Phase II study of capecitabine plus oxaliplatin (XELOX) as first-line treatment and followed by maintenance of capecitabine in patients with metastatic colorectal cancer. J Cancer Res Clin Oncol. 2010;136:503-510. [PMID: 19777259 DOI: 10.1007/s00432-009-0682-5]

Effect of Capecitabine Maintenance Therapy Plus Best Supportive Care vs Best Supportive Care Alone on Progression-Free Survival Among Patients With Newly Diagnosed Metastatic Nasopharyngeal Carcinoma Who Had Received Induction Chemotherapy: A Phase 3 Randomized Clinical Trial

IMPORTANCE

Capecitabine maintenance therapy improves survival outcomes in various cancer types, but data are limited on the efficacy and safety of capecitabine maintenance therapy in metastatic nasopharyngeal carcinoma (NPC).

OBJECTIVE

To investigate the efficacy and safety of capecitabine maintenance therapy in metastatic NPC.

DESIGN, SETTING, AND PARTICIPANTS

This randomized phase 3 clinical trial was conducted at Sun Yat-sen University Cancer Center from May 16, 2015, to January 9, 2020, among 104 patients with newly diagnosed metastatic NPC who had achieved disease control after 4 to 6 cycles of induction chemotherapy with paclitaxel, cisplatin, and capecitabine. The final follow-up date was May 30, 2021. All efficacy analyses were conducted in the intention-to-treat population.

INTERVENTIONS

Eligible patients were randomly assigned (1:1) to receive either capecitabine maintenance therapy (1000 mg/m2 orally twice daily on days 1-14) every 3 weeks plus best supportive care (BSC) (capecitabine maintenance group) or BSC alone after 4 to 6 cycles of induction chemotherapy.

MAIN OUTCOMES AND MEASURES

Progression-free survival (PFS). Secondary end points were objective response rate, duration of response, overall survival, and safety.

RESULTS

This study included 104 patients (84 men [80.8%]; median age, 47 years [IQR, 38-54 years]), with 52 assigned to the capecitabine maintenance group and 52 assigned to the BSC group. After a median follow-up of 33.8 months (IQR, 22.9-50.7 months), there were 23 events (44.2%) of progression or death in the capecitabine maintenance group and 37 events (71.2%) of progression or death in the BSC group. Median PFS survival was significantly higher in the capecitabine maintenance group (35.9 months [95% CI, 20.5 months-not reached]) than in the BSC group (8.2 months [95% CI, 6.4-10.0 months]), with a hazard ratio of 0.44 (95% CI, 0.26-0.74; P = .002). Higher objective response rates and longer median duration of response were observed in the capecitabine maintenance group (25.0%; 40.0 months) compared with the BSC group (objective response rate, 25.0% [n = 13] vs 11.5% [n = 6]; and median duration of response, 40.0 months [95% CI, not reached-not reached] vs 13.2 months [95% CI, 9.9-16.5 months]). The most common grade 3 or 4 adverse events during maintenance therapy were anemia (6 of 50 [12.0%]), hand-foot syndrome (5 of 50 [10.0%]), nausea and vomiting (3 of 50 [6.0%]), fatigue (2 of 50 [4.0%]), and mucositis (2 of 50 [4.0%]). No deaths in the maintenance group were deemed treatment-related.

CONCLUSIONS AND RELEVANCE

In this phase 3 randomized clinical trial, capecitabine maintenance therapy significantly improved PFS for patients with newly diagnosed metastatic NPC who achieved disease control after capecitabine-containing induction chemotherapy. Capecitabine exhibited manageable toxic effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02460419.

Profiling of polar urine metabolite extracts from Chinese colorectal cancer patients to screen for potential diagnostic and adverse-effect biomarkers

Background: Metabolomics has demonstrated its potential in the early diagnosis, drug safety evaluation and personalized toxicology research of various cancers. Objectives: We aim to screen for potential diagnostic and capecitabine-related adverse effect (CRAE) biomarkers from urinary endogenous metabolites in Chinese colorectal cancer (CRC) patients. Methods: The metabolic profiles of 139 CRC patients and 50 non-neoplastic controls were analyzed using ultra-high-performance liquid chromatography combined with quadrupole time-of-flight mass spectrometry. Results: There were 41 metabolites identified between the CRC patients and the non-neoplastic controls, and 19 metabolites were identified between CRC patients with and without CRAE. Based on these identified metabolites, bioinformatic analysis and prediction model construction were completed. Most of these differential metabolites have important roles in cell proliferation and differentiation and the immune system. Based on binary logistic regression, a CRC prediction model, composed of 3-methylhistidine, N-heptanoylglycine, N1,N12-diacetylspermine and hippurate, was established, with an area under curve (AUC) of 0.980 (95% CI: 0.953-1.000; sensitivity: 94.3%; specificity: 92.0%) in the training set, and an AUC of 0.968 (95% CI: 0.933-1.000; sensitivity: 89.9%; specificity: 92.0%) in the testing set. In addition, methionine and 4-pyridoxic acid can be combined to predict hand foot syndrome, with an AUC of 0.884; ubiquinone-1 and 4-pyridoxic acid can be combined to predict anemia, with an AUC of 0.889; and 5-acetamidovalerate and 3,4-methylenesebacic acid can be combined to predict neutropenia, with an AUC of 0.882. Conclusion: The profiling of urine polar metabolites has great potential in the early detection of CRC and the prediction of CRAE.

Effect of Reduced-Dose Capecitabine Plus Cetuximab as Maintenance Therapy for RAS Wild-Type Metastatic Colorectal Cancer: A Phase 2 Clinical Trial

IMPORTANCE

Fluorouracil-based chemotherapy combined with anti-epidermal growth factor receptor/vascular endothelial growth factor therapy is the standard first-line treatment for metastatic colorectal cancer followed by low-intensity maintenance therapy to balance the clinical efficacy and adverse effects (AEs). However, there have been concerns about the AEs of capecitabine plus cetuximab as a maintenance therapy in patients with RAS wild-type metastatic colorectal cancer.

OBJECTIVE

To evaluate the biological activity and safety of capecitabine plus cetuximab as a novel maintenance therapy for RAS wild-type metastatic colorectal cancer.

DESIGN, SETTING, AND PARTICIPANTS

This phase 2 prospective clinical trial was conducted from April 29, 2016, to April 29, 2019, at 5 centers in China. Patients diagnosed as having RAS wild-type metastatic colorectal cancer were recruited to receive fluorouracil-based cytotoxic agents combined with cetuximab followed by capecitabine plus cetuximab for maintenance therapy. Forty-seven patients with histologically confirmed metastatic colorectal cancer and genetic test results showing a wild-type RAS were enrolled in maintenance therapy.

INTERVENTIONS

Induction therapy for patients with RAS wild-type metastatic colorectal cancer was 8 to 12 cycles of fluorouracil-based chemotherapy combined with cetuximab. After stable disease status or better was achieved, reduced-dose capecitabine plus cetuximab was administered for maintenance therapy.

MAIN OUTCOMES AND MEASURES

The primary end point was progression-free survival during maintenance therapy. The secondary end points were total progression-free survival, overall survival, quality of life, safety, and toxic effects of treatment.

RESULTS

Forty-seven patients were enrolled in maintenance therapy, with a median age of 52 years (range, 25-81 years) and 32 (68%) of them being men. The median maintenance progression-free survival was 7.2 (95% CI, 5.8-8.6) months. The median progression-free survival was 12.7 (95% CI, 11.8-15.4) months. The median overall survival was 27.4 (95% CI, 21.4-35.5) months. Grade 3 to 4 AEs during induction therapy included neutropenia (4 patients [9%]), diarrhea (4 patients [9%]), nausea or vomiting (3 patients [6%]), rash acneiform (10 patients [21%]), and hand-foot syndrome (8 patients [17%]). Grade 3 to 4 AEs during maintenance therapy included diarrhea (2 patients [4%]), rash acneiform (8 patients [17%]), and hand-foot syndrome (5 patients [11%]).

CONCLUSIONS AND RELEVANCE

Reduced-dose capecitabine plus cetuximab after initial chemotherapy is a novel maintenance therapy for patients with RAS wild-type metastatic colorectal cancer that achieved good outcomes and tolerable nonserious AEs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02717923.

Longitudinal monitoring reveals dynamic changes in circulating tumor cells (CTCs) and CTC-associated miRNAs in response to chemotherapy in metastatic colorectal cancer patients

We evaluated the changes in CTC count and CTC-associated miRNAs during the course of chemotherapy in patients with metastatic colorectal cancer. Blood samples were collected from 9 metastatic colorectal cancer patients prior to chemotherapy and at every other chemotherapy session during the course of treatment. CTCs were isolated and enumerated using a size-exclusion method (CellSievo, Singapore). CTC-associated miRNAs were isolated using a paper-based, partitioning method, and analyzed using reverse transcription quantitative real-time PCR (MiRXES, Singapore). CTC count trends generally correlated with disease progression defined by radiological measurements and trends in carcinoembryonic antigen (CEA) levels; hence CTC counts may be useful in cases where CEA is not elevated. CTC-associated miRNAs identified were miR-15b, miR-16, miR-19a, miR-21, miR-25, miR-30d, miR-126, miR-185, miR-221, miR-222, and miR-324-5p. The expression of CTC-associated miRNAs did not appear to correlate with CTC count and exhibited inter-individual heterogeneity. This pilot study suggests that analysis of CTC changes during the course of treatment may be useful in monitoring response to therapy in metastatic colorectal cancer.

Single-agent capecitabine as maintenance therapy after induction of XELOX (or FOLFOX) in first-line treatment of metastatic colorectal cancer: randomized clinical trial of efficacy and safety

BACKGROUND

The optimal strategy of maintenance therapy for patients with mCRC is controversial. This study was to evaluate the efficacy and safety of maintenance therapy with capecitabine versus observation following inductive chemotherapy in patients with metastatic colorectal cancer.

PATIENTS AND METHODS

In this randomized, open-label, multicenter, phase III trial, patients who received 18-24 weeks of induction chemotherapy with XELOX or FOLFOX and achieved disease control were randomly assigned centrally (1:1) to receive maintenance therapy of capecitabine or only observation until disease progression. The primary end point was progression-free survival (PFS) from randomization; the secondary end points included overall survival (OS), PFS from induction treatment (PFS2) and safety. Analyses were done by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02027363.

RESULTS

Between 30 July 2010 and 15 September 2013, 274 patients were enrolled in the study from 11 sites in China and randomly assigned to maintenance group (n = 136) or observation group (n = 138). Clinicopathological characteristics were balanced in two groups. The median follow-up time from randomization was 29.0 months [interquartile range (IQR) 21-36 months]. The primary end point of PFS was statistically significantly longer in capecitabine maintenance group than in observation group {6.43 [95% confidence interval (CI) 5.26-7.71] versus 3.43 (2.83-4.16) months, HR 0.54 (0.42-0.70), P < 0.001}. The median OS of capecitabine maintenance group was longer than that of observation group, but not statistically significant [25.63 (22.46-27.80) versus 23.30 (19.68-26.92) months; HR 0.85 (0.64-1.11), P = 0.2247]. Similar safety profiles were observed in both arms. The most common grade 3 or 4 toxicities in capecitabine maintenance group versus observation group were neutropenia, hand-foot syndrome, and mucositis.

CONCLUSIONS

Maintenance therapy with a single agent of capecitabine can be considered an appropriate option following the induction of XELOX or FOLFOX in mCRC patients with acceptable toxicities.

CLINICAL TRIALS NUMBER

NCT02027363.

Clinical value of capecitabine maintenance therapy after first-line combination chemotherapy in patients with unresectable stage Ⅳ rectal cancer

AIM: To investigate the efficacy and safety of capecitabine maintenance therapy after first-line combination chemotherapy in patients with unresectable stage Ⅳ rectal cancer.

METHODS: Fifty-three patients with unresectable stage Ⅳ advanced rectal cancer who achieved clinical response after first-line chemotherapy (FOLFOX or FOLFIRI, q2w, 12 cycles) from June 2011 to June 2014 at the People's Hospital of Ji'an City were randomly divided into two groups: A and B. Group A (28 patients) received maintenance therapy with capecitabine (1000 mg/m², po, bid, d1-14, q21d). Group B (25 patients) did not receive any further chemotherapy. Progression-free survival (PFS) and adverse reactions were compared between the two groups.

RESULTS: The 28 patients treated with capecitabine maintenance therapy achieved a median progression free survival (PFS) of around 11.6 mo, significantly longer than the value (6.5 mo) in the 25 patients who did not receive maintenance treatment (P < 0.05). The response rate (RR) after first-line chemotherapy was 39.2% in the maintenance group and 32% in the non-maintenance group (P > 0.05). The adverse effects were reduced significantly in the maintenance therapy group and control group compared with those in first-line combination chemotherapy (P < 0.05). There was no statistical difference in adverse effects between the maintenance treatment and observation groups except for hand-foot syndrome and pigmentation (P > 0.05).

CONCLUSION: Patients with unresectable stage Ⅳ rectal cancer could benefit from capeciabine maintenance therapy in terms of longer PFS, better tolerance and milder adverse reactions.

Expert consensus on maintenance treatment for metastatic colorectal cancer in China

The impact of maintenance therapy on progression-free survival and overall survival as well as quality of life of Chinese patients with metastatic colorectal cancer has long been under discussion. Recently, some phase III clinical trials have revealed that maintenance therapy can significantly prolong the progression-free survival while maintain an acceptable safety profile. Based on this evidence and common treatment practice in China, we now generated one Expert Consensus on Maintenance Treatment for Metastatic Colorectal Cancer in China to further specify the necessity of maintenance therapy, suitable candidates for such treatment, and appropriate regimens.

Maintenance therapy following first-line chemotherapy in metastatic colorectal cancer: toxicity and efficacy-single-institution experience

A role of maintenance chemotherapy (mCT) in patients (pts) with metastatic colorectal cancer (mCRC) is still controversial. The purpose of this retrospective study was to investigate the toxicity and efficacy of mCT in pts with mCRC. There were 97/291 (33 %) pts with mCRC completed 18-20 weeks of first-line CT from 2007 to 2013 in our center. Then, pts who had no disease progression were non-randomly allocated to mCT with capecitabine ± bevacizumab (n = 35) or surveillance (n = 62). PFS was used as a primary endpoint and was calculated from the date of completion of first-line CT. Multivariate Cox stepwise regression analysis was performed to determine independent prognostic factors. Median follow-up time was 15 (range 5-60) months. Median PFS and OS were higher in pts with mCT: 7 versus 3 months (HR 0.5, 95 %CI 0.28-0.82, p = 0.007) and 29 vs 16 months (HR 0.6, 95 %CI 0.3-1.1, 0.04-Gehan-Breslow-Wilcoxon test). Following independent negative prognostic factors was significant on multivariate analysis: CEA level >2.5 ng/ml before start of first-line CT (p = 0.02), liver metastases (p = 0.03) and number of metastatic zones >2 (p = 0.008). MCT had an independent positive impact on PFS (HR 0.5, p = 0.003). MCT prolonged PFS in pts with at least one negative prognostic factors (7 vs. 3 months, p = 0.001, HR 0.38, 95 % CI 0.22-0.68). The mCT was most beneficial in pts with negative prognostic factors: CEA level >2.5 ng/ml before start of first-line CT and/or liver metastases and/or number of metastatic zones >2.

Comparison the efficacy of second-line modified EOX (epirubicin, oxaliplatin, and capecitabine) and irinotecan, 5-fluorouracil, and leucovorin (FOLFIRI) regimens in metastatic gastric cancer patients that progressed on first-line modified docetaxel and cisplatin plus fluorouracil (DCF) regimen

Gastric cancer is often diagnosed in advanced stage. Palliative chemotherapy or best supportive care is recommended for patients with metastatic gastric patients. In several clinical trials, palliative chemotherapy improved overall survival (OS) and progression-free survival (PFS), but the survival benefit of second-line chemotherapy was demonstrated in small cohort studies. The main aim of our study was to compare retrospectively the efficacy of second-line modified EOX (epirubicin, oxaliplatin and capecitabine) [mEOX] and irinotecan, 5-fluorouracil, and leucovorin (FOLFIRI) regimens in metastatic gastric cancer patients that progressed on first-line modified docetaxel-cisplatin-fluorouracil (DCF) regimen. Metastatic gastric cancer patients who progressed on modified DCF regimens were included. A total 105 patients were included to this study; 55 and 50 patients were treated with mEOX and FOLFIRI regimens, respectively. The clinicopathological and demographic characteristics of all patients were collected from the medical charts. Kaplan-Meier survival analysis was carried out for PFS and OS. The median follow-up of our study was 16 (4-85) months. In both groups, all of the patients were treated with first-line mDCF. Median cycle of second-line chemotherapy was 3 (1-8) and 3.5 (1-6) in EOX and FOLFIRI groups, respectively (P = 0.44). Overall response rate was observed in 34.6 % and 42.0 % of patients second-line chemotherapy in mEOX and FOLFIRI arms, respectively (P = 0.17). Median PFS was 5.5 and 6.3 months in mEOX and FOLFIRI arms, respectively (P = 0.98). Median OS was 6.9 and 7.0 months in mEOX and FOLFIRI arms, respectively, from the time of beginning second-line chemotherapy protocol (P = 0.89). As compared with FOLFIRI regimen, mEOX regimen was associated with less neutropenia, thrombocytopenia and anemia. Dose reduction and dose delay were significantly higher in FOLFIRI group compared to mEOX group (P < 0.001). In our trial, triplet regimens mEOX and FOLFIRI regimens have similar efficacy as second-line treatment for patients with metastatic gastric cancer. FOLFIRI regimen was associated with more hematological toxicity.

Role of capecitabine in treating metastatic colorectal cancer in Chinese patients

The China Food and Drug Administration approved the use of capecitabine in patients with metastatic colorectal cancer (mCRC) in 2004. This paper reviews the available information of capecitabine in Chinese patients with mCRC, focusing on its effectiveness and safety against mCRC. Identification of all eligible studies was made by searching the PubMed and Wanfang database from 2000 to 2013. Published data examining various aspects of clinical response and tolerability with capecitabine alone or in combination with other chemotherapeutic or biological agents for first- and second-line mCRC were examined. Capecitabine and its combination displayed high efficacy in Chinese patients with mCRC. Toxicities are generally manageable, and elderly patients can tolerate capecitabine well.

Efficacy and safety of capecitabine as maintenance treatment after first-line chemotherapy using oxaliplatin and capecitabine in advanced gastric adenocarcinoma patients: a prospective observation

The value of maintenance therapy after first-line chemotherapy has been verified in lung cancer and colorectal cancer, however, in gastric cancer, the role of maintenance therapy is still waiting for an answer. The aim of this study is to evaluate the efficacy and safety of capecitabine as maintenance treatment after first-line chemotherapy in advanced gastric adenocarcinoma patients in China. Specimens of patients with advanced gastric adenocarcinoma who were given 6 cycles of oxaliplatin and capecitabine (Xelox for short) as first-line chemotherapy, without disease progression and with grade 2 or higher neuropathy, were collected for analysis. Among them, 64 patients received capecitabine as maintenance (group A) and 222 patients without maintenance as group B. Survival analysis was performed with a Cox regression model. Grades 3-4 adverse events were uncommon; hematologic toxicity was infrequent (5%) and consistently mild in the phase of maintenance treatment. The median progression-free survival (PFS) was 11.4 months [95% confidence interval (CI), 10.2-12.6 months] for group A patients, while it was 7.1 months (95% CI, 6.1-8.0 months) for patients in group B, P < 0.001. The multivariated analysis showed that the maintenance treatment was an independent prognostic factor in advanced gastric adenocarcinoma patients. The style of first-line treatment-maintenance therapy (Xelox-X) was active and feasible for advanced gastric adenocarcinoma patients who had suffered from grade 2 or higher level of neuropathy.

Management of advanced colorectal cancer, Part 1

PURPOSE

Important developments in chemotherapy for advanced colorectal cancer over the past 15 years are reviewed, with an emphasis on the most recently published data from clinical trials of newer multidrug regimens, administration techniques, and dosing schedules.

SUMMARY

Eight agents are approved by the Food and Drug Administration (FDA) for use in treating patients with advanced colorectal cancer. Fluorouracil and leucovorin still constitute the foundation of most chemotherapy regimens for this population; combination fluorouracil-leucovorin therapy plus either irinotecan (the FOLFIRI regimen) or oxaliplatin (the FOLFOX regimen) are two firmly established first-line treatments shown to produce similar outcomes. In Phase III trials conducted over the past six to seven years, regimens of capecitabine plus oxaliplatin (CapeOx) were demonstrated to have clinical effectiveness comparable to that of FOLFOX therapy. Response rates of 35-55% and median overall survival of ≥20 months have been documented with some of the newer regimens. Research to define the optimal role of the three monoclonal antibody agents approved by FDA for use in managing advanced colorectal cancer is ongoing; bevacizumab has been shown to confer significant survival benefits when added to certain chemotherapy regimens, and other monoclonal antibodies (cetuximab and panitumumab) also appear to offer significant benefits in select patients as first- or second-line therapies.

CONCLUSION

Over the past 15 years, a shift toward multiagent treatment strategies including a variety of chemotherapy agents and monoclonal antibodies has yielded improved rates of response and prolonged survival among patients with advanced colorectal cancer. The CapeOx, FOLFOX, and FOLFIRI regimens are currently among the most widely used first-line treatments.

Systematic review on infusion reactions associated with chemotherapies and monoclonal antibodies for metastatic colorectal cancer

Objective:

The objective of this systematic review is to summarize the literature to date on the rates of infusion reactions (IR) associated with chemotherapies and monoclonal antibody (mAb) drug therapies used for the treatment of metastatic colorectal cancer (mCRC) and the associated clinical and economic impact.

Methods:

This study searched Medline, Medline (R) In-Process, Embase and Cochrane Library databases for studies on IRs associated with chemotherapy and mAbs in mCRC patients from 2000-2011.

Results:

For chemotherapy, the incidence of IRs ranged from 0-71% for all grades and 0-15% for grade 3-4. Rates of all grade IRs associated with cetuximab ranged from 7.6-33% and grade 3-4 IR rates were 0-22%. Rates of all grade IRs associated with panitumumab ranged from 0-4% and rates of grade 3-4 IRs ranged from 0-1%. The overall rate of IRs associated with bevacizumab ranged from 1.6-11%, with a rate of 0-4% for grade 3-4 IRs. A range of 50-100% of patients with grade 3-4 IRs terminated chemotherapy, and 34-100% of cetuximab patients with grade 3-4 IRs discontinued cetuximab therapy. No data were reported for bevacizumab or panitumumab. Only one study evaluated the economic impact of IRs. The study compared cetuximab administrations without an IR to those with an IR requiring resource utilization and found that mean costs were $9308 and $1725 higher for those with an IR requiring an emergency room visit or hospitalization and for those with an IR requiring outpatient treatment, respectively.

Conclusions:

The incidence of IRs varies among different mAbs; and IRs may cause treatment disruption and require costly medical interventions.