Chemotherapy versus best supportive care for extensive small cell lung cancer

Real-world burden of chemotherapy-induced myelosuppression in patients with small cell lung cancer: a retrospective analysis of electronic medical data from community cancer care providers

AIMS

Chemotherapy-induced myelosuppression, which commonly exhibits as neutropenia, anemia, or thrombocytopenia, represents a substantial burden for patients with cancer that affects health-related quality of life and increases healthcare resource utilization (HCRU). We evaluated the burden of myelosuppression among chemotherapy-treated patients with small cell lung cancer (SCLC) using real-world data from community cancer care providers in the Western United States.

MATERIALS AND METHODS

This was a retrospective, observational analysis of electronic medical records (EMRs) from Providence St. Joseph Health hospital-associated oncology clinics between January 2016 and December 2019. Patient demographics were assessed from the date of first SCLC diagnosis in adult patients with chemotherapy-induced grade ≥3 myelosuppression in first-line (1L) or second-line-and-beyond (2L+) treatment settings. Myelosuppressive adverse events (AEs), treatment patterns, and HCRU were assessed from the date of chemotherapy initiation (index date) until 12 months, date of the last visit, date of death, or study end, whichever occurred earliest.

RESULTS

Of 347 eligible patients with SCLC who had received chemotherapy (mean age 66; 49% female), all had received at least 1L treatment, and 103 (29.7%) had a 2L + treatment recorded within the EMR during the study period. Of 338 evaluable patients with longitudinal laboratory data, 206 (60.9%) experienced grade ≥3 myelosuppressive AEs, most commonly neutropenia, anemia, and thrombocytopenia (44.9, 41.1, and 25.4 per 100 patients, respectively). Rates of granulocyte colony-stimulating factor use and red blood cell transfusions were 47.0 and 41.7 per 100 patients, respectively. There was a trend toward increasing the use of supportive care interventions and visits to inpatient and outpatient facilities in patients with myelosuppressive AEs in more than one cell lineage.

CONCLUSIONS

Chemotherapy-induced myelosuppression places a substantial real-world burden on patients with SCLC in the community cancer care setting. Innovations to protect bone marrow from chemotherapy-induced damage have the potential to reduce this burden.

New molecular classification of large cell neuroendocrine carcinoma and small cell lung carcinoma with potential therapeutic impacts

Large cell neuroendocrine carcinoma (LCNECs) and small cell lung carcinomas (SCLCs) are high-grade neuroendocrine carcinomas of the lung with very aggressive behavior and poor prognosis. Their histological classification as well as their therapeutic management has not changed much in recent years, but genomic and transcriptomic analyses have revealed different molecular subtypes raising hopes for more personalized treatment. Indeed, four subtypes of SCLCs have been recently described, SCLC-A driven by the master gene ASCL1, SCLC-N driven by NEUROD1, SCLC-Y by YAP1 and SCLC-P by POU2F3. Whereas SCLC standard of care is based on concurrent chemoradiation for limited stages and on chemotherapy alone or chemotherapy combined with anti-PD-L1 checkpoint inhibitors for extensive stage SCLC, SCLC-A variants could benefit from DLL3 or BCL2 inhibitors, and SCLC-N variants from Aurora kinase inhibitors combined with chemotherapy, or PI3K/mTOR or HSP90 inhibitors. In addition, a new SCLC variant (SCLC-IM) with high-expression of immune checkpoints has been also reported, which could benefit from immunotherapies. PARP inhibitors also gave promising results in combination with chemotherapy in a subset of SCLCs. Regarding LCNECs, they represent a heterogeneous group of tumors, some of them exhibiting mutations also found in SCLC but with a pattern of expression of NSCLC, while others harbor mutations also found in NSCLC but with a pattern of expression of SCLC, questioning their clinical management as NSCLCs or SCLCs. Overall, we are probably entering a new area, which, if personalized treatments are effective, will also lead to the implementation in practice of molecular testing or biomarkers detection for the selection of patients who can benefit from them.

Pretreatment prognostic nutritional index is a prognostic marker for extensive-stage small cell lung cancer patients treated with anlotinib

Background

Anlotinib is a multi-targeted tyrosine kinase inhibitor that inhibits tumor angiogenesis which has shown activity in several malignancies and approved for the treatment of small cell lung cancer (SCLC) in China. However, there are no markers can predict the clinical outcomes of anlotinib. We aimed to evaluate the efficacy of anlotinib in extensive stage SCLC (ES-SCLC) patients who failed at least two regimens treatment and to explore potential factors related to its survival benefit.

Methods

Patients with ES-SCLC treated with anlotinib monotherapy were screened between March 2017 and May 2019, prognostic nutritional index (PNI) before treatment were collected. Progression free survival (PFS) and overall survival (OS) were calculated and compared using the Kaplan–Meier method and the log-rank test. The prognostic values of each variable were evaluated with univariate and multivariate Cox proportional hazard regression (PHR) analyses.

Results

A total of 41 patients with ES-SCLC were received anlotinib treatment, the median age was 57 (range, 33–76). Median OS was significantly longer in the PNI high arm compared with the low arm [8.4 months (95% CI, 5.1–9.6 months) vs. 4.7 months (95% CI, 2.1–6.3 months); hazard ratio (HR) 0.42 (95% CI, 0.21–0.85); P=0.01]. The median PFS of two arms were 4.1 months (95% CI, 2.1–8.2 months) and 2.6 months (95% CI, 0.7–3.9 months), respectively (HR =0.53, 95% CI, 0.27–1.02, P=0.05). Multivariate analysis confirmed that PNI (P<0.01) and LDH (P<0.01) were significant independent biomarkers for OS.

Conclusions

The present study demonstrated that pretreatment PNI can be used as a novel and convenient biomarker to predict the prognosis in ES-SCLC patients treated with anlotinib.

Association between serum biomarkers CEA and LDH and response in advanced non-small cell lung cancer patients treated with platinum-based chemotherapy

BACKGROUND

In addition to radiological evaluation, biomarkers may be useful in providing early information on the response to treatment, and supporting clinical decision-making. The objective of this study was to investigate carcinoembryonic antigen (CEA) and lactate dehydrogenase (LDH) as biomarkers for early assessment of response in patients with advanced non-small cell lung cancer (NSCLC) treated with platinum-based chemotherapy.

METHODS

A retrospective follow-up study was conducted from 2012 to 2017 among 593 consecutive patients with advanced NSCLC treated with first-line platinum-based chemotherapy in a large teaching hospital in the Netherlands. Pretreatment biomarker levels and changes from pretreatment levels were studied for association with radiologic response (partial response [PR] or complete response [CR], according to RECIST 1.1) using multivariate logistic regression, and with overall survival using COX proportional hazard modeling. Patient and disease characteristics such as age and disease stage were taken into account as potential confounding factors.

RESULTS

Decreases in CEA and LDH (≥ 20%), particularly early in treatment, were significantly associated with better radiological response. Increases in these biomarkers (≥ 20%) and high pretreatment LDH levels (≥ 247 U/L) were significantly associated with lower overall survival.

CONCLUSIONS

Our results support determination of CEA and LDH levels for earlier assessment of response to platinum-based chemotherapy in patients with advanced NSCLC. Hence, routine determination and evaluation of CEA and LDH levels, prior to each cycle of platinum-based chemotherapy in advanced NSCLC, should be considered as part of daily clinical practice.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Serum biomarkers in monitoring of treatment in advanced NSCLC would be useful. CEA and LDH decrease (≥ 20%) is favorable for achieving radiological response. High LDH levels and CEA/LDH increase (≥ 20%) is associated with reduced survival.

WHAT THIS STUDY ADDS

Monitoring of CEA seems to be particularly relevant in early stage of treatment. CEA and LDH determination should be considered as part of daily clinical practice.

Knockdown of neuron-specific enolase suppresses the proliferation and migration of NCI-H209 cells

Neuron-specific enolase (NSE) is generally considered as a marker for diagnosis and evaluation of the response to therapy in small cell lung cancer (SCLC). However, the role of NSE in the progression of SCLC remains to be elucidated. In the present study, the functions of NSE in SCLC, in addition to the potential mechanisms, were investigated using a loss-of-function approach with NSE-targeting small interfering (si)RNA. The knockdown of NSE markedly decreased the proliferation of NCI-H209 cells, as indicated by MTT assay (P<0.05). Furthermore, the silencing of NSE resulted in the formation of smaller and fewer colonies compared with that in the control group (P<0.001). Flow cytometric analysis indicated that the silencing of NSE resulted in a decreased S-phase population among NCI-H209 cells (P<0.05). Transwell assay demonstrated that the silencing of NSE suppressed the migration of NCI-H209 cells (P<0.001). NCI-H209 cells transfected with NSE siRNA-1 or negative control were collected and the protein levels of metastasis-associated genes were detected using western blot analysis. The results indicated that the knockdown of NSE led to downregulation of the pro-metastatic gene vascular endothelial growth factor (VEGF; P<0.05) and the upregulation of metastasis suppressor genes NM23 and E-cadherin (P<0.05). Taken together, the results of the present study demonstrated that the silencing of NSE suppressed the migration, proliferation and colony formation ability of SCLC cells and decreased the S-phase population. In addition, the knockdown of NSE resulted in the upregulation of E-cadherin and NM23 and the downregulation of VEGF. Collectively, these results indicated that intracellular NSE may have an important role in the progression of SCLC.

Paclitaxel for relapsed small-cell lung cancer patients with idiopathic interstitial pneumonias

Although first-line chemotherapy is highly sensitive against small-cell lung cancer (SCLC), most patients subsequently experience disease progression. Topotecan is the standard therapy for sensitive-relapsed SCLC patients, and subgroup analysis of a randomized phase III trial suggests that amrubicin is effective for refractory-relapsed SCLC. However, because of the lack of the evidence based on clinical trials, the effectiveness of systemic chemotherapy for relapsed SCLC patients with idiopathic interstitial pneumonias (IIPs) is unclear. In the presentstudy, 17 relapsed SCLC patients with IIPs who received a paclitaxel (PTX)-containing regimen as a second-line chemotherapy were retrospectively reviewed. The overall response rate and the disease control rate of the PTX-containing regimens were 29.4 and 47.1%, respectively. The median progression-free survival and the overall survival of the regimens were 2.7 months [95% confidence interval (CI), 1.6-3.6 months] and 3.6 months (95% CI, 2.3-14.0 months), respectively. Grade 3-4 neutropenia and febrile neutropenia occurred in 12 (70.6%) and 2 (11.8%) patients, respectively. During the treatment period, acute exacerbation (AE) of IIPs was observed in five patients (29.4%). Treatment-associated fatality was observed in 1 patient with febrile neutropenia and in 1 patient with AE of IIPs. PTX had promising anti-tumor activity against refractory-relapsed SCLC with IIPs. However, the survival benefit of the treatment was limited because of the high incidence of AE of IIPs and treatment-related death.

Clinical predictors of survival in young patients with small cell lung cancer: Results from the California Cancer Registry

BACKGROUND

Small cell lung cancer (SCLC) is an often lethal disease that commonly occurs in older individuals with a history of heavy tobacco use. Limited epidemiologic and outcomes data are available on young SCLC patients aged less than 50 years of age. We assessed clinical variables related to cause specific survival (CSS) of young patients with SCLC.

METHODS

SCLC patients in the California Cancer Registry diagnosed between 1998 and 2012 were included. Primary outcome measure was CSS. Hazard ratios (HR) for CSS were calculated using Cox Proportional Hazards (pH) models for all ages & for patients <50 years, adjusted for baseline variables: age, gender, stage, race, year of diagnosis, initial treatment, socioeconomic status (SES), and location (urban vs. rural).

RESULTS

We identified 22,863 SCLC patients, of which 975 were less than 50 years of age (4.2%). Most patients <50years of age were male (51%), white race (71%), and had stage IV disease (60%). A lower proportion of patients aged 50 years or younger was diagnosed in later years: from 40% in 1998-2002 to 24% in 2008-2012. For all SCLC patients, age less than 50 years was an independent predictor of improved CSS (HR=0.82, p<0.0001). Multivariate Cox pH models showed that in younger patients, female sex (HR=0.81, p=0.0045), Asian race (HR=0.57, p=0.0075), and rural residence (HR=0.75, p=0.042) were associated with better CSS, among other variables.

CONCLUSIONS

In patients with SCLC, age less than 50 years was an independent predictor of improved CSS. Baseline clinical variables associated with better CSS were identified. These results have potential clinical applications.

Survival and Toxicity After Cisplatin Plus Etoposide Versus Carboplatin Plus Etoposide for Extensive-Stage Small-Cell Lung Cancer in Elderly Patients

PURPOSE

Elderly patients with cancer are under-represented in clinical trials and risk greater toxicity from chemotherapy. These patients and their physicians need better evidence to decide among guideline-recommended regimens. We test whether patients with extensive-stage small-cell lung cancer (ES SCLC) have noninferior survival and less hospital-based health care after carboplatin/etoposide compared with cisplatin/etoposide.

METHODS

We analyzed SEER-Medicare data for beneficiaries with ES SCLC diagnosed at age 67 years and older between 1995 and 2009. Among patients treated with first-line chemotherapy in the ambulatory setting, 831 received cisplatin/etoposide and 2,846 received carboplatin/etoposide. Propensity score matching (2:1 ratio) yielded 778 cisplatin/etoposide and 1,502 carboplatin/etoposide patients.

RESULTS

Survival was nearly identical in the two groups: 35.7 weeks for cisplatin/etoposide and 35.9 weeks for carboplatin/etoposide. The hazard ratio of 1 (95% CI, 0.91 to 1.09) excluded our prespecified threshold, indicating noninferiority. Mortality at 6 months was indistinguishable: 35% for cisplatin/etoposide and 34% for carboplatin/etoposide. After carboplatin/etoposide, patients were less likely to be admitted to a hospital (80% v 86%, P < .001) and had fewer hospitalizations (median 1 v 2, odds ratio 0.76, 95% CI, 0.65 to 0.9), ED visits (median 1 v 2, odds ratio 0.82, 95% CI, 0.7 to 0.96), and ICU stays (median 0 v 0, odds ratio 0.82, 95% CI, 0.69 to 0.99).

CONCLUSION

First-line carboplatin/etoposide is associated with similar survival and less subsequent hospital-based health care use than cisplatin/etoposide among elderly patients with ES SCLC treated in ambulatory settings.

Extrapulmonary small cell carcinoma of lymph node: Pooled analysis of all reported cases

AIM

To study clinical outcomes and management of lymph nodes extrapulmonary small cell carcinoma (LNEPSCC).

METHODS

Herein, we perform a systematic search of published literature in the PubMed and EMBASE databases for studies describing LNEPSCC. For uniformity of reporting, LNEPSCC was staged as limited if it involved either single lymph node station or if surgery with curative intent had been undertaken. The disease was staged extensive if it involved two or more lymph node regions.

RESULTS

The systematic literature review yielded eight descriptions (n = 14) involving cervical, submandibular and inguinal lymph nodes. Eleven (64.7%) patients had limited disease (LD) and six (35.3%) had extensive disease (ED) at presentation. Chemotherapy (n = 6, 35.3%) or surgery (n = 4, 23.5%) were the most common form of treatment given to these patients. Complete response was achieved in 12 (70.6%) of the patients. Median (interquartile range) progression free survival and overall survival was 15 (7-42) mo and 22 (12.75-42) mo respectively. Of the three illustrative cases, two patients each had ED at presentation and achieved complete remission with platinum based combination chemotherapy.

CONCLUSION

LNEPSCC is a rare disease with less than 15 reported cases in world literature. Surgical resection with curative intent is feasible in those with LD while platinum based combination chemoradiation is associated with favorable outcomes in patients with ED. Prognosis of LNEPSCC is better than that of small cell lung cancer in general.

VAC chemotherapy with valproic acid for refractory/relapsing small cell lung cancer: a phase II study

Salvage chemotherapy (CT) for relapsing or refractory small cell lung cancer (SCLC) remains disappointing. In vitro experiments showed that valproic acid increases apoptosis of SCLC cell lines exposed to doxorubicin, vindesine and bis(2-chloroethyl)amine. The primary objective of this phase II study was to determine whether epigenetic modulation with valproic acid in addition to a doxorubicin, vindesine and cyclophosphamide (VAC) regimen improves 6-month progression-free survival (PFS).

Patients with pathologically proven SCLC refractory to prior platinum derivatives and etoposide were eligible. After central registration, patients received VAC plus daily oral valproic acid.

64 patients were registered, of whom six were ineligible. Seven patients did not receive any CT, leaving 51 patients assessable for the primary end-point. The objective response rate was 19.6%. Median PFS was 2.8 months (95% CI 2.5–3.6 months) and 6-month PFS was 6%. Median survival time was 5.9 months (95% CI 4.7–7.5 months). Toxicity was mainly haematological, with 88% and 26% grade 3–4 neutropenia and thrombopenia, respectively.

Despite an interesting response rate, the addition of valproic acid to VAC did not translate into adequate PFS in relapsing SCLC or SCLC refractory to platinum–etoposide.

Epigenetic modulation with valproic acid does not improve CT efficacy in refractory SCLC after platinum–etoposidehttp://ow.ly/R0rBt

Trends, predictors, and impact of systemic chemotherapy in small cell lung cancer patients between 1985 and 2005

BACKGROUND

The last 3 decades have witnessed limited therapeutic advances in small cell lung cancer (SCLC) management. This study evaluated real-world trends in the use of systemic therapies and the impact on patient outcomes in the United States.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare database was used to find patients diagnosed with SCLC between 1985 and 2005. The 1985-1990 period served as the baseline for a temporal analysis conducted at 5-year intervals (1985-1990, 1991-1995, 1996-2000, and 2001-2005). Cox proportional models were used to estimate the effect of chemotherapy on survival. Results were validated with a propensity-matched analysis.

RESULTS

There were 47,351 eligible patients: 52% were male; the median age was 71 years; and 87% were white, 7% were black, and 1.4% were Asian. The proportion of patients treated with chemotherapy was low but increased over time (38%, 55%, 50%, and 53%; P < .001). Race, diagnosis period, age, stage, and location of residence significantly predicted chemotherapy use. Females (51%), Asians (53%), and rural residents (60%) were more likely to receive chemotherapy. The median overall survival with and without chemotherapy was 9.6 and 3.6 months, respectively. Linear trend analyses showed a modest reduction in the impact of chemotherapy on survival for patients treated with chemotherapy versus untreated patients (hazard ratios [HRs], 0.59, 0.61, 0.64, and 0.62; P < .001) but an overall trend of improved survival for treated (HRs, 1.0, 1.03, 1.00, and 0.96; P = .005) and untreated patients (HRs, 1.0, 0.99, 0.94, and 0.92; P < .001). There was no survival difference between patients treated with carboplatin and patients treated with cisplatin (HR, 0.99; confidence interval [CI], 0.81-1.19; P = .875). Additional therapy beyond platinum-based chemotherapy was associated with a survival benefit (HR, 0.78; CI, 0.75-0.81; P < .001).

CONCLUSIONS

Chemotherapy use was associated with a survival benefit in Medicare patients with SCLC treated in a real-world setting.

Multiple primary cancers involving lung cancer at a single tertiary hospital: Clinical features and prognosis

Background

The development of other primary cancers in patients with lung cancer is unfortunate and uncommon, although the frequency is increasing. The aim of this study was to determine the clinical features and prognosis in patients with multiple primary cancers (MPC) involving lung cancer.

Methods

After a retrospective review of 1644 patients who were newly diagnosed with primary lung cancer between 1998 and August 2012 at a tertiary hospital, 105 patients were included.

Results

The median age at the time of lung cancer diagnosis was 67 years, and 68 patients were male. Synchronous primary cancers occurred in 47% of the study population (49/105). Among those with metachronous cancer (56/105), the median interval between the diagnosis of lung cancer and another malignancy was 47.1 months; 21 patients were diagnosed with lung cancer as the first primary tumor. The most frequent type of other malignancy was urogenital (30%), followed by gastrointestinal (30%) and thyroid malignancies (16%). Advanced stage of lung cancer (hazard ratio (HR), 3.2; 95% confidence interval (CI), 1.8–5.7; P < 0.001), supportive care only as treatment for lung cancer (HR, 2.8; 95% CI, 1.3–6.0; P = 0.006), and head and neck cancer as another malignancy (HR, 3.9; 95% CI, 1.4–10.8; P = 0.010) were independent predictors of shorter survival from the time of diagnosis of the second primary cancer.

Conclusion

Advanced lung cancer stage, symptomatic supportive care only without antitumor therapy for lung cancer, and head and neck cancer as another primary malignancy were poor prognostic factors in patients with MPC involving primary lung cancer.