Three-arm randomized study of two cisplatin-based regimens and paclitaxel plus gemcitabine in advanced non-small-cell lung cancer: a phase III trial of the European Organization for Research and Treatment of Cancer Lung Cancer Group--EORTC 08975

Alternating weekly administration of paclitaxel and gemcitabine: a phase II study in patients with advanced non-small-cell lung cancer

BACKGROUND

We sought to evaluate toxicity and efficacy of an alternating week schedule of paclitaxel and gemcitabine in patients with advanced non-small-cell lung cancer (NSCLC).

METHODS

Patients (n=27, mean age 56 years, range 27-73 years) received paclitaxel (100 mg/m(2) i.v. infusion over 1 h) on days 1 and 15 alternating with gemcitabine (1000 mg/m(2)) on days 8 and 22 of a 36-day cycle. Responses were evaluated after three cycles, and after the proposed six cycles.

RESULTS

In total, 116 cycles were administered (mean 4.25 cycles per patient). Haematological toxicity was slight: febrile neutropenia (n=1) and neutropenia grade III-IV (n=5). Non-haematological toxicities included arthromyalgia grade II (n=6) and neurotoxicity grade III (n=1). Objective response was 29%, stable disease 25% and disease progression 46%. Median duration of response was 8 months (95% CI 5-11 months), median progression-free survival was 7 months (95% CI 4-11 months), median overall survival was 13 months (95% CI 7-17 months) and survival at 1 year was 52%.

CONCLUSIONS

A regimen of alternating weekly paclitaxel and gemcitabine is feasible in patients with advanced NSCLC, showing a lower toxicity profile compared with other platinum-based combinations, which makes this novel scheme attractive for these patients.

Pemetrexed in the treatment of advanced non-small-cell lung cancer: a review of the clinical data

Pemetrexed is a novel multitargeting antimetabolite that has first-line and second-line activity against non-small cell lung cancer (NSCLC). Phase II studies have shown significant efficacy and a favorable toxicity profile of the combination of pemetrexed plus platinum as first-line therapy for NSCLC. Second-line activity against NSCLC was demonstrated in a phase III trial comparing single-agent pemetrexed with docetaxel; in that trial, survival was comparable between these agents but side effects were significantly less for patients who received pemetrexed. Pemetrexed is also an active agent against mesothelioma. A phase III trial comparing pemetrexed plus cisplatin with cisplatin alone showed for the first time a regimen that improves survival in this disease and led to FDA approval of pemetrexed in combination with cisplatin for mesothelioma. As a radiosensitizer, pemetrexed has been well-tolerated when given concurrent with chest radiation, and a phase I study is under way assessing its tolerability in combination with carboplatin in this setting. Pemetrexed is clearly a useful agent in the treatment of thoracic malignancies, and is worthy of further study in combination with other drugs having novel mechanisms of action.

Phase II Study of Pemetrexed-Gemcitabine Combination in Patients with Advanced-Stage Non-Small Cell Lung Cancer

PURPOSE

Cisplatin is one of the most active agents for the treatment of non-small cell lung cancer (NSCLC). It is also known for significant toxicity, which makes it unsuitable for certain patients. Our purpose was to evaluate the efficacy and toxicity of a promising cisplatin-free combination, gemcitabine plus pemetrexed, in NSCLC.

EXPERIMENTAL DESIGN

Chemo-naive patients with inoperable NSCLC were eligible for this study. Gemcitabine (1250 mg/m2) was given intravenously on days 1 and 8, followed by intravenous pemetrexed (500 mg/m2) on day 8. After inclusion of 13 patients, folic acid and vitamin B12 supplementation was added to lower pemetrexed-induced toxicity. Quality of life was assessed with the Lung Cancer Symptom Scale.

RESULTS

Sixty patients enrolled; 58 were evaluable for response. All patients had a World Health Organization performance status of 0 or 1. Eighty-seven percent had stage IV disease. Nine patients had a confirmed partial response [overall response rate, 15.5%; 95% confidence interval (CI), 7.3-27.4%]. Twenty-nine (50.0%) patients had stable disease. Median overall survival was 10.1 months (95% CI, 7.9-13.0 months), with a 1- and 2-year overall survival of 42.6% (95% CI, 30.0-55.3%) and 18.5% (95% CI, 7.9-29.1%). Median progression-free survival was 5.0 months. Median response duration was 3.3 months. There were no deaths attributed to treatment. Common Toxicity Criteria grade 3/4 toxicities were neutropenia (61.7%), febrile neutropenia (16.7%), fatigue (23.3%), and elevations of aspartate aminotransferase (15.0%) and alanine aminotransferase (20.0%).

CONCLUSIONS

This combination had good tolerance and achieved promising overall survival with extended 1- and 2-year survival rates. This cisplatin-free regimen warrants further evaluation in randomized trials.

Therapy of advanced non-small-cell lung cancer (take home message)

Palliative therapy of advanced NSCLC aims at symptom relief, improvement of quality of life and prolongation of survival. This goal is usually achieved by one or more of the following treatment modalities: chemotherapy, radiotherapy, special palliative interventions and general supportive care measures.

Dilemmas in Management: The Controversial Role of Chemotherapy in PS 2 Advanced NSCLC and the Potential Role of CT‐2103 (Xyotax ™ )

Platinum-based chemotherapy improves long-term survival in patients with advanced non-small cell lung cancer (NSCLC). Meta-analyses have demonstrated an improvement in median and 1-year survival times as well as quality of life. However, these benefits are largely confined to patients with a good performance status (PS), one of the most critical determinants influencing outcome. Several clinical trials that initially included PS 2 patients ultimately discontinued their enrollment due to a high propensity of adverse reactions to treatment. The advent of more active, less toxic agents has revitalized investigator interest in treating PS 2 patients. CT-2103 is a novel paclitaxel conjugate undergoing investigation in the treatment of advanced NSCLC. The median survival for PS 2 patients treated with single-agent CT-2103 in one small trial proved similar to that reported for paclitaxel/carboplatin in NSCLC patients and was associated with an improved safety profile compared with conventional taxanes. Phase III studies comparing CT-2103 as a single agent and in combination with carboplatin to current standards of care are in progress. Unlike a well-defined population with good PS, the therapeutic index in PS 2 patients is narrower and not as clearly defined. These and other efforts will determine the optimal mode of therapy in PS 2 individuals with NSCLC.

Front-line paclitaxel–vinorelbine versus paclitaxel–carboplatin in patients with advanced non-small-cell lung cancer: a randomized phase III trial

PURPOSE

This randomized phase III trial of advanced or metastatic non-small-cell lung cancer (NSCLC) was designed to compare a standard treatment such as carboplatin (CRP)-paclitaxel (PCT) with a new combination, vinorelbine (VRL)-PCT-two agents acting in microtubules.

PATIENTS AND METHODS

Three hundred and sixty patients (stage IIIa, IIIb and IV) were included and evaluated for response rate, survival and toxicity. Arm A patients were treated with the control combination of CRP 6 AUC and PCT 175 mg/m(2) repeated every 3 weeks for six cycles, and arm B with the investigational combination of VRL 25 mg/m(2) and PCT 135 mg/m(2) repeated every 2 weeks for nine cycles. The patients were well balanced with respect to gender, disease stage and performance status. Arm A received 849 cycles (mean 4.59 per patient) and arm B 951 cycles (mean 5.39 per patient).

RESULTS

Complete and partial response rates were 45.95% and 42.86% for arms A and B, respectively. Median survival was 11 and 10 months, 1-year survival 42.7% and 37.85% and 2-year survival 10.12% and 19% for arms A and B, respectively. Toxicity was similar in all patients, except for neutropenia, which was significantly greater in arm B.

CONCLUSIONS

PCT combined with VRL produces similar (non-significant) response rates, survival and toxicity (except for neutropenia, as noted above) to standard CRP-PCT treatment in untreated advanced-stage NSCLC.

Combination of gemcitabine and cisplatin as first-line therapy in advanced non-small-cell lung cancer

PURPOSE

The prognosis of patients with advanced non-small-cell lung cancer (NSCLC) is extremely poor. Many prospective randomized trials on patients with advanced NSCLC suggested systemic chemotherapy improves both the survival and quality of life. A phase II trial was conducted to evaluate the efficacy and safety profile of the combination chemotherapy of gemcitabine and cisplatin in advanced NSCLC.

MATERIALS AND METHODS

Forty-four patients with locally advanced or metastatic NSCLC were enrolled. The patients received a cisplatin, 75 mg/m(2), infusion over 30 minutes on days 1, followed by a gemcitabine, 1,250 mg/m(2), infusion over 30 minutes on days 1 and 8 every 3 weeks.

RESULTS

The median age of the patients was 64 years (range: 27 approximately 75). Forty-one patients were assessable for response and toxicity analyses. The overall response rate was 53.6%, but with no complete remissions. The median time to progression was 5.6 months (range: 1 approximately 15.4). The median survival was 14.2 months (95% confidence interval (CI), 13.8 approximately 22.5). A total of 179 cycles were administered, with a median of 4 cycles of chemotherapy, ranging from 2 to 9 cycles. The most common hematological toxicities were NCI grades 3/4 neutropenia (24%) and thrombocytopenia (7.8%). The most common non-hematological toxicity was fatigue (42.4%). There were no life-threatening toxicity or treatment related mortalities. The median duration of follow up was 9.4 months, ranging from 1.6 to 30.3 months.

CONCLUSION

In this trial, the combination of gemcitabine and cisplatin showed significant activity, with acceptable and manageable toxicities as a first-line regimen for patients with advanced NSCLC.

Phase I/II study of cisplatin combined with weekly paclitaxel in patients with advanced non-small-cell lung cancer

To determine the maximum-tolerated dose (MTD) and the recommended dose (RD) of paclitaxel administered weekly with a fixed dose of cisplatin, and to assess the toxicity and activity of this combination, we conducted a phase I/II trial in patients with advanced non-small-cell lung cancer (NSCLC). In this study, patients with stage IIIB/IV NSCLC were eligible. Paclitaxel, at a starting dose of 40 mg m⁻² week⁻¹ on days 1, 8, and 15, was combined with a fixed dose of cisplatin 80 mg m⁻² on day 1. Chemotherapy was given in a 4-week cycle. In this phase I/II study, 38 patients were enrolled. Dose-limiting toxicities (DLT) were neutropenia, fatigue, and omission of treatment due to leucopenia, thrombocytopenia, or febrile neutropenia. The MTD and RD were estimated to be 70 mg m⁻². Of the 37 assessable patients, 23 had a partial response and one had a complete response. Overall response rate was 62.1% (95% confidence interval (CI): 46.5–77.7%). The progression-free survival, the median survival time, and the 1-year survival rate were 5.5 months, 13.7 months, and 56.9%, respectively. This regimen is tolerable and very active against advanced NSCLC, and its efficacy should be confirmed in a phase III study.

Clinical Issues in the Management of Non–Small-Cell Lung Cancer and the Role of Platinum-Based Therapy

Although the benefits of chemotherapy have been established for treating non-small-cell lung cancer (NSCLC), several clinical issues remain. Currently, doublets offer the maximum benefit in terms of balancing efficacy with tolerability to patients with advanced-stage disease. The optimal duration of therapy continues to be evaluated, and several agents have emerged for treating patients with recurrent advanced NSCLC. Chemotherapy benefits for populations underrepresented in clinical trials, such as elderly patients and patients with poor performance status, also need to be established. Although combination therapy with carboplatin/paclitaxel is one regimen of choice for treating advanced NSCLC, there may be ways to optimize its delivery schedule including use of weekly administration of paclitaxel and monthly administration of carboplatin. In addition, biologic approaches are being investigated to determine if these agents may be appropriate for treating patients with advanced NSCLC and how best to administer them. In resectable stage IIIA disease, benefits of preoperative chemotherapy and chemotherapy/radiation therapy followed by surgery continue to be evaluated. Although associated with esophageal toxicity, in non-resectable stage IIIA/IIIB disease, concurrent chemotherapy/radiation therapy has emerged as the schedule of choice. Yet, benefits of higher radiation dosage need evaluation. Based on phase II studies, preoperative chemotherapy with or without radiation may benefit patients with early-stage disease, but studies have been inconclusive, yielding mixed results. Recent trials of adjuvant chemotherapy following surgical resection in early-stage NSCLC have yielded conflicting results, with some trials showing no benefit to adjuvant therapy. Trials under way will determine the future of adjuvant or induction chemotherapy in treating this patient population.

[The role of meta-analysis in assessing the treatment of advanced non-small cell lung cancer]

Meta-analysis is a statistical method allowing an evaluation of the direction and quantitative importance of a treatment effect observed in randomized trials which have tested the treatment but have not provided a definitive conclusion. In the present review, we discuss the methodology and the contribution of meta-analyses to the treatment of advanced-stage or metastatic non-small-cell lung cancer. In this area of cancerology, meta-analyses have provided determining information demonstrating the impact of chemotherapy on patient survival. They have also helped define a two-drug regimen based on cisplatin as the gold standard treatment for patients with a satisfactory general status. Recently, the meta-analysis method was used to measure the influence of gemcitabin in combination with platinium salts and demonstrated a small but significant benefit in survival, confirming that gemcitabin remains the gold standard treatment in combination with cisplatin.

A 21-day schedule of gemcitabine and cisplatin administration in the treatment of advanced non-small cell lung carcinoma: a phase II study

PURPOSE

To evaluate the efficacy and toxicity of gemcitabine and cisplatin combination chemotherapy, we conducted a phase II study of this regimen in patients with advanced non-small cell lung carcinoma (NSCLC).

MATERIALS AND METHODS

From June 2001 to August 2003, 36 chemotherapy-naive patients with stage IIIB or IV NSCLC were enrolled. The median age was 59 years (range, 42 to 75 years), and performance status was 0 or 1. Eleven patients had stage IIIB disease, and 25 patients had stage IV disease. 1,000 mg/m(2) of gemcitabine was administered on day 1 & 8, and 60 mg/m(2) of cisplatin was administered on day 1. Each cycle was repeated every 21 days.

RESULTS

Everyone subject who participated were assessable. A total of 160 cycles of chemotherapy were delivered, and the median number of chemotherapy courses was 3.5 (range, 2 to 9). Two patients (5.6%) achieved a complete response, and 14 patients (38.9%) achieved a partial response. The overall response rate was 44.5% (95% confidence interval [CI], 32.5 to 56.5%). The median follow-up duration was 9.3 months. The median time to disease progression was 8.6 months (95% CI 7.4 to 9.9 months), and median survival time was 12.2 months (95% CI, 10.5 to 12.9 months). Grade 3/4 neutropenia occurred in 9 patients (25.0%), neutropenic fever occurred in 3 patients (8.3%), and grade 3/4 thrombocytopenia occurred in 7 patients (19.5%). Mild forms of non-hematologic toxicities, such as nausea, vomiting or skin reactions, were observed.

CONCLUSION

The combination of gemcitabine and cisplatin in a 21-day schedule is an effective regimen for patients with NSCLC in its advanced stages.