotherapy regimens in which gemcitabine is combined with a second cytotoxic agent. Several such combinations appear to be associated with higher objective response rates than single-agent gemcitabine and have been well-tolerated in early clinical trials. Ongoing, prospectively randomised clinical trials will help better define the efficacy of these new combinations and will determine if they result in a significant benefit when compared to gemcitabine monotherapy. A number of novel chemotherapeutic and biological agents also appear promising and are likely to play a future role in the treatment of patients with advanced pancreatic cancer.

Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care

This update is devoted to discussion of optimal supportive and palliative care of patients with pancreatic cancer. Approximately 33,000 new cases of pancreatic cancer are predicted for the U.S. in 2002. Because diagnosis and intervention occur late in the course of this disease, the vast majority of patients already have metastatic disease at the time of diagnosis. These tumors are relatively resistant to systemic chemotherapy, making pancreatic cancer the fourth leading cause of cancer-related death in the U.S. and the Western world. For these reasons, efforts at identifying and treating disease-related symptomatology are priorities. This update overviews symptom management, supportive care strategies, and both standard and emerging palliative chemotherapy options. The incorporation of molecularly targeted therapies into treatment of metastatic pancreatic cancer is reviewed as well. These strategies are of relevance to internists, gastroenterologists, oncologists, and other specialists who care for patients with pancreatic cancer.

Thermal enhancement of new chemotherapeutic agents at moderate hyperthermia

BACKGROUND

Hyperthermia enhances the cytotoxicity of some chemotherapeutic agents. We have studied the effect of moderate hyperthermia (41.5 degrees C) on the cytotoxicity of five new chemotherapeutic agents (docetaxel, paclitaxel, irinotecan, oxaliplatin, and gemcitabine) and melphalan against a spontaneous murine fibrosarcoma.

METHODS

The tumor was an early-generation isotransplant of a spontaneous C3Hf/Sed mouse fibrosarcoma, FSa-II. Hyperthermia was administered by immersing the tumor-bearing foot into a constant temperature water bath set at 41.5 degrees C for 30 minutes when the tumor reached 34 mm(3). Chemotherapy was administered intraperitoneally immediately before hyperthermia. Tumor response was studied by the mean tumor growth time and the mean tumor growth delay time.

RESULTS

Hyperthermia significantly increased the tumor growth times of the animals treated with docetaxel, irinotecan, and gemcitabine at low dose and these drugs plus oxaliplatin at high dose. Docetaxel at high dose showed the greatest control of tumor growth by hyperthermia, with a 26% reduction. Concerning the taxanes, paclitaxel cytotoxicity was not enhanced by hyperthermia, but docetaxel was enhanced by hyperthermia at both doses of drug.

CONCLUSIONS

Moderate hyperthermia increases the cytotoxicity of docetaxel, irinotecan, and gemcitabine on mouse fibrosarcoma. Paclitaxel did not show heat enhancement. Oxaliplatin and docetaxel showed greater heat enhancement when the drug dose was high.

Adjuvant therapy in pancreatic cancer: historical and current perspectives

The results from pancreatic ductal adenocarcinoma appear to be improving with increased resection rates and reduced postoperative mortality reported by specialist pancreatic cancer teams. Developments with medical oncological treatments have been difficult, however, due to the fundamentally aggressive biological nature of pancreatic cancer and its resistance to chemotherapy coupled with a relative dearth of randomised controlled trials. The European Study Group for Pancreatic Cancer (ESPAC)-1 trial recruited nearly 600 patients and is the largest trial in pancreatic cancer. The results demonstrated that the current best adjuvant treatment is chemotherapy using bolus 5-fluorouracil with folinic acid. The median survival of patients randomly assigned to chemoradiotherapy was 15.5 months and is comparable with many other studies, but the median survival in the chemotherapy arm was 19.7 months and is as good or superior to multimodality treatments including intra-operative radiotherapy, adjuvant chemoradiotherapy and neo-adjuvant therapies. The use of adjuvant 5-fluorouracil with folinic acid may be supplanted by gemcitabine but requires confirmation by ongoing clinical trials, notably ESPAC-3, which plans to recruit 990 patients from Europe, Canada and Australasia. Major trials such as ESPAC-1 and ESPAC-3 have set new standards for the development of adjuvant treatment and it is now clear that such treatment in this field has the potential to significantly improve both patient survival and quality of life after curative resection.

Developments in the systemic therapy of pancreatic cancer

Pancreatic adenocarcinoma is the fourth leading cause of cancer mortality in the United States of America. Progress in the treatment of this disease in the past several decades has been very modest. Several new agents with activity against pancreatic cancer have been identified. Of these, gemcitabine is the most promising agent when used in combination with other drugs. Pilot phase II studies combining gemcitabine with 5-flourouracil, irinotecan, docetaxel, or cisplatin show improved outcomes in objective response rates and survival that need to be confirmed in larger randomized studies. Advancement in the understanding of the molecular biology of neoplasia in recent years has helped identify several molecular targets for future new drug development in pancreatic cancer. Assessment of response to therapy of pancreatic cancer has been a difficult challenge. Functional imaging with techniques such as positron emission tomography (PET) may yield a more precise and timely objective evaluation of response to treatment.

Biotherapeutic approaches to pancreatic cancer

The incidence of adenocarcinoma of the pancreas has risen steadily over the past four decades. Since pancreatic cancer is usually diagnosed at an advanced stage and because of the lack of effective therapies, the prognosis of such patients is extremely poor. Despite advances in our understanding of the molecular biology of pancreatic cancer, the systemic treatment of this disease remains unsatisfactory. Conventional chemotherapy has not produced dramatic improvements in response rates or patient survival. New treatment strategies are clearly needed. This paper will review emerging therapies for pancreatic carcinoma. A deeper understanding of the molecular biology of cell growth and proliferation, as well as of neoplastic cell transformation, has led to advances in several areas, including the use of hormones and antihormones as adjuvant therapy; inhibition of tumour growth and metastasis by inhibitors of matrix metalloproteases and angiogenesis, and by small molecules, such as retinoids, which interfere with progression through the cell cycle; immunotherapy with monoclonal antibodies; disruption of intracellular signal transduction with farnesyltransferase inhibitors; and, finally, gene therapy with specifically designed vaccines.

Current approaches to novel therapeutics in pancreatic cancer

Pancreatic cancer is one of the most refractory neoplasms to medical treatment. Until now there has been only modest improvement in the treatment of this disease. Standards of care for combined-modality treatment of resectable as well as locally advanced, unresectable disease have not been uniformly accepted to date because of an equivocal or conflicting data. The inception of gemcitabine introduced the new era in the management of metastatic pancreatic cancer, however, new therapeutic approaches still need to be defined. The article discusses the current knowledge of the biology of this lethal disease, its impact on treatment options, and explores novel therapeutic modalities that are likely to improve outcomes and survival for patients in the future.

Metastatic pancreatic cancer

Metastatic pancreatic cancer is one of the leading causes of cancer-related deaths in North America and Europe. In the past, patients with metastatic pancreatic cancer have had few treatment options. However, recently, several effective palliative therapies and procedures have become available. The systemic administration of gemcitabine has been shown to result in clinical benefit and in a prolongation of median survival, and is now established as the standard first-line treatment for patients with metastatic pancreatic cancer. Clinical trials are exploring whether the use of gemcitabine-based chemotherapy combinations will result in further benefit. Several novel chemotherapeutic and biologic agents appear promising, and are likely to play a role in the treatment of patients with pancreatic cancer in the future. Palliative procedures, such as biliary or duodenal stenting and celiac plexus blockade, should be considered in conjunction with systemic therapy in patients with specific complications from pancreatic cancer.

Gemcitabine therapy in patients with advanced pancreatic cancer

BACKGROUND

Advanced, unresectable pancreatic cancer is an extremely aggressive disease. The 5-year survival rate for pancreatic cancer is only less than 5%. Current therapeutic options for patients with locally advanced or metastatic disease are limited. This analysis is a retrospective evaluation of the efficacy and toxicity of gemcitabine regimen as first-line chemotherapy in patients with advanced pancreatic cancer.

METHODS

Seventeen chemotherapy-naive patients with advanced or recurred pancreatic cancer were consecutively treated. Gemcitabine was diluted in normal saline and administered intravenously over 1 hour. Gemcitabine 1,000 mg/m2 was administered once weekly for 3 out of every 4 weeks.

RESULTS

The median age of patients was 55 years (range 44-82 years). Based on RECIST criteria, there were 5 cases of stable disease (45%) and 6 cases of progressive disease (55%) among the 11 assessable patients. The median survival time was 189 days (range, 84 to 409 days), the 1 year survival rate was 18% in all 17 patients. Grade 3-4 toxic side effect was leucopenia only (29%) and was easily managed without infection.

CONCLUSION

Gemcitabine is well tolerated, but has no objective response in advanced pancreatic cancer.

Effect of the vascular endothelial growth factor receptor-2 antibody DC101 plus gemcitabine on growth, metastasis and angiogenesis of human pancreatic cancer growing orthotopically in nude mice

Vascular endothelial growth factor (VEGF) is the major pro-angiogenic factor for most tumors. VEGF expression has been shown to be associated with a poor prognosis in human pancreatic cancer. The purpose of our study was to determine the effect of blockade of VEGF receptor-2 activity with or without gemcitabine on tumor growth and metastasis in an orthotopic model of human pancreatic cancer in nude mice. Therapy with gemcitabine or DC101, a VEGF receptor-2 antibody, resulted in a significant reduction of primary pancreatic tumor growth compared to untreated controls. The combination of DC101 and gemcitabine inhibited primary pancreatic tumor growth and lymphatic metastasis to a greater degree than either agent alone. Treatment with DC101 decreased vessel counts and increased the area of hypoxic tumor tissue compared to controls. Immunofluorescent double staining for apoptotic endothelial cells demonstrated a significant increase in the number apoptotic endothelial cells 24 days after initiation of therapy with DC101 plus gemcitabine. DC101 plus gemcitabine also increased tumor cell death and decreased tumor cell proliferation in pancreatic tumors. These findings indicate that blockade of VEGF receptor activation interferes with the survival of tumor endothelial cells, resulting in a reduction of primary pancreatic tumor growth in nude mice. Furthermore, the data demonstrate that anti-VEGF receptor-2 therapy potentiates the tumoricidal effect of gemcitabine in this model. Anti-VEGF receptor-2 therapy in combination with gemcitabine may be a novel therapeutic approach for advanced pancreatic cancer.

Phase II study of a fixed dose-rate infusion of gemcitabine associated with uracil/tegafur in advanced carcinoma of the pancreas

BACKGROUND

The objectives of this study were to evaluate the efficacy and toxicity of a fixed dose-rate infusion of gemcitabine associated with uracil/tegafur (UFT) in patients with advanced adenocarcinoma of the pancreas.

PATIENTS AND METHODS

Forty-three chemotherapy-naïve patients with adenocarcinoma of the pancreas were included in this phase II study. All of whom had a Karnofsky performance status >or=50 and bi-dimensionally measurable disease (either advanced non-resectable or metastatic); median age 59 years (range 39-77); male:female ratio 29:14. Eight patients (19%) had locally advanced disease and 35 (81%) distant metastases. Treatment consisted of gemcitabine 1200 mg/m(2) given as a 120-min infusion weekly for 3 consecutive weeks, plus oral UFT 400 mg/m(2)/day (in 2-3 doses per day) on days 1-21, cycles were given every 28 days. Measurements of efficacy included response rate, clinical benefit response, time to disease progression and overall survival.

RESULTS

A total of 192 cycles of chemotherapy were delivered with a median of four per patient. There were two complete responses (5%) and 12 partial responses (28%), producing an overall response rate of 33% [95% confidence interval (CI) 16% to 49%]. Thirteen patients (30%) had stable disease, whereas 16 (37%) had a progression. The median time to progression was 6 months and the median overall survival was 11 months. Twenty-five patients (64%, 95% CI 47% to 78%) experienced a clinical benefit response. Grade 3-4 WHO toxicities were: neutropenia in nine patients (21%); thrombocytopenia in four (9%); anaemia in five (12%); diarrhoea in four (9%); and asthenia in one (2%).

CONCLUSIONS

A fixed dose-rate infusion of gemcitabine associated with UFT was well tolerated and showed promising activity in patients with locally advanced or metastatic carcinoma of the pancreas. This is an appropriate palliative treatment in this setting.