Dose intensity and high dose therapy. Two different concepts

Autologous Stem-Cell Transplantation for High-Risk Neuroblastoma: Historical and Critical Review

Simple Summary

The original idea that providing higher doses of cytotoxic agents will result in higher rates of tumor cell killing was proposed in the 1980s. Preclinical data supported clinical testing. Advancements in bone marrow and peripheral stem-cell support technologies during the 1980s and 1990s allowed for clinical developments that permitted testing the higher dose hypothesis in oncology patients. The results of almost 20 years of clinical trials proved the linear relationship between dosing and clinical outcome to be mostly inaccurate. As a consequence, the adult oncology field abandoned high-dose chemotherapy strategies by the turn of the 21st century. Neuroblastoma is the only pediatric extracranial solid tumor where high-dose chemotherapy has remained part of the standard management for high-risk cases. This systematic review aims to understand the historical reason for such an exception and analyzes data challenging the benefit of high-dose chemotherapy and autologous stem-cell transplants in the era of anti-GD2 immunotherapy.

Abstract

Curing high-risk neuroblastoma (HR-NB) is a challenging endeavor, which involves the optimal application of several therapeutic modalities. Treatment intensity for cancer became highly appealing in the 1990s. Investigative trials assumed that tumor response correlated with the dosage or intensity of drug(s) administered, and that this response would translate into improved survival. It was postulated that, if myelotoxicity could be reversed by stem-cell rescue, cure might be possible by increasing the dose intensity of treatment. The principle supported autologous stem-cell transplant (ASCT) strategies. High-dose therapy transformed clinical practice, legislation, and public health policy, and it drove a two-decade period of entrepreneurial oncology. However, today, no ASCT strategies remain for any solid tumor indication in adults. As with most solid malignancies, higher dosing of cytotoxic agents has not resulted in a clear benefit in survival for HR-NB patients, whereas the long-term toxicity has been well defined. Fortunately, novel approaches such as anti-GD2 immunotherapy have demonstrated a significant survival benefit with a much less adverse impact on the patient’s wellbeing. On the basis of extensive experience, persisting with administering myeloablative chemotherapy as the standard to treat children with HR-NB is not consistent with the overall aim in pediatric oncology of curing with as little toxicity as possible.

Short-term and long-term prognostic value of histological response and intensified chemotherapy in osteosarcoma: a retrospective reanalysis of the BO06 trial

OBJECTIVES

Cure rate models accounting for cured and uncured patients, provide additional insights into long and short-term survival. We aim to evaluate the prognostic value of histological response and chemotherapy intensification on the cure fraction and progression-free survival (PFS) for the uncured patients.

DESIGN

Retrospective analysis of a randomised controlled trial, MRC BO06 (EORTC 80931).

SETTING

Population-based study but proposed methodology can be applied to other trial designs.

PARTICIPANTS

A total of 497 patients with resectable highgrade osteosarcoma, of which 118 were excluded because chemotherapy was not started, histological response was not reported, abnormal dose was reported or had disease progression during treatment.

INTERVENTIONS

Two regimens with the same anticipated cumulative dose (doxorubicin 6×75 mg/m²/week; cisplatin 6×100 mg/m²/week) over different time schedules: every 3 weeks in regimen-C and every 2 weeks in regimen-DI.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is PFS computed from end of treatment because cure, if it occurs, may happen at any time during treatment. A mixture cure model is used to study the effect of histological response and intensified chemotherapy on the cure status and PFS for the uncured patients.

RESULTS

Histological response is a strong prognostic factor for the cure status (OR 3.00, 95% CI 1.75 to 5.17), but it has no clear effect on PFS for the uncured patients (HR 0.78, -95% CI 0.53 to 1.16). The cure fractions are 55% (46%-63%) and 29% (22%-35%), respectively, among patients with good and poor histological response (GR, PR). The intensified regimen was associated with a higher cure fraction among PR (OR 1.90, 95% CI 0.93 to 3.89), with no evidence of effect for GR (OR 0.78, 95% CI 0.38 to 1.59).

CONCLUSIONS

Accounting for cured patients is valuable in distinguishing the covariate effects on cure and PFS. Estimating cure chances based on these prognostic factors is relevant for counselling patients and can have an impact on treatment decisions.

TRIAL REGISTRATION NUMBER

ISRCTN86294690.

A novel method to address the association between received dose intensity and survival outcome: benefits of approaching treatment intensification at a more individualised level in a trial of the European Osteosarcoma Intergroup

PURPOSE

There is lack of consensus on the prognostic value of received high dose intensity in osteosarcoma survivorship. Many studies have not shown a clear survival benefit when dose intensity is increased. The aim of this study is to go beyond chemotherapy intensification by arm-wide escalation of intended dose and/or compression of treatment schedule, while conversely addressing the relationship between treatment intensity and survival at the patient level. The study focusses on the difference in outcome results, based on a novel, progressively more individualised approach to dose intensity.

METHODS

A retrospective analysis of data from MRC BO06/EORTC 80931 randomised controlled trial for treatment of osteosarcoma was conducted. Three types of post hoc patient groups are formed using the intended regimen: the individually achieved cumulative dose and time on treatment, and the increase of individual cumulative dose over time. Event-free survival is investigated and compared in these three stratifications.

RESULTS

The strata of intended regimen and achieved treatment yields equivalent results. Received cumulative dose over time produces groups with evident different survivorship characteristics. In particular, it highlights a group of patients with an estimated 3-year event-free survival much larger (more than 10%) than other patient groups. This group mostly contains patients randomised to an intensified regimen. In addition, adverse events reported by that group show the presence of increased preoperative myelotoxicity.

CONCLUSIONS

The manuscript shows the benefits of analyzing studies by using longitudinal data, e.g. recorded per cycle. This has impact on the drafting of future trials by showing why such a level of detail is needed for both treatment and adverse event data. The novel method proposed, based on cumulative dose received over time, shows that longitudinal treatment data might be used to link survival outcome with drug metabolism. This is particularly valuable when pharmacogenetics data for metabolism of cytotoxic agents are not collected.

TRIAL REGISTRATION

ISRCTN86294690.

Management of advanced lung cancer in resource-constrained settings: a perspective from India

Advanced lung cancer (LC) is an important cause of cancer-related morbidity and mortality in resource-constrained settings (RCSs). Cytological/pathological confirmation of diagnosis of LC is essential prior to treatment initiation for ruling out mimickers such as pulmonary tuberculosis. Accurate staging is necessary for optimal management, and investigations should be prioritized based on availability and cost-effectiveness. Platinum-based doublet chemotherapy remains the standard of care for advanced LC. Cost of therapy, lack of medical insurance and frequency of visits are important determinants of treatment regimen. EGF receptor mutation testing may not be readily available in RCSs and chemotherapy should be preferred for unselected patients with advanced non-small-cell lung cancer. Generic drugs may be more affordable than innovator brands. Treatment efficacy should be assessed with traditional end points (survival and objective response rates) as well as those relevant to RCSs (quality of life, toxicity profile and healthcare facility utilization). Issues related to LC treatment in first- and subsequent-line settings in RCSs are discussed in detail in this evidence-based review.

Cost of neutropenic complications of chemotherapy

BACKGROUND

Cost of neutropenic complications of myelosuppressive chemotherapy has been reported to be substantial. Prior research, however, has focused on initial hospitalization only and has failed to account for follow-on care.

PATIENTS AND METHODS

Using a US health-care claims database, all adult cancer patients who received a course of chemotherapy were identified. For each such patient, each unique cycle of chemotherapy within the course and each occurrence of neutropenic complications within these cycles were characterized. Patients developing neutropenic complications in a given cycle (neutropenia patients), starting with the first, were matched (1:1) to those who did not develop neutropenic complications in that cycle (comparison patients), and health-care costs (i.e. expenditures) were tallied for each matched pair.

RESULTS

Neutropenia patients (n = 373) and comparison patients were similar in terms of baseline characteristics. Costs of neutropenia-related care were $12,397 (95% confidence interval $10,274-$14,754) higher for neutropenia versus comparison patients [$14,407 ($12,357-$16,743) versus $2010 ($1490-$2553)]. Among neutropenia patients, mean cost of initial hospitalization for neutropenic complications was $7813 ($6537-$9379); cost of all subsequent neutropenia-related care averaged $6594 ($5217-$8272).

CONCLUSIONS

Neutropenic complications of myelosuppressive chemotherapy are costly. Prior research focusing on initial hospitalization only may have underestimated the cost of these complications by as much as 40%.

Incidence, cost, and mortality of neutropenia hospitalization associated with chemotherapy

BACKGROUND

Neutropenia is a common side effect of chemotherapy, often requiring hospitalization for treatment of severe cases. Neutropenia hospitalization (NH) rates have been reported in individual studies, but national estimates are needed.

METHODS

Chemotherapy-induced NHs were identified in the 1999 hospital discharge data bases from 7 states. Cancer and chemotherapy prevalence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program and the National Cancer Data Base were used to calculate national NH rates for 13 cancer types. NH cost was estimated by multiplying charges by institution-specific, cost-to-charge ratios from the 1999 Centers for Medicare and Medicaid Services Hospital Cost Report. NH incidence was projected to national levels using population data from the United States Census and the Centers for Disease Control and Prevention.

RESULTS

There were 20,780 discharges with documentation of cancer, chemotherapy, and neutropenia identified. Projecting to national levels, NH incidence was estimated at 60,294 cases (7.83 cases per 1000 cancer patients). The mean NH cost was 13,372 dollars. The mortality rate among patients with NH was estimated at 6.8% or 1 death for every 14 hospitalized patients. Among 13 selected cancer types, the NH rate was 34.20 cases per 1000 patients receiving chemotherapy (1 in 29 patients). NH was particularly common in patients with hematologic tumors, with an incidence of 43.3 cases per 1000 patients with such tumors (1 in 23 patients). The average NH cost for hematologic malignancies was 20,400 dollars, more than double the cost of NH for solid tumors.

CONCLUSIONS

According to the current study, NH affects > 60,000 patients with cancer each year in the United States, with an average cost of 13,372 dollars per hospitalization and an associated inpatient mortality rate of 6.8%.

Epirubicin versus CMF as adjuvant therapy for stage I and II breast cancer: a prospective randomised study

We compared a relatively short regimen of monochemotherapy with epirubicin versus polychemotherapy with CMF (cyclophosphamide, methotrexate, 5-fluorouracil) as adjuvant treatment for stage I and II breast cancer patients. 348 patients with oestrogen receptor negative (ER-) node negative and ER- or ER+ node-positive with <10 nodes were accrued. CMF was given intravenously (i.v.) on days 1 and 8, every 4 weeks, for six courses; epirubicin was given weekly for 4 months. Postmenopausal patients received tamoxifen for 3 years. The primary endpoints were overall survival (OS), relapse-free survival (RFS) and event-free survival (EFS). Outcome evaluation was performed both in eligible patients and in all randomised patients according to the intention-to-treat principle. 8 randomised patients were considered ineligible. At a median follow-up of 8 years, there was no difference in OS (Hazard Ratio (HR)=1.11, 95% Confidence Interval (CI): 0.77-1.61, P=0.58), EFS (HR=1.14, 95% CI: 0.78-1.64, P=0.48), and RFS (HR=1.14, 95% CI: 0.8-1.64, P=0.48) between the two arms for all of the patients. At 8 years, the RFS percentages (+/-Standard Error (S.E.)) were 65.4% (+/-4%) in the CMF arm and 62.7% (+/-4%) in the epirubicin arm; for EFS these were 64.2% (+/-4%) for CMF and 60.8% (+/-4%) for epirubicin, respectively. A significant difference in RFS (P=0.015) was observed in patients with 4-9 positive nodes in favour of the CMF arm. Toxicity in the two arms was superimposable except for more frequent grade 3 alopecia in the epirubicin-treated patients (P=0.001). Overall, at a median follow-up of 8 years, there were no differences between the two arms in terms of OS, EFS and RFS.

Dose-dense anthracycline-based chemotherapy for node-positive breast cancer

PURPOSE

Theoretical considerations and clinical experience suggest that dose-dense chemotherapy may be superior to other approaches using the same drugs. We studied a dose-dense combination of doxorubicin and cyclophosphamide, with or without fluorouracil, as adjuvant therapy.

PATIENTS AND METHODS

Patients with resected breast cancer were treated if they were node-positive and estrogen receptor-negative, positive for overexpression of Her-2-neu, or had four or more involved nodes. Doxorubicin was given weekly to a total dose of 480 mg/m(2). Cyclophosphamide 60 mg/m(2) was given daily by mouth during the period of doxorubicin treatment. The first 30 patients received fluorouracil at 300 mg/m(2)/wk intravenously concurrently with doxorubicin administration. In the last 22, it was omitted because of symptomatic hand-foot syndrome in the majority of patients. Filgrastim (granulocyte colony-stimulating factor [G-CSF]) was administered during chemotherapy every day except the day of intravenous administration and continued until 1 week after the completion of the chemotherapy.

RESULTS

Between October 20, 1992, and June 10, 1997, we enrolled 52 patients. The mean delivered dose-intensity for doxorubicin was 18.6 mg/m(2)/wk. Hospitalization was required in 6% of patients for reversible febrile neutropenia. There were no acute treatment-related deaths, but one patient subsequently died of acute leukemia with a characteristic translocation for anthracycline-related exposure. At 5 years, the event-free survival was 86% for all patients (95% confidence interval, 75% to 95%).

CONCLUSION

Continuous dose-dense chemotherapy with G-CSF support produced encouraging results, which seem to be superior to those expected with "standard" doxorubicin and cyclophosphamide chemotherapy. It deserves a test in the form of a randomized trial where this approach to anthracycline-based treatment is compared with intermittent administration.

Cisplatin, ifosfamide, and vinorelbine combination chemotherapy in stage III-IV non-small-cell lung cancer: a phase II study

The authors evaluate the combination of three drugs, vinorelbine, ifosfamide, and cisplatin, which have been shown to produce good response rates and a significant gain in survival when any two of them are given together. Seventy-seven untreated patients with inoperable stage III-IV non-small-cell lung cancer from three centers were included. The combination consisted of cisplatin 30 mg/m2 daily, ifosfamide 1,500 mg/m2 daily, mesna 1,500 mg/m2 daily on days 1-3, and vinorelbine 25 mg/m2 daily on days 1 and 8. Four cycles were administered every 4 weeks for a total of 267 cycles, before an assessment for toxicity, effective dose intensity, response rate, and survival was made. Toxicity was mainly hematologic (grade 3-4 neutropenia (15.7%), anemia (8.2%), and thrombopenia (2.6%)) but did not require granulocyte colony-stimulating factors. Objective response rate was 41.1% (95% confidence interval, 29.5-52.9%) in 68 patients suitable for assessment. The mean time to progression and median survival were 7.7 +/- 1.3 months and 11.6 months, respectively. One-year survival was 47.1%. The effective dose intensity of cisplatin and ifosfamide correlated strongly with survival, whereas stage and performance status did not. This study confirms previously reported favorable results for response and survival rates obtained in stage III-IV non-small-cell lung cancer with the vinorelbine, ifosfamide, and cisplatin combination. Respect of a scheduled dose intensity has a clear-cut influence on survival and should be evaluated routinely in future polychemotherapy trials.

Neutropenia and neoplasia: an overview of the pharmacoeconomics of sargramostim in cancer therapy

Sargramostim is a myeloid growth factor that is widely used as adjunctive support in patients with neutropenia. Sargramostim enhances neutrophil recovery and myeloid engraftment, reduces infectious complications, and shortens the duration of hospitalization in selected patients. The high cost of sargramostim and other myeloid growth factors and their ability to reduce infections and days of hospitalization have generated interest in their pharmacoeconomic impact. Cost minimization studies in patients receiving chemotherapy for acute myelogenous leukemia and in recipients of autologous bone marrow transplantation (BMT) show estimated cost savings with sargramostim of 1996 US$12,513 and 1994 US$14,500, respectively. These data are consistent with cost savings of 1989 US$16,000 using molgramostim in autologous BMT recipients. Although no pharmacoeconomic data have been published in patients with other conditions, clinical outcomes research demonstrates a clear benefit for sargramostim administration in recipients of peripheral blood progenitor cell and allogeneic BMT and in patients who experience graft delay or failure. Because of reductions in the duration of hospitalization and infectious complications, economic outcomes of these conditions would probably also support sargramostim use. More data regarding the use of sargramostim for chemotherapy-induced neutropenia are required to properly assess the pharmacoeconomic impact in these patients.

The case for high-dose adjuvant chemotherapy in breast cancer: (I) theoretical considerations

Adjuvant systemic therapy of breast cancer is now a well-established treatment resulting in improved survival. However, the available evidence suggests that it is most unlikely that an individual woman will be cured as a consequence of such treatment. There is, therefore, a pressing need for more effective therapy, particularly for younger women whose degree of axillary nodal involvement indicates a high risk of subsequent relapse. The case for using myelo-ablative chemotherapy for such women is presented in this article. In a subsequent publication we will discuss the clinical data to suggest that such an approach is not only possible with acceptable toxicity, but also could actually offer the increased cure rate sought by clinicians and patients alike.

Inflammatory breast carcinoma

Inflammatory breast cancer (IBC) is a rare subtype of breast cancer traditionally associated with an extremely poor prognosis. The appearance of the effected breast can be misleading, with the incorrect diagnosis of an infective process, rather than a malignant disease, further delaying treatment. Compared with the results achieved by monotherapy with either surgery, radiotherapy or chemotherapy; multimodality treatments have achieved significant improvements in both disease-free and overall survival. The purpose of this article is to provide a comprehensive review of the current literature and highlight those areas where potential advances in the overall management of IBC have been made.