Third-line chemotherapy for small cell lung cancer

The Efficacy and Safety of Anlotinib in Extensive-Stage Small Cell Lung Cancer: A Multicenter Real-World Study

Purpose

Anlotinib, an antiangiogenic multi-target tyrosine kinase inhibitor (TKI), has shown favorable anticancer efficacy and acceptable safety in treating extensive-stage small cell lung cancer (ES-SCLC) in some clinical studies. This research aimed to explore the real-world efficacy and safety of anlotinib in ES-SCLC.

Methods

Pathologically confirmed ES-SCLC patients receiving anlotinib were enrolled for this retrospective study. The primary endpoint of this study was progression-free survival (PFS), and secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), and adverse reactions.

Results

In total, 202 patients were included in this study. The median PFS of all patients was 4.8 months [95% confidence interval (CI): 3.9–5.7], and the median OS was 7.6 months (95% CI 6.5–8.7). Respectively, the overall ORR and DCR were 30.2% and 87.1%. The univariate and multivariate Cox regression analyses revealed that patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≤1, plus chemotherapy or immunotherapy, plus radiotherapy, and post-medication hypertension might have longer PFS and OS. The PFS and OS were significantly prolonged in combination group than that in monotherapy group [PFS 6.0 vs 3.6 months, hazards ratio (HR)=0.49, 95% CI 0.34–0.70, P < 0.001; OS 9.2 vs 4.8 months, HR = 0.48, 95% CI 0.32–0.72, P < 0.001]. The main treatment-related adverse reactions were generally tolerated. The incidence of adverse reactions in combination group was higher than that in monotherapy group (75.0% vs 52.6%, P = 0.001). The most common adverse reaction was hypertension, followed by hand-foot syndrome and fatigue, regardless of monotherapy or combination group.

Conclusion

Anlotinib is effective and well tolerated in patients with ES-SCLC in the real-world. The clinical efficacy of anlotinib combined with chemotherapy or immunotherapy is better than that of monotherapy. Further investigations are needed for prospective studies with larger sample size.

Effectiveness and Safety of Anlotinib Monotherapy for Patients with Extensive-stage Small-Cell Lung Cancer Who Progressed to Chemotherapy: A Real-world Exploratory Study

Background:

Anlotinib demonstrated promising efficacy for patients with extensive-stage small-cell lung cancer (ES-SCLC) in clinical trials. However, the real-world evidence of anlotinib monotherapy in ES-SCLC was still limited currently. Therefore, present study was to investigate the effectiveness and safety of anlotinib for patients with ES-SCLC who progressed to chemotherapy in real-world and the potential biomarker during anlotinib monotherapy.

Methods:

A total of 89 patients with ES-SCLC who failed the previous chemotherapy treatment were recruited. All the patients were administered with anlotinib monotherapy. Demographic data of the patients were collected; effectiveness and safety profile during anlotinib monotherapy were documented through electronic medical record system in the hospital. Progression-free survival (PFS) and overall survival (OS) were presented using Kaplan-Meier survival curves and multivariate analysis was adjusted by Cox regression analysis.

Results:

All the 89 patients with ES-SCLC who progressed to chemotherapy were available for the assessment of effectiveness and safety profile. Best overall response indicated that partial response was observed in 6 patients (6.7%), stable disease was noted in 61 patients (68.5%), and progressive disease was found in 22 patients (24.7%). Therefore, the objective response rate (ORR) and disease control rate (DCR) of the 89 patients with ES-SCLC was 6.7% (95% confidence interval [CI]: 2.5%-14.1%) and 75.3% (95% CI: 65.0%-83.8%), respectively. The prognostic data suggested that the median PFS of the 89 patients was 3.1 months (95% CI: 2.10-4.10), and the median OS was 8.6 months (95% CI: 7.42-9.78). In addition, the most common adverse reactions of the patients who received anlotinib monotherapy were hypertension (34.8%), hand-foot syndrome (30.3%), fatigue (29.2%), loss of appetite (27.0%), and hematological toxicity (21.3%). Association analysis between biomarker (hypertension status) and prognosis indicated that the median PFS of patients with hypertension and patients with non-hypertension was 5.5 and 3.0 months, respectively (χ² = 4.64, P = .031). Furthermore, multivariate Cox analysis for PFS suggested that hypertension status was an independent factor for PFS (hazard ratio [HR] = 0.71, P = .035].

Conclusion:

Anlotinib monotherapy showed encouraging effectiveness and acceptable safety profile for patients with ES-SCLC in real world. Hypertension induced by anlotinib administration might be used as a potential biomarker to predict superior PFS for patients with ES-SCLC.

Clinical Activity and Safety of Anlotinib Combined with PD-1 Blockades for Patients with Previously Treated Small Cell Lung Cancer

Objective

Anlotinib was the standard monotherapy for patients with previously treated small cell lung cancer (SCLC) in recent years. Programmed cell death protein 1 (PD-1) blockade combined with antiangiogenic targeted drugs have proved to play a synergistic action for cancer treatment clinically. Consequently, the present study was to investigate the efficacy and safety of anlotinib combined with PD-1 blockades for patients with previously treated SCLC.

Methods

A total of 36 patients with SCLC who were treated with at least one previous systemic chemotherapy regimen participated in this study retrospectively. All the patients were administered with anlotinib plus PD-1 blockades therapy. Clinical activity was assessed according to the change of target lesion by imaging evidence and all the subjects were followed up regularly. Safety profiles were collected and documented during the treatment. Univariate analysis was carried out using Log rank test and multivariate analysis was adjusted by Cox regression analysis.

Results

All the 36 patients with previously treated SCLC were able to have their efficacy and safety profile evaluated. The best overall response of the combination regimen showed that complete response was observed in one patient, partial response was noted in 9 patients, stable disease was reported in 19 patients, progressive disease was seen in 7 patients. Therefore, the objective response rate (ORR) of the 36 patients was 27.8% (95% CI: 14.2-45.2%), disease control rate (DCR) was 80.6% (95% CI: 64.0-91.8%). Regarding the prognostic data, the median PFS and OS of the 36 patients was 4.6 months (95% CI: 3.13-6.07) and 9.3 months (95% CI: 3.30-15.30), respectively. The most common treatment-related adverse reactions were hypertension (52.8%), fatigue (47.2%), diarrhea (38.9%), hand and foot reaction (38.9%) and dermal toxicity (33.3%). Furthermore, multivariate Cox regression analysis for PFS indicated that ECOG performance status was an independent factor to predict PFS.

Conclusion

Anlotinib combined with PD-1 blockades regimen preliminarily demonstrated encouraging efficacy and tolerable safety for patients with previously treated SCLC. The conclusion should be validated in prospective clinical trials subsequently.

Irinotecan monotherapy as third- or further-line treatment for patients with small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is a very aggressive cancer and recurrence is inevitable. Treatment of recurrent disease is important for improving the prognosis of patients with SCLC.

METHODS

We conducted a retrospective observational study to investigate the efficacy and safety of irinotecan monotherapy as third- or further-line treatment in patients with SCLC.

RESULTS

Data of 15 patients who had received irinotecan monotherapy as third- or further-line treatment between 2004 and 2019 were analyzed. The median progression-free survival duration (95% confidence interval) from the initiation of treatment with irinotecan was 2.7 (1.4-3.8) months, and the median overall survival duration (95% confidence interval) from the initiation of irinotecan treatment was 10.0 (3.9-12.9) months. Partial response, stable disease or non-complete response/non-progressive disease, and progressive disease were observed in 1, 6, and 8 patients, respectively. Adverse events ⩾ grade 3 in severity were observed in 2/2 (100%) patients who were homozygous for UGT1A1 mutation, 2/3 (66.7%) patients who were heterozygous for UGT1A1 mutation, 4/6 (66.7%) patients who had wild-type UGT1A1, and 2/4 (50.0%) patients in whom the UGT1A1 mutation status was unknown.

CONCLUSION

Our results suggest that irinotecan monotherapy can be a useful alternative treatment option in the third-line setting for patients with SCLC.

Real World Analysis of Small Cell Lung Cancer Patients: Prognostic Factors and Treatment Outcomes

In this observational study, we assessed treatment patterns and prognostic factors in patients with small cell lung cancer (SCLC) in a large state-mandated healthcare organization in Israel. Methods: All incident cases with histologically confirmed SCLC who initiated systemic anti-cancer treatment between 2011 and 2017 were identified. Treatment patterns and overall survival (OS) were evaluated for each line of therapy. Results: A total of 235 patients were identified (61% male, median age 64 years, 95% ever smokers, 64% had extensive stage). The first-line treatment was platinum-etoposide regimen for 98.7% of the cohort. The second and third-line regimen were given to 43% and 12% of patients, respectively. Mean OS for extensive and limited stage patients was 9.1 and 23.5 months respectively. In a multivariable model, increased risk for mortality was observed among patients with an ECOG performance status (PS) of 2 compared to a PS of 0-1 for the extensive stage patients (Hazard ratio (HR) = 1.63, 95% confidence ratios (CI): 1.00-2.65); and for males compared to females for the limited stage patients (HR = 2.17; 95% CI: 1.12-4.20). Regarding all 2nd line patients in a multivariable model incorporating relevant confounding factors, demonstrated a significantly better outcome with platinum-based regimens compared to topotecan. Median survival after initiation of 2nd line in platinum-sensitive patients was longer (p = 0.056) for those re-challenged with platinum-based regimen (n = 7): 6.8mo (6.1-not reported (NR)), compared with those switched to a different treatment (n = 27): 4.5 mo (2.6-6.6) for extensive stage patients, and a non-significant difference was also observed for limited stage patients. Conclusion: To our knowledge, this is one of the largest real-world studies of SCLC patients. OS for SCLC patients was similar to that reported in clinical trials. PS for extensive stage patients and sex for limited stage patients were significant correlates of prognosis. Re-challenge of the platinum-based doublet was associated with longer OS compared to switching treatment in extensive stage patients.

Comparative effectiveness of nivolumab versus standard of care for third-line patients with small-cell lung cancer

Aim: To estimate the comparative effectiveness of nivolumab versus standard of care (SOC) in terms of overall survival (OS) for small-cell lung cancer patients treated with two prior lines of chemotherapy, in other words, third line in the USA. Materials & methods: Data were from CheckMate 032, a single-arm trial of nivolumab, and real-world electronic patient records. Comparisons of OS were conducted using three different methods to adjust for differences (regression, weighting and doubly robust) between the populations. Results: Nivolumab was associated with longer survival compared with SOC (hazard ratio for OS: 0.58-0.70) across all methods for adjustment. Conclusion: Nivolumab was more efficacious in terms of OS as third-line treatment for small-cell lung cancer compared with current SOC in the USA.

Efficacy and Safety of Anlotinib for Elderly Patients with Previously Treated Extensive-Stage SCLC and the Prognostic Significance of Common Adverse Reactions

Background

This study was to investigate the efficacy and safety of anlotinib for elderly patients with previously treated extensive-stage small cell lung cancer (ES-SCLC) and the prognostic significance of common adverse reactions.

Patients and Methods

A total of 79 elderly patients (≥60 years) with ES-SCLC who failed after at least two lines of previous systemic therapy were included. Baseline characteristics of the patients were collected. Follow-up was conducted regularly. Adverse reactions were documented. Survival curves were drawn using Kaplan–Meier method. Univariate analysis was assessed using log rank test, and multivariate analysis was adjusted by Cox regression analysis. Additionally, the prognostic significance of common adverse reactions was performed.

Results

All of the 79 patients were available for evaluation of efficacy. Partial response (PR) was observed in 7 patients, stable disease (SD) was noted in 48 patients and progressive disease (PD) was confirmed in 24 patients. Consequently, the objective response rate (ORR) was 8.9% and disease control rate (DCR) was 69.6%. The median progression-free survival (PFS) of the 79 elderly patients with ES-SCLC was 3.0 months [95% confidence interval (CI): 2.02–3.98]. The median overall survival (OS) was 7.1 months (95% CI: 5.07–9.13). Safety profile demonstrated that the relatively common adverse reactions of the elderly patients with ES-SCLC receiving anlotinib treatment were hypertension (40.5%), hand-foot syndrome (HFS, 31.6%), diarrhea (27.8%), decreased appetite (20.3%), fatigue (17.7%) and weight loss (17.7%). Interestingly, the prognostic significance of common adverse reactions indicated that the median PFS of patients with hypertension and without hypertension was 4.35 and 2.95 months, respectively (P=0.01), and the median PFS of patients with HFS and without HFS was 4.20 and 2.95 months, respectively (P=0.03).

Conclusion

The preliminary efficacy and safety of anlotinib in the treatment for elderly patients with previously treated ES-SCLC was satisfactory, and patients with hypertension and hand-foot syndrome might confer superior prognosis.

A Prospective Study of Apatinib in Patients with Extensive-Stage Small Cell Lung Cancer After Failure of Two or More Lines of Chemotherapy

Background

Because of rapid disease progression and lack of optimal treatment strategies beyond the second‐line, the prognosis of patients with extensive‐stage (ES) small cell lung cancer (SCLC) still remains depressing. Alternative treatment strategies are required to improve their prognosis. In this prospective clinical study, we aimed to evaluate the feasibility of single‐agent apatinib, a vascular endothelial growth factor receptor‐2 tyrosine kinase inhibitor, as a treatment option for patients with ES‐SCLC after failure of at least two prior chemotherapy regimens.

Materials and Methods

Twenty‐two patients with ES‐SCLC treated with 500 mg single‐agent apatinib as subsequent‐line regimen in our institution from November 2016 to August 2018 were enrolled in the study. The primary endpoint was progression‐free survival (PFS). The secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), and adverse events (AEs).

Results

Clinical outcomes included partial response in 3 patients (13.6%), stable disease in 18 patients (81.8%), and disease progression in 1 patient (4.5%), with an ORR of 13.6% and DCR of 95.5%. The median PFS and OS were 5.4 and 10.0 months, respectively. Apatinib demonstrated a manageable toxicity profile, with grade I–III secondary hypertension and proteinuria as the most common AEs. No grade IV and V AEs were observed among the patients. Multivariate analysis revealed secondary hypertension as an independent predictor of OS (p = .047); however, the association became insignificant after Q correction (p = .455).

Conclusions

Apatinib was safe and effective in the management of patients with ES‐SCLC and can be considered as a treatment option after failure of at least two prior chemotherapy regimens. http://ClinicalTrials.govidentifier. NCT02995187

Implications for Practice

This study indicated the acceptable toxicity profile and promising efficacy of apatinib in the management of patients with extensive‐stage small cell lung cancer after failure from at least two prior chemotherapy regimens. Secondary hypertension can be a potential prognostic factor for apatinib treatment.

Alternative treatment strategies are needed to improve prognosis for patients with small‐cell lung cancer. This article evaluates the feasibility of single‐agent apatinib as a treatment option for patients with extensive‐stage small‐cell lung cancer.

Paclitaxel for treatment of advanced small cell lung cancer (SCLC): a retrospective study of 185 patients

Background

Etoposide-/platinum-based chemotherapy is the standard first-line treatment for extensive-disease small cell lung cancer (SCLC), but responses are short-lived and subsequent options limited. Here, we present our experience with paclitaxel in advanced treatment lines.

Methods

We retrospectively studied the clinical course of all paclitaxel-treated SCLC patients between 2005 and 2015 in our institution. Prognostic and predictive factors were analyzed by Kaplan-Meier and Cox regression analyses.

Results

A total of 185 patients [119 men, median age 65 years, median ECOG performance status (PS) 1] were identified. One hundred and sixty-eight patients had extensive disease (ED) at the time of paclitaxel therapy. Paclitaxel was mainly given as third- or fourth-line therapy (93%). The response rate (RR) was 17% and disease control rate (DCR) 28%. Patients reached a median progression-free survival (PFS) of 1.6 (95% CI: 1.4-1.8) months and median overall survival (OS) of 3.3 (95% CI: 2.8-3.9) months. Main toxicities were fatigue (25%) and polyneuropathy (17%). Dose reduction of ≥25% was associated with shorter PFS [1.9 (95% CI: 1.5-2.3) vs. 1.4 (95% CI: 1.3-1.5) months; P=0.004]. Further independent predictive factors for PFS were gender, age, and hepatic/brain metastases (P<0.05). Tumor response to paclitaxel, PS, number and location of metastases, dose reduction, and smoking history were significant factors for OS in univariable analyses (P<0.05), while PS, dose reduction, status of cerebral/hepatic metastases, tumor response, and smoking history were retained as independent prognostic factors in multivariable testing. Notably, ECOG PS 2 patients had toxicity rates similar to ECOG PS 0-1 patients (63% vs. 62%), as well as a comparable DCR (29% vs. 28%), which was associated with prolonged survival (4.5 vs. 3.2 months for refractory cases, P=0.034).

Conclusions

Paclitaxel has clinically relevant activity in heavily pretreated SCLC. While patients with good PS and no cerebral/hepatic metastases derive the greatest benefit, ECOG PS 2 per se should not be used as a criterion to exclude patients.

Apatinib in patients with extensive-stage small-cell lung cancer after second-line or third-line chemotherapy: a phase II, single-arm, multicentre, prospective study

BACKGROUND

Small-cell lung cancer (SCLC) remains an aggressive cancer with short-term survival due to limited therapeutic options. Apatinib is a small-molecule tyrosine kinase inhibitor that selectively inhibits vascular endothelial growth factor receptor-2. This study aimed to investigate the efficacy and safety of apatinib in patients with extensive-stage (EC) SCLC who had progressed after two or three previous therapies.

METHODS

Eligible patients were histologically confirmed ES-SCLC after two or three previous treatments, including a platinum-based regimen. Patients received apatinib at an initial dose of 500 mg once daily. The primary endpoint was the objective response rate.

RESULTS

Forty patients were enrolled. At the data cut-off time (November 15, 2018), the median follow-up was 7.4 months; no patients remained on treatment, and five were still in follow-up. An objective response was achieved in 7 of 40 patients (17.5%) in the intention-to-treat population, and 7 of 38 patients (18.4%) in the per-protocol population. The median progression-free survival and overall survival were 3.0 months and 5·8 months, respectively. The most commonly observed grade 3 or greater treatment-related adverse events were hypertension, hand-foot syndrome, increased L-gamma-glutamyltransferase.

CONCLUSIONS

Apatinib exhibited efficacy and an acceptable safety profile in previously heavily-treated ES-SCLC patients. Further exploration of apatinib in phase III trials is warranted.

TRIAL REGISTRATION

NCT02945852.

Real-world effectiveness and tolerability of small-cell lung cancer (SCLC) treatments: A systematic literature review (SLR)

OBJECTIVES

SCLC makes up approximately 15% of all lung carcinomas and is characterized by relatively aggressive spread and poorer prognosis compared to other lung cancers. Treatment options are limited, and their efficacy in randomized trials is poor, whilst outcomes in clinical practice remain unclear. The aim of this study was to assess the real-world effectiveness and tolerability of SCLC treatments.

METHODS

An SLR was conducted across nine databases accessed through OVID, capturing observational, non-randomized studies published between 01/2006-11/2018. In total, 554 abstracts were retrieved and systematically screened for eligibility. The eligible publications included effectiveness and tolerability data from adult SCLC patients (at any line of therapy). Additional grey literature searches were conducted.

RESULTS

Forty-three publications were included in this review-data from first-line therapies were captured most often (n = 32), while data from second (n = 14) and third line (n = 7) and beyond (n = 7) were less frequent. The publications reported primarily on chemotherapy/radiotherapy. The majority of publications lacked robustness and only 14/43 conducted statistical analyses or controlled for bias. Median OS for the largest SCLC populations were 9.6 months at first line (n = 23,535) and 4.9 months at second line (n = 254) for treatment with chemotherapy, and 4.7 months at third line (n = 120) for predominantly platinum-based chemotherapy or cyclophosphamide/adriamycin/vincristine. Hematologic toxicities (such as neutropenia, thrombocytopenia and anemia) were the most frequently reported TRAEs (n = 9).

CONCLUSIONS

Real-world treatment effectiveness and tolerability data were fragmented and inconsistently reported, and available publications were primarily of poor quality and lacked statistical analyses. This SLR showed limited treatment options and poor OS in SCLC, with no treatment option being clearly superior. TRAEs additionally increased the burden of this already challenging disease. Recent data suggest real-world outcomes are even poorer that those reported in clinical trials, and that novel therapies are needed to offer new treatment options for patients.

Apatinib for chemotherapy-refractory extensive-stage SCLC: a retrospective study

PURPOSE

There is no standard treatment strategy for patients with extensive-stage small cell lung cancer (SCLC) who have failed two or more prior chemotherapeutic regimens. In this study, we retrospectively evaluated the efficacy and safety of apatinib in patients with extensive-stage SCLC after failure of more than second-line chemotherapy.

METHODS

A study group comprised of 22 patients with extensive-stage SCLC after failure of more than two prior chemotherapeutic regimens was given apatinib orally at an initial dose of 500 mg daily until disease progression or unacceptable toxicity. This study was analyzed according to the National Cancer Institute Common Toxicity Criteria for adverse events (AEs) and Response Evaluation Criteria in Solid Tumors (RECIST) for response assessment.

RESULTS

Between August 30, 2015, and May 26, 2017, 22 patients were enrolled for evaluating the efficacy and safety of apatinib. Among them, 12/22 (54.5%) underwent dose reduction during treatment. Up to July 31, 2018, the median progression-free survival rate was 135.0 days [95% confidence interval (CI) 63.8-206.2]. According to the RECIST criteria, the disease control rate (DCR) was 86.4%, 19/22 [comprised of partial response (PR) 18.2%, 4/22; and stable disease (SD) 68.2%, 15/22 patients]. The most frequent AEs were hand-foot syndrome (45.5%, 10/22), secondary hypertension (45.5%, 10/22) and fatigue (40.9%, 9/22). The primary grade 3 or 4 toxicities were hypertension (22.7%, 5/22), hand-foot syndrome (13.6%, 3/22), and proteinuria (9.1%, 2/22).

CONCLUSIONS

Apatinib exhibits modest activity and acceptable toxicity for patients with heavily pretreated extensive-stage SCLC.

Rovalpituzumab Tesirine: A Novel DLL3-Targeting Antibody-Drug Conjugate

Small cell lung cancer (SCLC) comprises about 15% of all cases of lung cancer. In recent years, owing to a change in the epidemiology of smoking habits, the incidence of the tumor has decreased; however, it remains a significant challenge to global health. While the tumor has a favorable initial response to chemoradiation, relapse is invariable, and second-line regimens may be intolerable given the severity of side effects. For patients with tumors resistant to second-line regimens, no current standard regimens exist. Rovalpituzumab tesirine is a novel antibody-drug conjugate, targeting delta-like protein 3, fundamental in the downstream cellular signaling for proliferation and apoptosis. This drug is reported to have shown promise in pre-clinical and phase I trials. It appears effective in decreasing tumor burden and is reported to be well tolerated, albeit with a significant adverse effect profile. Currently, it is being studied as part of initial and subsequent line chemotherapeutic regimens; it remains to be seen if this is a viable option in the treatment of SCLC. This may add to the agents that can be used against SCLC, and help improve outcomes.

Third-Line Nivolumab Monotherapy in Recurrent SCLC: CheckMate 032

Introduction:

For patients with recurrent SCLC, topotecan remains the only approved second-line treatment, and the outcomes are poor. CheckMate 032 is a phase 1/2, multicenter, open-label study of nivolumab or nivolumab plus ipilimumab in SCLC or other advanced/metastatic solid tumors previously treated with one or more platinum-based chemotherapies. We report results of third- or later-line nivolumab monotherapy treatment in SCLC.

Methods:

In this analysis, patients with limited-stage or extensive-stage SCLC and disease progression after two or more chemotherapy regimens received nivolumab monotherapy, 3 mg/kg every 2 weeks, until disease progression or unacceptable toxicity. The primary end point was objective response rate. Secondary end points included duration of response, progression-free survival, overall survival, and safety.

Results:

Between December 4, 2013, and November 30, 2016, 109 patients began receiving third- or later-line nivolumab monotherapy. At a median follow-up of 28.3 months (from first dose to database lock), the objective response rate was 11.9% (95% confidence interval: 6.5–19.5) with a median duration of response of 17.9 months (range 3.0–42.1). At 6 months, 17.2% of patients were progression-free. The 12-month and 18-month overall survival rates were 28.3% and 20.0%, respectively. Grade 3 to 4 treatment-related adverse events occurred in 11.9% of patients. Three patients (2.8%) discontinued because of treatment-related adverse events.

Conclusions:

Nivolumab monotherapy provided durable responses and was well tolerated as a third- or later-line treatment for recurrent SCLC. These results suggest that nivolumab monotherapy is an effective third- or later-line treatment for this patient population.

Managing Patients With Relapsed Small-Cell Lung Cancer

Despite high response rates to initial therapy, relapses are common in patients with small-cell lung cancer (SCLC). Systemic therapy after first-line failure remains important in the treatment paradigm of SCLC. Reinitiation of a previously administered first-line chemotherapy regimen is recommended for relapse > 6 months from completion of initial therapy. For relapse ≤ 6 months of initial therapy, sequential therapy with single agents is recommended. Clinical trial enrollment should be considered at all stages of treatment of SCLC. This review highlights the available treatment options in relapsed SCLC. In particular, we focus on prospective clinical trials demonstrating activity for the most commonly used agents in this setting. We end with a discussion on future directions and emerging targets with potential to improve outcomes in relapsed SCLC.

Prognostic Factor Analysis in Patients With Small-Cell Lung Cancer Treated With Third-Line Chemotherapy

BACKGROUND

There is little information on the clinical outcome of patients with small-cell lung cancer (SCLC) treated with third-line chemotherapy. The purpose of this study was to clarify the prognostic factors of SCLC patients receiving third-line chemotherapy.

PATIENTS AND METHODS

Between November 2001 and October 2011, 202 of 648 consecutive SCLC patients at the National Cancer Center Hospital East received third-line chemotherapy. Multivariate Cox regression analysis was performed to identify the prognostic factors for overall survival after third-line chemotherapy.

RESULTS

The demographics of the 202 patients were as follows: median age 66 years, 83% male, and Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1, 2, and 3 values of 22, 122, 49, and 9, respectively. Median time to treatment failure after second-line chemotherapy (TTF2) was 4.5 months (TTF2 ≥ 5/< 5 months, 82/120). The median overall survival after third-line chemotherapy was 5.1 months. Multivariate Cox regression analysis showed that PS 0-1 (hazard ratio, 0.38; 95% confidence interval, 0.27-0.54; P < .001) and TTF2 ≥ 5 months (hazard ratio, 0.57; 95% confidence interval, 0.41-0.79; P < .001) were independent prognostic factors. TTF2 threshold of 5 months was determined on the basis of concordance probability adjusted by PS.

CONCLUSION

PS 0-1 and TTF2 ≥ 5 months were associated with a favorable prognosis among SCLC patients receiving third-line chemotherapy. These 2 factors might be helpful for the selection of candidates for third-line chemotherapy and for patient stratification when conducting future clinical trials in the third-line setting.

Retrospective analysis of outcomes and prognostic factors of chemotherapy for small-cell lung cancer

BACKGROUND

Small-cell lung cancer (SCLC) is responsive to initial chemotherapy but becomes resistant to cytotoxic drugs. The aim of this study was to evaluate what proportion of patients with SCLC had received the first- and further-line chemotherapy and which patients had benefited from chemotherapy.

METHODS

We retrospectively reviewed medical records of patients with SCLC who had been treated with the best supportive care alone and the first-, second-, or third-line chemotherapy at the Osaka Police Hospital from June 2007 until March 2015.

RESULTS

Among 145 patients diagnosed with SCLC and eligible for analysis, 118 patients received chemotherapy. We added five patients who initiated the second-line chemotherapy during the study period at our institution. Sixty-five and 31 patients received the second- and third-line chemotherapies, respectively. Multivariate logistic regression analysis detected age ≥75 years (odds ratio, 2.80; 95% confidence interval, 1.01-7.75; P=0.047) and European Clinical Oncology Group Performance Status (ECOG PS) 3-4 (14.3; 4.86-41.9; P<0.01) as factors disturbing the introduction of chemotherapy. Multivariate Cox hazard analyses also detected ECOG PS 2-4 (3.34; 2.00-5.58; P<0.01) as a factor decreasing overall survival after the first-line chemotherapy, and C-reactive protein level ≥1.0 mg/dL (2.67; 1.30-5.47; P<0.01) and progression-free survival after the first-line chemotherapy ≥6 months (2.85; 1.50-5.43; P<0.01) as factors influencing overall survival after the second-line chemotherapy.

CONCLUSION

Approximately two-thirds and one-third of the patients who receive chemotherapy proceed to the second- and third-line chemotherapies, respectively. Several factors, such as age, ECOG PS, C-reactive protein level, and progression-free survival after previous treatment may be useful when considering the introduction of further-line chemotherapy.

Survival analysis in second-line and third-line chemotherapy with irinotecan followed by topotecan or topotecan followed by irinotecan for extensive-stage small-cell lung cancer patients: a single-center retrospective study

Purpose

The number of patients who make it to receive third-line chemotherapy is increasing owing to the improvements in adverse-event management of chemotherapy for small-cell lung cancer (SCLC). Sequencing of optimal treatment for SCLC is still a challenge for oncologists. In this paper, we aim to present a different approach to the treatment of SCLC.

Methods

Between January 2008 and July 2014, all patients diagnosed with extensive-stage SCLC and treated with third-line chemotherapy at Gaziantep University Oncology Hospital were analyzed retrospectively. Disease control rates and progression-free survival (PFS) for first-, second-, and third-line chemotherapy, and overall survival (OS) were recorded. Survival analysis was calculated by using Kaplan–Meier method.

Results

A total of 255 SCLC patients were screened, and 25 of those patients who received third-line chemotherapy were included in this study. Median age was 57±10.131 years (range: 39–74 years). Disease control rates at first-, second-, and third-line chemotherapy were 92%, 68%, and 44%, respectively. Fourteen patients received irinotecan followed by topotecan, and eleven patients received topotecan followed by irinotecan. Second-line median PFS was statistically better in patients treated with irinotecan at second-line compared with those treated with topotecan (21 vs 12 weeks, P=0.018). Comparison of third-line median PFS of the two groups was not statistically significant (14 vs 12 weeks, P=0.986). Median OS was not statistically significant in patients who received irinotecan followed by topotecan vs those who received topotecan followed by irinotecan (18 vs 14 months, P=0.112).

Conclusion

Sequential monotherapy with topotecan and irinotecan provides a considerable contribution to OS, and second-line irinotecan showed a better PFS, despite a similar OS, compared with topotecan.

Third-line chemotherapy in small-cell lung cancer: an international analysis

INTRODUCTION

Small-cell lung cancer is an aggressive disease for which the mainstay of treatment is chemotherapy. Despite good initial responses most patients will relapse. Some will receive second-line therapy with clinical benefit, but for third-line chemotherapy there is little evidence to guide treatment decisions and the benefits of treatment are unknown. This study investigated the treatment of SCLC in the third-line setting.

PATIENTS AND METHODS

An international, multicenter retrospective analysis of patients who received at least 3 lines of chemotherapy for their SCLC was performed.

RESULTS

From 2000 to 2010, 120 patients were identified from 5 centers: median age 61, 40% (n = 72) limited stage, and 79% (n = 95) Eastern Cooperative Oncology Group performance status of 0 to 1. Only 22% of these patients received 3 distinct lines of chemotherapy. The remainder were rechallenged with a chemotherapy regimen used at least once previously. Six percent received platinum-based chemotherapy in all 3 lines. In third-line, response rate was 18% and median overall survival was 4.7 months. Factors associated with longer survival included normal baseline LDH levels and response to second-line chemotherapy. On multivariate analysis only normal baseline LDH retained statistical significance. Thirty-five patients went on to receive chemotherapy beyond the third line.

CONCLUSION

Few SCLC patients receive 3 chemotherapy lines. Most patients were rechallenged with a similar regimen at least once. Response and survival in the third-line setting are modest. Lack of response to second-line chemotherapy and elevated baseline LDH level might predict lack of benefit from third-line treatment. This data set does not include patients receiving fewer lines for comparison.

[Small cell lung cancer]

With about 20% of all lung cancers small cell lung cancer (SCLC) represents a major subset of this entity. Although therapeutic improvements did not receive as much attention as in non small cell lung cancer (NSCLC), many small steps of clinical progress have been achieved within the last 20 years. An optimal treatment should be based on an interdisciplinary treatment plan. The standard treatment in localized stages represents combined radiation and chemotherapy. Cisplatin and etoposide are in this concern considered as a gold standard. 3D-planned conformal radiotherapy should start as early as possible and should be applied concomitantly to chemotherapy and in certain cases even in a hyperfractionated treatment protocol. In very early stages surgical resection could be an option in selected cases. In advanced stages a platinum-based doublet offers high response rates. As already established in limited disease prophylactic cranial irradiation is now also indicated in extensive disease in case of any tumor remission. In the second line treatment and in patients with reduced performance status topotecan is recommended. Similar as in NSCLC pemetrexed might become an alternative treatment option in the second line setting. In the field of new targeted therapies bevacizumab achieved the most promising results. The present review highlights historical milestones and up-to-date trends in radiotherapy, chemotherapy and surgery. Furthermore, the role of experimental strategies and the management of certain special clinical situations are discussed.

Combination chemotherapy with paclitaxel and ifosfamide as the third-line regimen in patients with heavily pretreated small cell lung cancer

The efficacy of salvage regimens for small cell lung cancer remains to be established. We evaluated the efficacy and safety of the paclitaxel and ifosfamide (PI) combination chemotherapy salvage regimen in heavily pretreated small cell lung cancer (SCLC) patients. Thirty-five patients who had received more than two prior chemotherapy regimens were treated with PI chemotherapy. Paclitaxel (175 mg/m(2)) was administered on day 1 and ifosfamide (2500 mg/m(2)) on day 1-2 every 3 weeks. Thirty-three patients were available for treatment response evaluation. Median age was 63 years (range, 40-78) and Eastern Cooperative Oncology Group (ECOG) performance scores of 0/1/2 were 29.4%, 61.8%, and 11.8%, respectively. A median of 2 cycles (range, 1-6) of chemotherapy were administered. The overall response rate (RR) in the intent-to-treat population was 20.0% (95% Confidence Interval (CI), 6.7-33.3%) with 7 partial responses (PR) and no complete response (CR). Patients who responded to previous chemotherapy just before PI showed significantly higher RR than non-responders (RR, 57.1% versus 10.7%, P=.023). After a median follow-up of 8.8 months (range, 1.6-14.7), the median time to progression was 3.3 months (95% CI, 2.3-4.4) and the median overall survival was 7.6 months (95% CI, 6.7-8.5). The most common toxicity observed was mild nausea/vomiting and grade 3/4 adverse events were observed in 4 (11.4%) patients. There were no treatment-related deaths in the study. Our findings suggest that salvage PI chemotherapy is a feasible and well tolerated regimen for previously treated SCLC patients. Further studies are warranted to define the effects of PI chemotherapy on quality of life and survival benefits.

Phase II trial of irinotecan, cisplatin and mitomycin for relapsed small cell lung cancer

There is no standard therapy for relapsed small cell lung cancer (rSCLC). We evaluated the efficacy and toxicity of a new triplet consisting of irinotecan (100 mg/m(2) Days 1 and 15 q28), cisplatin (40 mg/m(2) Days 1 and 15 q28) and mitomycin (6 mg/m(2) d1 q28) administered to a maximum of 6 cycles in individuals with rSCLC that had relapsed following first line treatment. Partial remissions were observed in 35% and progression in 30% of patients. Progression free survival measured 4.5 months (95% CI 0.8-8.2) and overall survival was 7.8 months (95% CI 5.3-10.3). QoL showed improvement in activity symptoms and stabilization of physical symptoms. As IPM was a well-tolerated regimen with activity in rSCLC, a phase III trial comparing this triplet with other regimens in this setting is warranted.