2011 Focused Update of 2009 American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV Non-Small-Cell Lung Cancer

[Development and validation of a tool for evaluating core competencies in nursing cancer patients on chemotherapy]

PURPOSE

This study was done to develop tool to evaluate the core competencies regarding nursing cancer patients on chemotherapy, and to verify the reliability and efficacy of the developed tool.

METHODS

A tool to evaluate the core competencies was developed from a preliminary tool consisting of 112 items verified by expert groups. The adequacy of the preliminary tool was analyzed and refined to the final evaluation tool containing 76 items in 8 core competencies and 18 specific competencies. The evaluation tool is in the form of a self-report, and each item is evaluated according to a 3-point scale. From September 22 to October 14, 2011, 349 survey responses were analyzed using SPSS 20.0 and the WINSTEPS program that employs the Rasch model.

RESULTS

Results indicated that there were no inappropriate items and the items had low levels of difficulty in comparison with the knowledge levels of the study participants. The results of factor analysis yielded 18 factors, and the reliability of the tools was very high with Cronbach's α=.97.

CONCLUSION

The results of this study can be used for training and evaluation of core competencies for nursing cancer patients, and for standardizing nursing practices associated with chemotherapy.

A randomized, phase 2 study comparing pemetrexed plus best supportive care versus best supportive care as maintenance therapy after first-line treatment with pemetrexed and cisplatin for advanced, non-squamous, non-small cell lung cancer

BACKGROUND

Maintenance therapy for non-small cell lung cancer (NSCLC) aims to extend disease control after first-line chemotherapy with active and well-tolerated agents. The utility of continuation maintenance therapy requires further research.

METHODS

This multicenter, randomized, phase 2 study compared continuation maintenance therapy with pemetrexed (500 mg/m2 every 21 days) and best supportive care (BSC) versus BSC alone in patients with advanced, non-squamous NSCLC who had not progressed after 4 cycles of induction chemotherapy with pemetrexed (500 mg/m2) and cisplatin (75 mg/m2). The primary endpoint was progression-free survival (PFS) from randomization, was analyzed using a Cox model, stratified for the tumor response at the end of induction therapy, at a one-sided alpha of 0.2. Secondary endpoints: response and disease control rates, overall survival (OS), one year survival rates, and treatment-emergent adverse events (TEAEs).

RESULTS

A total of 106 patients commenced induction therapy, of whom 55 patients were randomized to maintenance pemetrexed/BSC (n = 28) or BSC (n = 27). Although the median PFS time for maintenance phase for both arms was 3.2 months, the one-sided p-value for the PFS HR comparison was less than the prespecified limit of 0.2 (HR = 0.76, two-sided 95% confidence interval [CI]: 0.42 to 1.37; one-sided p-value = 0.1815), indicating that PFS was sufficiently long in the pemetrexed/BSC arm to warrant further investigation. Similar PFS results were observed for the overall study period (induction plus maintenance) and when the PFS analysis was adjusted for sex, baseline disease stage, and the ECOG PS prior to randomization. The median OS for the maintenance phase was 12.2 months (95%CI: 5.6 to 20.6) for the pemetrexed/BSC arm and 11.8 months (95% CI: 6.3 to 25.6) for BSC arm. The one-year survival probabilities were similar for both arms for the maintenance phase and the overall study period. Both the induction and continuation maintenance therapies were generally well-tolerated, and similar proportion of patients in each arm experienced at least 1 grade 3/4 TEAE (pemetrexed/BSC, 17.9%; BSC, 18.5%).

CONCLUSIONS

Continuation pemetrexed maintenance therapy resulted in promising PFS with an acceptable safety profile in a Middle Eastern population with advanced non-squamous NSCLC and is worthy of further investigation.

TRIAL REGISTRATION

NCT00606021.

Aflibercept and Docetaxel versus Docetaxel alone after platinum failure in patients with advanced or metastatic non-small-cell lung cancer: a randomized, controlled phase III trial

PURPOSE

To compare the efficacy of aflibercept (ziv-aflibercept), a recombinant human fusion protein targeting the vascular endothelial growth factor (VEGF) pathway, with or without docetaxel in platinum-pretreated patients with advanced or metastatic nonsquamous non-small-cell lung cancer.

PATIENTS AND METHODS

In this international, double-blind, placebo-controlled phase III trial, 913 patients were randomly assigned to (ziv-)aflibercept 6 mg/kg intravenous (IV; n = 456) or IV placebo (n = 457), both administered every 3 weeks and in combination with docetaxel 75 mg/m(2). The primary end point was overall survival (OS). Other efficacy outcomes, safety, and immunogenicity were also assessed.

RESULTS

Patient characteristics were balanced between arms; 12.3% of patients had received prior bevacizumab. (Ziv-)Aflibercept did not improve OS (hazard ratio [HR], 1.01; 95% CI, 0.87 to 1.17; stratified log-rank P = .90). The median OS was 10.1 months (95% CI, 9.2 to 11.6 months) for (ziv-)aflibercept and 10.4 months (95% CI, 9.2 to 11.9 months) for placebo. In exploratory analyses, median progression-free survival was 5.2 months (95% CI, 4.4 to 5.6 months) for (ziv-)aflibercept versus 4.1 months (95% CI, 3.5 to 4.3 months) for placebo (HR, 0.82; 95% CI, 0.72 to 0.94; P = .0035); overall response rate was 23.3% of evaluable patients (95% CI, 19.1% to 27.4%) in the (ziv-)aflibercept arm versus 8.9% (95% CI, 6.1% to 11.6%; P < .001) in the placebo arm. Grade ≥ 3 adverse events occurring more frequently in the (ziv-)aflibercept arm versus the placebo arm were neutropenia (28.0% v 21.1%, respectively), fatigue (11.1% v 4.2%, respectively), stomatitis (8.8% v 0.7%, respectively), and hypertension (7.3% v 0.9%, respectively).

CONCLUSION

The addition of (ziv-)aflibercept to standard docetaxel therapy did not improve OS. In exploratory analyses, secondary efficacy end points did seem to be improved in the (ziv-)aflibercept arm. The study regimen was associated with increased toxicities, consistent with known anti-VEGF and chemotherapy-induced events.

Efficacy assessment of pemetrexed treatment of an NSCLC case with brain metastasis

Non-small cell lung cancers (NSCLCs) are among the most common malignancies. Although pemetrexed is often used clinically to cure cancers, its efficacy in NSCLC patients with progressive brain metastases remains unclear. Here, we report a successful NSCLC (adenocarcinoma) case treated with pemetrexed. The detected tumors were treated with 900 mg of pemetrexed disodium (500 mg/m(2)) was administered to the patient on day 1, and 40 mg of cisplatin (25mg/m(2)) was administered on days 1-3, at the interval of 3 weeks. After two cycles of chemotherapy, the brain metastases were reduced. The lesion in the lung was reduced as determined by chest CT-scan. Our results suggest that pemetrexed is an effective therapy for patients with NSCLC and progressive brain metastases.

Maintenance therapy for advanced non-small-cell lung cancer: ready for clinical practice?

The treatment paradigm for advanced non-small-cell lung cancer has changed in recent years with the importance of histological subtyping for the choice of chemotherapy, and the use of molecular markers to select patients for targeted therapy. Maintenance therapy (MT) is another focus of interest. The potential benefit of MT for the patient is that it prolongs tumor control reached with first-line chemotherapy in order to improve overall survival with little added toxicity. Historical studies have never reached this goal, as the agents used for MT were too poorly tolerated. We review the data of the two types of recent MT studies, 'continuation' and 'switch' or 'consolidation' MT. We comment on how the benefits demonstrated in these studies may change clinical practice and reflect on factors that may identify subgroups of patients who derive the greatest benefit from MT in general, as this will help in a rational use of MT.

Vinorelbine and gemcitabine vs vinorelbine and carboplatin as first-line treatment of advanced NSCLC. A phase III randomised controlled trial by the Norwegian Lung Cancer Study Group

Background:

Platinum-based doublet chemotherapy is the standard first-line treatment for advanced non-small cell lung cancer (NSCLC), but earlier studies have suggested that non-platinum combinations are equally effective and better tolerated. We conducted a national, randomised study to compare a non-platinum with a platinum combination.

Methods:

Eligible patients had stage IIIB/IV NSCLC and performance status (PS) 0–2. Patients received up to three cycles of vinorelbine 60 mg m⁻² p.o.+gemcitabine 1000 mg m⁻² i.v. day 1 and 8 (VG) or vinorelbine 60 mg m⁻² p.o. day 1 and 8+carboplatin area under the curve=5 (Calvert's formula) i.v. day 1 (VC). Patients ⩾75 years received 75% of the dose. Endpoints were overall survival, health-related quality of life (HRQoL), toxicity, and the use of radiotherapy.

Results:

We randomised 444 patients from September 2007 to April 2009. The median age was 65 years, 58% were men and 25% had PS 2. Median survival was VG: 6.3 months; VC: 7.0 months, P=0.802. Vinorelbine plus carboplatin patients had more grade III/IV nausea/vomiting (VG: 4%, VC: 12%, P=0.008) and grade IV neutropenia (VG: 7%, VC: 19%, P<0.001). Infections, HRQoL and the use of radiotherapy did not differ significantly between the treatment groups.

Conclusion:

The two regimens yielded similar overall survival. The VG combination had only a slightly better toxicity profile.

Lung cancer chemotherapy decisions in older patients: the role of patient preference and interactions with physicians

PURPOSE

Lung cancer chemotherapy decisions in patients ≥ 70 years old are complex because of toxicity, comorbidity and the limited data on patient preferences. We examined the relationships between preferences and chemotherapy use in this group of patients.

METHODS AND PATIENTS

We used a questionnaire describing four hypothetical lung cancer treatment options. Eighty-three elderly (≥ 70 years old) lung cancer patients were informed about their diagnosis and therapeutic choices and then asked to choose one of the four options. Patients had previously been included in a prospective study to explore geriatric evaluation in an oncology unit and all had given written informed consent.

RESULTS

Older patients (n=83) diagnosed with lung cancer (non-small- and small-cell lung cancer) from January 2006 to February 2008 were recruited from a single centre. The mean patient age was 77 years (range: 70-91). Eighty-one patients (97.6%) were men. Non-small-cell lung cancer (NSCLC) was the diagnosis in 63 patients (76%). Most patients selected active treatment (38.6% most survival benefit, 18% less survival benefit) and 31.3% selected no active treatment. Elderly lung cancer patients were significantly more likely to accept aggressive treatments despite high reported toxicities. Although most of the patients were symptomatic at diagnosis, the "symptom relief" option was chosen less frequently than the options that could prolong survival. Factors significantly related to patients' attitude toward chemotherapy were age (p<0.001), frailty (p=0.0039), depression and poor performance status (PS).

CONCLUSION

Elderly lung cancer patients want to be involved in the decision-making process. Survival was the main treatment objective for more than half of the patients in this study. We have not found other published studies about elderly lung cancer patients' decisions about chemotherapy.

The effectiveness of maintenance pharmacotherapies for non-small cell lung cancer

Although current recommendations for the treatment of advanced non-small cell lung cancer (NSCLC) include a maximum of six cycles of platinum-based combination therapy as a first-line approach, most patients experience progression within 3-4 months. Therefore, a new treatment strategy, maintenance therapy, has been proposed, and several large randomized prospective controlled trials have shown benefits with maintenance therapy. Maintenance therapy can be classified as either continuation maintenance, which is defined as a prolongation of a part of the first-line chemotherapy or molecularly targeted agent until progression, or switch-maintenance, which is defined as the administration of a different cytotoxic chemotherapy or molecularly targeted agent immediately after induction therapy. In this article, recent results from large randomized phase III trials regarding maintenance therapy are reviewed in order to evaluate the role of maintenance therapy in NSCLC.

Projecting future drug expenditures--2012

PURPOSE

Factors likely to influence drug expenditures, drug expenditure trends in 2010 and 2011, and projected drug expenditures for 2012 are discussed.

SUMMARY

Data were analyzed to provide drug expenditure trends for total drug expenditures and the hospital and clinic sectors. Data were obtained from the IMS Health National Sales Perspectives database. From 2009 to 2010, total U.S. drug expenditures increased by 2.7%, with total spending rising from $299.2 billion to $307.5 billion. Drug expenditures in clinics grew by 6.0% from 2009 to 2010. Hospital drug expenditures increased at the moderate rate of 1.5% from 2009 to 2010; through the first nine months of 2011, hospital drug expenditures increased by only 0.3% compared with the same period in 2010. The dominant trend over the past several years is substantial moderation in expenditure growth for widely used drugs, primarily due to the ongoing introduction and wide use of generic versions of high-cost, frequently used medications. At the end of 2010, generic drugs accounted for 78% of all retail prescriptions dispensed. Another pattern is substantial increases in expenditures for specialized medications, particularly in the outpatient setting as growth in prescription drug expenditures for clinic-administered drugs consistently outpaces growth in total expenditures. Various factors are likely to influence drug expenditures in 2012, including drugs in development, the diffusion of new drugs, generic drugs, drug shortages, and biosimilars.

CONCLUSION

For 2012, we project a 3-5% increase in total drug expenditures across all settings, a 5-7% increase in expenditures for clinic-administered drugs, and a 0-2% increase in hospital drug expenditures.

Maintenance therapy in non-small-cell lung cancer

With standard doublet chemotherapy for patients with advanced non-small-cell lung cancer (NSCLC), we have reached an outcome plateau of about 10 months median overall survival over the last decades. Several studies have now demonstrated some survival benefits for patients treated beyond induction chemotherapy. In the current discussion about treatment duration, the terms "switch" and "continuation" maintenance therapy are now most commonly used by the scientific community. Switch maintenance is the treatment with an agent with a different mode of action after completion of induction chemotherapy in patients who's tumors have not progressed, whereas continuation maintenance is the continuation of one compound of the induction regimen. Chemotherapeutic compounds successfully investigated in the maintenance setting are Gemcitabine, Docetaxel and Pemetrexed. Targeted agents, recently investigated as maintenance therapy are Bevacizumab, Cetuximab and Erlotinib. New peer-reviewed publications of phase III randomized clinical trials on maintenance chemotherapy have led to a change in current practice guidelines and the use of maintenance therapy represents a new treatment option in advanced NSCLC. The pivotal trials are described and summarized in this review article.

Lung cancer in Brazil

Cancer is now the second leading cause of death in Brazil (after cardiovascular diseases) and a public health problem, with around 500,000 new cases in 2012. Excluding nonmelanoma skin cancer, lung cancer is the second most incident cancer type in men, with 17,210 expected new cases. In women, it is the fifth most incident cancer, with 10,110 expected new cases. The estimated age-adjusted lung cancer mortality rate is about 13/100,000 for men and 5.4/100,000 for women. Lung cancer rates in men increased until the early 1990s and decreased thereafter, especially in the younger population. In contrast, a steady upward trend was observed for women. The positive effects in men were probably due to the successful anti-tobacco campaign conducted in Brazil over the last decades, which led to a decrease in the adult smoking population, from 32% in the early 1980s to 17% in the 2000s. Although the Brazilian National Cancer Institute is strongly committed to providing excellence in multimodality care to cancer patients, limitations in availability and adequate geographic distribution of specialists and well-equipped cancer centers are evident. Major disparities in patient access to proper staging and state-of-the-art treatment still exist. Considering that World Health Organization (WHO) officials estimate that cancer will become the number one cause of death in most developing countries, including Brazil, in the next decades, it is highly recommended for government authorities to implement firm actions to face this tremendous challenge.

Prospective phase II trial of a combination of gemcitabine and UFT as first-line treatment in elderly patients with advanced non-small cell lung cancer

BACKGROUND

The standard regimen in elderly patients with non-small-cell lung cancer (NSCLC) is still uncertain. Gemcitabine is one of the most widely used drugs for the treatment of NSCLC, and several phase II trials specifically designed for elderly patients with advanced NSCLC have confirmed the role of gemcitabine in this setting. In addition, oral uracil-tegafur (UFT) was associated with a survival advantage in the adjuvant setting. Therefore, we performed a phase II study using the combination of gemcitabine and UFT as first-line therapy in elderly patients with advanced NSCLC.

METHODS

Chemotherapy-naïve, elderly (≥ 70 years) patients who had histologically or cytologically confirmed with stage IIIB or IV NSCLC with a performance status of 1-2 were enrolled. Patients received gemcitabine (1250 mg/m(2) on days 1 and 8, respectively) and UFT (400mg/day on days 1-14) every 3 weeks for up to four cycles. Patients who had not progressed after four cycles continued UFT monotherapy until progression. Primary endpoint was overall response rate and secondary endpoints were overall survival, time to progression and safety profiles.

RESULTS

Between March 2008 and November 2010, 48 patients were enrolled. The median age was 74.5 years (range: 70-84 years), and there were 29 males. The performance status was 1 in 41 and 2 in 7 patients. Thirty-one (64.6%) patients were stage IV and seventeen (35.4%) patients were stage IIIB. Thirty patients (62.5%) completed four cycles of chemotherapy. Response was evaluated in 44 patients. Partial response was achieved in twelve (25.0%) patients and stable disease in 23 (47.9%) patients. Disease control rate was 72.9%. The median survival time was 6.1 months (95% confidence interval [CI]; 5.1-7.0 months), the 1-year survival rate was 29.1% and the median time to progression was 4.6 months (95% CI; 3.7-5.5 months). Toxicities were mild and mostly hematological adverse events. Grade 3/4 neutropenia occurred in 8.3% of patients and one patients experienced febrile neutropenia. Grade 3/4 anemia and thrombocytopenia occurred in 2.1% and 2.1% of patients, respectively. Non-hematological toxicities were tolerable.

CONCLUSIONS

The combination of gemcitabine and UFT was effective in disease control and well tolerated first-line regimen in elderly patients with advanced NSCLC.

2011 Focused Update of 2009 American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV Non-Small-Cell Lung Cancer

ASCO produced the 2011 Focused Update based on phase III randomized clinical trials published on maintenance chemotherapy, addressing one question from the 2009 Guideline Update on chemotherapy for stage IV NSCLC: what is the optimal duration of first-line chemotherapy for stage IV NSCLC?

Prognostic role of ERCC1 in advanced non-small-cell lung cancer: a systematic review and meta-analysis

Small observational studies have demonstrated an association between high ERCC1 expression level and poor prognosis in advanced NSCLC treated with platinum-based chemotherapy. This meta-analysis presents pooled estimates of association from 11 studies. High ERCC1 patients had lower response rates and higher risk of death relative to low ERCC1 patients. These results support the prognostic significance of ERCC1 expression level in advanced NSCLC.

BACKGROUND

Observational studies have demonstrated an association between excision repair cross-complementation group 1 (ERCC1) expression level and health outcomes in patients with advanced non-small-cell lung cancer (NSCLC) treated with platinum-based regimens. This analysis presents pooled estimates of association from these studies to better elucidate the prognostic role of ERCC1 in advanced NSCLC.

METHODS

A systematic literature search was conducted using the MEDLINE, EMBASE, and American Society of Clinical Oncology (ASCO) annual meeting databases from June 1995 to December 2010. Included studies were evaluated for clinical, methodological, and statistical heterogeneity. Pooled analyses were conducted using fixed and random effects models.

RESULTS

In high ERCC1 expression versus low ERCC1 expression patients, pooled analysis results demonstrated a significantly lower response (risk ratio [RR], 0.80, 0.66-0.98) and significantly higher risk of death (hazard ratio [HR], 2.04, (1.48-2.80)), respectively. Subgroup analyses demonstrated significant heterogeneity in outcomes by ERCC1 measurement method (I(2): 90.7%, P = 0.001) and patient population ethnicity (I(2): 66%, P = 0.003).

CONCLUSION

This study's findings support the hypothesis that ERCC1 expression is associated with response rate and overall survival (OS) in patients with advanced NSCLC treated with platinum-based chemotherapy. Heterogeneity in subgroup analyses demonstrates the need for standardized methods to classify ERCC1 expression level, studies evaluating the association between ERCC1 expression and OS in non-Asian populations, and studies evaluating interaction between ERCC1 and other known prognostic factors in advanced NSCLC.

American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV Non-Small-Cell Lung Cancer

ASCO published a guideline on use of chemotherapy in advanced stage non-small-cell lung cancer in 1997. The latest update covers treatment with chemotherapy and biologic agents and reviews literature from 2002 to 2009.