Unfavourable effects of long-term adjuvant chemotherapy with Endoxan in radically operated bronchogenic carcinoma

Chemotherapy for non-small cell lung cancer

BACKGROUND

The role of chemotherapy in the treatment of patients with non-small cell lung cancer was not clear. A systematic review and quantitative meta-analysis was therefore undertaken to evaluate the available evidence from all relevant randomised trials.

OBJECTIVES

To evaluate the effect of cytotoxic chemotherapy on survival in patients with non-small cell lung cancer. To investigate whether or not pre-defined patient sub-groups benefit more or less from chemotherapy.

SEARCH STRATEGY

MEDLINE and CANCERLIT searches were supplemented by information from trial registers and by hand searching relevant meeting proceedings and by discussion with relevant trialists and organisations.

SELECTION CRITERIA

Trials comparing primary treatments of surgery, surgery + radiotherapy, radical radiotherapy or supportive care versus the same primary treatment, plus chemotherapy were eligible for inclusion provided that they randomised non-small cell lung cancer patients using a method which precluded prior knowledge of treatment assignment.

DATA COLLECTION AND ANALYSIS

A quantitative meta-analysis using updated information from individual patients from all available randomised trials was carried out. Data from all patients randomised in all eligible trials were sought directly from those responsible. Updated information on survival, and date of last follow up were obtained, as were details of treatment allocated, date of randomisation, age, sex, histological cell type, stage and performance status. To avoid potential bias, information was requested for all randomised patients including those who had been excluded from the investigators' original analyses. All analyses were done on intention to treat on the endpoint of survival. For trials using cisplatin-based regimens, subgroup analyses by age, sex, histological cell type, tumour stage and performance status were also done.

MAIN RESULTS

Data from 52 trials and 9387 patients were included. The results for modern regimens containing cisplatin favoured chemotherapy in all comparisons and reached conventional levels of significance when used with radical radiotherapy and with supportive care. Trials comparing surgery with surgery plus chemotherapy gave a hazard ratio of 0.87 (13% reduction in the risk of death, equivalent to an absolute benefit of 5% at 5 years). Trials comparing radical radiotherapy with radical radiotherapy plus chemotherapy gave a hazard ratio 0.87 (13% reduction in the risk of death equivalent to an absolute benefit of 4% at 2 years), and trials comparing supportive care with supportive care plus chemotherapy gave a hazard ratio of 0.73 (27% reduction in the risk of death equivalent to a 10% improvement in survival at one year). The essential drugs needed to achieve these effects were not identified. No difference in the size of effect was seen in any subgroup of patients. In all but the radical radiotherapy setting, older trials using long term alkylating agents tended to show a detrimental effect of chemotherapy. This effect reached conventional significance in the adjuvant surgical comparison.

REVIEWER'S CONCLUSIONS

At the outset of this meta-analysis there was considerable pessimism about the role of chemotherapy in the treatment of non-small cell lung cancer. These results offer hope of progress and suggest that chemotherapy may have a role in treating this disease.

Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials. Non-small Cell Lung Cancer Collaborative Group

OBJECTIVE

To evaluate the effect of cytotoxic chemotherapy on survival in patients with non-small cell lung cancer.

DESIGN

Meta-analysis using updated data on individual patients from all available randomised trials, both published and unpublished.

SUBJECTS

9387 patients (7151 deaths) from 52 randomised clinical trials.

MAIN OUTCOME MEASURE

Survival.

RESULTS

The results for modern regimens containing cisplatin favoured chemotherapy in all comparisons and reached conventional levels of significance when used with radical radiotherapy and with supportive care. Trials comparing surgery with surgery plus chemotherapy gave a hazard ratio of 0.87 (13% reduction in the risk of death, equivalent to an absolute benefit of 5% at five years). Trials comparing radical radiotherapy with radical radiotherapy plus chemotherapy gave a hazard ratio of 0.87 (13% reduction in the risk of death; absolute benefit of 4% at two years), and trials comparing supportive care with supportive care plus chemotherapy 0.73 (27% reduction in the risk of death; 10% improvement in survival at one year). The essential drugs needed to achieve these effects were not identified. No difference in the size of effect was seen in any subgroup of patients. In all but the radical radiotherapy setting, older trials using long term alkylating agents tended to show a detrimental effect of chemotherapy. This effect reached conventional significance in the adjuvant surgical comparison.

CONCLUSION

At the outset of this meta-analysis there was considerable pessimism about the role of chemotherapy in non-small cell lung cancer. These results offer hope of progress and suggest that chemotherapy may have a role in treating this disease.

Adjuvant radiotherapy versus combined sequential chemotherapy followed by radiotherapy in the treatment of resected nonsmall cell lung carcinoma. A randomized trial of 267 patients. GETCB (Groupe d'Etude et de Traitement des Cancers Bronchiques)

BACKGROUND

The effect of adjuvant chemotherapy after resection of nonsmall cell lung cancer (NSCLC) remains an unresolved question.

METHODS

From October, 1982, to November, 1986, 267 patients with resected NSCLC were included in a randomized trial. The adjuvant allocated treatments were either postoperative radiotherapy, 60 Gy in 6 weeks (radiotherapy group = 129 patients), or three courses of postoperative COPAC (cyclophosphamide, doxorubicin, cisplatin, vincristine, lomustine) chemotherapy followed by a similar radiotherapy schedule (chemotherapy/radiotherapy group = 138 patients).

RESULTS

The sex ratio (M:F) was 19/1; mean age was 57 +/- 9 years. According to postoperative staging, 8 patients were Stage I, 70 were Stage II, and 189 were Stage III. The histologic type was squamous cell carcinoma in 175 patients, adenocarcinoma in 57, and large cell carcinoma in 35. The minimum follow-up was 6 years. Four patients were lost to follow-up. Death was recorded in 233 patients. No significant difference was observed in terms of disease free interval (P = 0.47, log-rank test), or overall survival (P = 0.68, log-rank test). With respect to the first site of relapse, distant metastasis occurred more frequently in the radiotherapy group (P = 0.09, log-rank test) whereas local relapse occurred similarly in both groups (P = 0.27). An interaction was observed between lymph node involvement and treatment in terms of overall survival.

CONCLUSIONS

The COPAC chemotherapy as postoperative treatment failed to improve overall survival in patients with resected NSCLC receiving postoperative radiotherapy but decreased the pattern of metastatic progression, mainly in the N2 patients.

Failure of the perioperative PCV neoadjuvant polychemotherapy in resectable bronchogenic non-small cell carcinoma. Results from a randomized phase II trial

In 1985, the authors began a phase II study to assess the PCV perioperative polychemotherapy (cisplatin 100 mg/m2, cyclophosphamide 600 mg/m2, vindesine 3 mg/m2) in patients with resectable bronchogenic non-small cell carcinoma. Patients were randomized to receive either two preoperative courses of PCV chemotherapy, surgery, and two postoperative courses of PCV chemotherapy (PCV group) or immediate surgery (surgery group). A staging procedure using the CT scan was performed before randomization and, additionally, before surgery in the PCV group. There were 26 randomized patients, 13 in each group. In the PCV group, 11 patients agreed to receive the two preoperative courses of chemotherapy. A response was observed in five patients (45%), and a progression was observed in four patients (36%) leading to a cancellation of surgery in two of them. Postoperative care was the same for each group. Although no death could be related to chemotherapy, it was decided to stop entering new patients into this trial because of the rate of preoperative progression in the PCV group.

Suppression of in vitro peripheral blood lymphocyte mitogenesis by cytotoxic drugs commonly used in the treatment of breast cancer: a comparative study

Cultures of normal donor peripheral blood mononuclear cells were tested in vitro for suppression by chemotherapeutic agents or their metabolites. The drugs tested were those commonly used in the treatment of breast cancer, namely, 5-fluorouracil, doxorubicin, vincristine, methotrexate and cyclophosphamide (actually testing its active metabolite, 4-hydroxy-cyclophosphamide). The lymphocytes were stimulated by phytohaemagglutinin (PHA), and the inhibitory effect of the drugs on subsequent DNA synthesis was measured by tritiated thymidine uptake. Drug concentrations used were equivalent to expected in vivo plasma and body fluid levels following i.v. injection of a standard therapeutic dose. Results suggest that the drugs may be ranked for suppression of T-cell function as follows: doxorubicin greater than vincristine = cyclophosphamide greater than 5-fluorouracil greater than methotrexate.

Adjuvant therapy with levamisole in resectable lung cancer

In view of the discouraging results that have been obtained so far with the use of cytotoxic chemotherapy as an adjunct to surgery, a double-blind placebo-controlled evaluation of the adjuvant use of levamisole was conducted in 211 resectable lung cancer patients, following these patients for 2 years after their operation. Levamisole (or the placebo) was given for 3 days every 2 weeks and the dose level ranged 1.1--3.8 mg/kg per day (a fixed dose of 3 x 50 mg was given to all patients). It appeared that recurrences and carcinomatous deaths had occurred significantly less often in patients who had received a high dose (i.e., 2.1--3,8 mg/kg: patients weighing 70 kg or less) but not in the patients who received a lower dose. Patients who had more advanced cancers at the time of surgery seemed to have profited more from the treatment, but the results did not seem to depend upon the histologic type of the tumor or on the immune status of the patients as estimated from the skin test reactivity at the start. There was also suggestive evidence that levamisole may be more effective in preventing hematogenous dissemination than in inhibiting recurrences in the lung or the mediastinal tissues. Levamisole, if dosed adequately, appears to be a very suitable adjuvant treatment in resectable lung cancer patients as judged from its efficacy and its lack of troublesome side-effects.

Adjuvant cancer chemotherapy after resection of carcinoma of the lung

A prospective randomized trial was conducted by the Veterans Administration Surgical Adjuvant Group in an attempt to discern the value of prolonged intermittent courses of adjuvant cancer chemotherapy after a successful curative resection of a carcinoma of the lung in men. Four hundred and seventeen patients were randomized into three groups; 132 patients received cyclophosphamide (Cytoxan), regimen A; 142 patients received cyclophosphamide alternating with methotrexate, regimen b; and 143 patients received no additional therapy, the controls. The patients in the two treatment groups received an average of 7.1 drug courses. No drug mortality was noted, but toxic symptoms of varying severity were seen after 43.6% of the drug courses. Five-year survival in the two treatment groups was 24.9% (regiment A) and 25.7% (regimen B), respectively, and 23.5% in the control group. No treatment benefit was associated with adjuvant chemotherapy in this trial.

Metastasis of a transplantable mammary tumour in rats treated with cyclophosphamide and/or irradiation

We report observations on the spread by metastasis and infiltration of a transplantable tumour in rats treated by 60Co gamma-irradiation of the primary, irradiation plus parenteral cyclophosphamide, or parenteral cyclophosphamide alone. The proportion of animals with overt disseminated disease and the extent of spread were measured with respect to the time elapsed after implantation and treatment of the primary tumour. The incidence of metastatic disease was broadly similar for all treatment groups, but the extent of dissemination was greater in rats whose treatment included cyclophosphamide.

[Intra- or Postoperative Chemoprophylaxis? (author's transl)]

The surgical cure rates for most operable cancers have remained unchanged over the past few decades despite progress in local treatment and "prophylactic" preor postoperative radiotherapy. Due to the limitations of primary and secondary prophylaxis (prevention and "early" diagnosis), tertiary prophylaxis (adjuvant chemotherapy to prevent relapse or dissemination) has aroused considerable interest in tumor management recently. Definite progress in prolongation of the postoperative tumorfree interval has been obtained in controlled studies of breast cancer, osteogenic sarcomas and other target neoplasms. Long-term chemoprophylaxis has proved to be more effective than peroperative short courses of chemotherapy.

Combined chemotherapy and surgery in breast cancer: a review

The current results of trials testing combined surgery and chemotherapy in patients with breast cancer is reviewed. Information concerning eight trials utilizing nine single-agent regimens was obtained. The results at this time are conflicting. There appear to be differences among the regimens utilized in the various patient subsets. Some of the possible reasons for the observed differences, and their implications for future studies, are discussed.

Thymus-dependent lymphocyte levels in bronchogenic carcinoma: correlations with histology, clinical stage, and clinical course after surgical treatment

The in vitro spontaneous lymphocyte rosette (T cell) assay was used to determine cellular immunologic competence in 112 patients with bronchogenic carcinoma. Among preoperative patients with localized tumors. T cell levels were significantly lower than in 237 normal controls. With advanced stages of disease, T cell levels declined progressively among patients with squamous cell carcinoma, oat cell carcinoma, and undifferentiated carcinoma, but not among patients with adenocarcinoma. Squamous carcinoma patients considered cured had persisting low T cell levels, but cured adenocarcinoma patients had normal levels. Serial determinations that showed a fall in T cell levels preceded the development of clinically evident metastases by an average of 2.5 months. Postoperative patients with rising T cell levels have remained clinically free of disease. The data indicate that T cell levels correlate with extent of tumor and clinical course of patients with bronchogenic carcinoma. The assay may, therefore, provide a rational basis for the selection of patients who are at high risk for the development of recurrence after surgical resection and who may benefit from the early institution of adjunctive therapy.

Treatment of small-cell carcinoma of bronchus

A randomised trial comparing radiotherapy with a multiple chemotherapy regimen in 68 patients with small cell carcinoma of bronchus is reported. Although overall survival was poor, radiotherapy resulted in significantly longer survival, better amelioration of symptoms, and less side-effects than chemotherapy. Patients achieving complete or partial remission on radiotherapy relapsed mainly with extrathoracic disease, in contradistinction to those treated with chemotherapy whose thoracic disease recurred.

The effect of surgery and pretreatment or posttreatment adjuvant chemotherapy on primary tumor growth in an animal model

The Ca755 solid tumor in the C57B1 mouse has been used as a model to study the interrelationship of surgery and adjuvant chemotherapy on primary tumor growth. Surgery was performed on various days after tumor implantation. Surgical mortality increased with delay in surgery. The mean survival time (MST) was significantly increased by surgery. An increased cure rate in mice with late surgery may be due to immunological factors. Pretreatment cytoxan chemotherapy prior to a number of surgical days on the most effect schedule increased MST in the later surgical days primarily due to shrinkage of tumor and a diminished surgical mortality. Posttreatment chemotherapy significantly increased MST primarily on the basis of reducing tumor cell population after surgery and increasing both the cure rate and the time until death of those mice dying of regrowth of tumor. Optimal chemotherapy alone significantly increased MST compared to untreated controls. Optimal postsurgery chemotherapy increased survival longer than the additive increase of chemotherapy alone and surgery alone. This paper illustrates relationships between day of surgery dose and schedule of chemotherapy and effect on various measurable parameters. The results can best be understood in relationship to each other. It is suggested that adjuvant chemotherapy has specific definable benefits. It is apparent from human studies that carefully devised designs which consider these interrelationships are necessary if optimal therapeutic results are to be achieved.

Chemotherapy for carcinoma of the bronchus--a brief review

A brief theoretical approach to the chemotherapy of carcinoma of the bronchus is considered. Some of the currently available data and prospects for the future are reviewed.