Combination chemotherapy with docetaxel, vinorelbine and cisplatin as first-line treatment of advanced non-small-cell lung cancer: a multicenter phase II study of the Greek Cooperative Group for Lung Cancer

A Retrospective Analysis of Second-Line Chemotherapy or Best Supportive Care in Patients with Advanced-Stage Non–Small-Cell Lung Cancer

BACKGROUND

We retrospectively evaluated the clinical characteristics and outcome of patients with stage IIIB/IV non-small-cell lung cancer (NSCLC) enrolled in first-line chemotherapy trials conducted by our group with respect to receiving or not receiving subsequent treatment.

PATIENTS AND METHODS

Data were collected from 634 patients with stage IIIB/IV NSCLC treated with platinum and nonplatinum agent-based first-line regimens. Patient survival was calculated from the day of registration to first-line chemotherapy trials (OS1) as well as from the day of first-line treatment failure or the initiation of second-line chemotherapy (OS2) until death. The decision for administering second-line chemotherapy was, in all cases, at the discretion of the physician. Two hundred twenty-four patients (35.3%) received second-line chemotherapy (second-line group) in the context of second-line clinical trials run by the same group, and 410 (64.7%) received best supportive care (BSC group). There were significant differences between second-line and BSC groups in terms of age, histology, early discontinuation of first-line chemotherapy, and performance status after first-line treatment.

RESULTS

Three (1.3%) complete and 25 (11.2%) partial responses to second-line chemotherapy were observed for an overall response rate of 12.5% (95% confidence interval, 8.2%-16.8%). The median OS1 was 13 months and 7 months (P < 0.001) and the OS2, 7 months and 3 months (P < 0.001) for the second-line and BSC groups, respectively. Multivariate analysis revealed that good performance status, disease stage IIIB, response to first-line treatment, and late termination of first-line chemotherapy were significantly associated with increased survival. The administration of second-line chemotherapy was also independently correlated with better outcome.

CONCLUSION

The second-line chemotherapy and BSC groups represent different populations of patients with NSCLC. Factors indicative of increased probability of survival could be used to identify the subgroup of patients most likely to benefit from second-line chemotherapy.

Paclitaxel, Cisplatin, and Vinorelbine Combination Chemotherapy in Metastatic Non–Small-Cell Lung Cancer

Vinorelbine-cisplatin combination chemotherapy is a standard approach for the treatment of advanced non-small-cell lung cancer (NSCLC). The addition of paclitaxel as a third therapeutic agent seems promising. The aim of the present study was to evaluate the activity and toxicity of this new regimen. Forty-six nonselected and chemotherapy-naive patients with stage IV NSCLC and an Eastern Cooperative Oncology Group performance status of 0 to 2 were treated every 4 weeks with paclitaxel (135 mg/m2 given iv in 3 hours) and cisplatin (120 mg/m2 given iv in 6 hours) on day 1 and vinorelbine (30 mg/m2 given iv in 30 minutes) on days 1 and 15. All patients were evaluated for toxicity and response according to the intent-to-treat principle. An objective response was observed in 39% of the patients (95% CI: 25% to 55%). World Health Organization grade III to IV neutropenia, thrombocytopenia, and anemia occurred in 43%, 2%, and 17%, respectively. There was one treatment-related death. Nonhematologic toxicities were mild, mainly grade III nausea and vomiting in 20% of the patients. After a median follow-up period of 54 months, the median progression-free survival was 14.3 weeks and the median overall survival was 31.3 weeks. This three-drug chemotherapy combination is feasible, well tolerated, and shows activity in metastatic NSCLC.

[Docetaxel in combination with cisplatin for first-line treatment of locally advanced or metastatic non-small cell lung cancer: meta-analysis of randomized and controlled clinical trials]

BACKGROUND AND OBJECTIVE

Recent approval of docetaxel in combination with cisplatin (DP) for non-small cell lung cancer (NSCLC) treatment means that an assessment of its effectiveness and toxicity is necessary. The aim of this study was to evaluate docetaxel/cisplatin combination versus other cisplatin-based regimens as the front-line treatment of metastatic or locally advanced NSCLC.

MATERIAL AND METHOD

We searched randomized and controlled phase III clinical trials comparing DP versus other cisplatin combinations. Patients had to be diagnosed of advanced NSCLC and had not previously received chemotherapy.A meta-analysis was performed using the Mantel-Haenzel method. Antitumoral activity and adverse events were both evaluated. We also made a heterogeneity test and determined the NNT Index (Number Needed to Treat) for two-year survival.

RESULTS

We found three clinical trials that fulfilled our criteria. Results showed significant enhanced two-year survival for DP (11-47% higher than others), but a greater incidence of diarrhea (odds ratio [OR] = 2.525; confidence interval 95% [CI], 1.697-3.756]). Heterogeneity was significant for response, anemia and thrombopenia. NNT was 17 patients for two-year survival.

CONCLUSIONS

DP is a good option in first-line therapy of advanced NSCLC. The two-year survival is significantly longer and its toxic profile similar to other treatments, except for diarrhea.

Nonneutropenic febrile episodes associated with docetaxel-based chemotherapy in patients with solid tumors

BACKGROUND

Docetaxel is associated with severe lymphopenia and increased incidence of nonneutropenic infection. This study investigated the incidence of nonneutropenic infections and/or febrile episodes in patients with solid tumors receiving frontline docetaxel-based chemotherapy.

METHODS

Chemotherapy-naive patients with solid tumors treated with docetaxel-based chemotherapy were studied prospectively for the development of nonneutropenic infections.

RESULTS

During a 2-year period, 680 cancer patients enrolled in 24 protocols received 2867 cycles of docetaxel-containing chemotherapy. Fifty-three patients (7.8%) developed nonneutropenic infections and/or febrile episodes. The most common of these were pulmonary infections (n = 25), Pneumocystis carinii interstitial pneumonias (n = 5), and candidal (n =11), herpetic (n =4), and cytomegaloviral (n =3) infections. Thirty-six patients (68%) had severe lymphopenia (< 900 cells per deciliter) and 49 (92%) had less than 400 CD4(+) cells per deciliter. Patients with a low CD4(+) cell count (</= 200 cells per deciliter) had a significantly higher probability to develop opportunistic than common infections (P = 0.002). The incidence of nonneutropenic infections and/or febrile episodes was significantly higher in patients treated with docetaxel/gemcitabine (18.3%; P = 0.0001) and docetaxel/CDDP (11.7%; P = 0.012) than in those treated with docetaxel alone (3.6%). Conversely, 175 patients who received 752 cycles of chemotherapy with paclitaxel-containing regimens and 410 patients who received 2174 cycles with nontaxane-based regimens developed 6 (3.4%; p=0.042) and 12 (3%; p=0.001) nonneutropenic infections, respectively. Less than 10% of the patients of the two latter groups were lymphopenic. The risk of nonneutropenic infection in patients receiving docetaxel-based chemotherapy was 2.38 and 2.8 times higher than in patients receiving paclitaxel and nontaxane-based chemotherapy, respectively.

CONCLUSIONS

Patients treated with docetaxel-based chemotherapy are at increased risk of developing nonneutropenic infections. This may be related, at least partly, to severe postchemotherapy CD4(+) lymphopenia.

A phase I-II study of docetaxel-ifosfamide-cisplatin (DIP) combination chemotherapy regimen in advanced nonsmall cell lung cancer

In an attempt to develop more effective chemotherapy regimens in advanced nonsmall cell lung cancer (NSCLC), we evaluated docetaxel-ifosfamide-cisplatin (DIP) based on our previous experience with paclitaxel-ifosfamide-cisplatin. Patients with advanced NSCLC (stages III-IV), WHO-PS< or =2, no prior chemotherapy and unimpaired hematopoietic and organ function were eligible. Chemotherapy was administered in successive dose levels (DLs) and included docetaxel (80-100 mg/m2 day 1), ifosfamide (4-5 g/m2) and cisplatin (80-100 mg/m2), both divided over days 1 and 2 every 21 days. G-CSF (lenograstin) was administered from days 4-13. Fifty-five patients were accrued (phase I: 15; phase II: 40) and all are evaluable for response and toxicity: median age = 58 (40-72); PS = 1 (0-2); gender = 48 males, 7 females; stages IIIA = 8, IIIB = 19, IV = 28; and histologies were adenocarcinoma (29), squamous (20), large cell (6). Metastatic sites at diagnosis included lymph nodes (33), bone (8), liver (6), brain (6), lung nodules (9), adrenals (7) and soft tissue (1). The dose-limiting toxicity (DLT) was reached at DL4 (Docetaxel: 100 mg/m2-Ifosfamide: 5 g/m2-Cisplatin: 100 mg/m2) consisting of 2 cases of febrile neutropenia (FN), and DL3 (Docetaxel: 100 mg/m2-Ifosfamide: 5 g/m2-Cisplatin: 80 mg/m2) was considered as the maximum tolerated dose (MTD) and recommended for further phase II testing. Among evaluable patients in phase II, 31/46 (67%; CI = 54-81%) responded; 4 were complete responses, 27 partial responses, 12 with stable disease and 3 with progressive disease. The median response duration was 7 months (2-21+), median time to progression (TTP) 8 months (1-23+) and median overall survival (OS) 13 months (2-23+). The 1-year survival was 57%. Grade (Gr) 3/4 toxicities included neutropenia 39/46 with 27 developing Gr4 (< or =7 days) and 20% FN managed successfully with broad-spectrum antibiotics, thrombocytopenia Gr3 3/46-Gr4 1/46, no Gr3 neuropathy, Gr1-2 CNS toxicity in 12, no renal toxicity, 15 Gr2 myalgias, 17 Gr2 diarrhea and 10 Gr3 vomiting. In the present phase I-II study, DIP appears highly active and tolerable in advanced NSCLC in the outpatient setting. Randomized comparisons to current standard 2-drug regimens will be warranted.

Developments in cytotoxic chemotherapy: advances in treatment utilising vinorelbine

Vinorelbine is a third generation vinca alkaloid which has been in clinical development for 15 years. Recent exploration of its pre-clinical activity has revealed unexpected evidence of potential synergy with taxane compounds and early clinical results support the suggestion of enhanced efficacy particularly in breast cancer. The initial studies establishing the clinical activity of vinorelbine in breast cancer and non-small cell lung cancer have been extended to encompass a thorough evaluation of its contribution to combination chemotherapy for these disorders. In the treatment of breast cancer useful activity has been established for vinorelbine in combination with anthracyclines, anthracenediones, antimetabolites and the taxanes; additive toxicity is not a limiting factor. The activity of vinorelbine in the treatment of non-small cell lung cancer is significantly extended by incorporation into schedules utilising cisplatin and other agents. Vinorelbine has also demonstrated useful activity in the treatment of a wide range of other malignancies including prostatic carcinoma, multiple myeloma, cancer of the ovary, cervix and head and neck and malignant lymphomas.

Docetaxel-induced lymphopenia in patients with solid tumors: a prospective phenotypic analysis

BACKGROUND

The quantitative abnormalities of the different peripheral blood lymphocyte subsets during docetaxel administration were prospectively studied.

METHODS

Forty-six chemotherapy-naive patients with solid tumors were treated with docetaxel either in a 3 weekly (n = 33) or weekly (n = 13) schedule. Twenty patients with central nervous system (CNS) metastatic disease as the first clinical presentation of cancer and 35 patients with metastatic colorectal carcinoma treated with chemotherapy were enrolled as controls. The phenotype of peripheral blood lymphocytes was determined by indirect immunofluorescence using appropriate monoclonal antibodies and fluorescent-activated cell sorter analysis.

RESULTS

After the administration of the first docetaxel cycle, the absolute number of peripheral blood lymphocytes (P < 0.005), CD3(+) (P < 0.01), CD4(+) (P < 0.01), CD8(+) (P < 0.01), and CD56(+) (P < 0. 01) but not CD20(+) (P < 0.3) cells was significantly decreased compared with the pretreatment values. Further treatment resulted in a further decrease of these lymphocyte subsets including CD20(+) cells (P < 0.01). Similarly, after the administration of the first weekly dose of docetaxel, the absolute number of total lymphocytes, CD3(+), CD4(+), and CD8(+) cells was decreased. The administration of the second weekly docetaxel dose resulted in a further decrease of CD56(+) (P = 0.012) and CD20(+) (P = 0.007) cells. The administration of either high dose corticosteroids in patients with CNS metastases or an irrelevant chemotherapy (CPT-11/5-FU) did not result in similar abnormalities. The discontinuation of docetaxel was associated with a recovery of CD3(+) and CD4(+) lymphocytes within a 3-month period. Eight (17%) patients developed nonneutropenic infections during docetaxel treatment.

CONCLUSIONS

Docetaxel has an important but reversible nonspecific lymphopenic effect that seems to be associated with an increased risk for nonneutropenic infections.

Novel combination chemotherapy in the treatment of non-small cell lung cancer

Treatment of patients with advanced non-small cell lung cancer (NSCLC) remains a vexing problem and long-term survival beyond 5 years is extremely rare. Five new agents, paclitaxel, docetaxel, vinorelbine, gemcitabine and irinotecan, have been introduced for the treatment of NSCLC and investigated extensively both preclinically and clinically. Monotherapy with one of these agents has produced survival benefits over the best supportive care in Phase III studies. Combination chemotherapy with a new agent and platinum produced a higher response rate than conventional cisplatin-based chemotherapy and improved survival was observed in some randomised trials. There was little difference in efficacy and toxicity between the chemotherapeutic regimens with a new agent and a platinum in Phase III trials, suggesting the clinical utility of these regimens is similar. Many trials have focused on regimens containing two new agents, with or without platinum. Preliminary results of Phase III trials of three drug combinations versus two drug combinations suggested the former to be more promising, in terms of response rates and survival. Whether the era of platinum-based chemotherapy in the treatment of NSCLC should continue or not must be determined by Phase III trials, evaluating the use of a platinum agent with one of the new agent combinations. These aggressive chemotherapeutic combinations will hopefully improve survival and quality of life for patients with advanced NSCLC.

Docetaxel in Combination with Platinum Compounds for Non–Small-Cell Lung Cancer

Assessing the combination of docetaxel with cisplatin or carboplatin was based on their activity as single agents, their nonoverlapping toxicity profiles, and their lack of cross-resistance. Phase I studies of docetaxel in combination with cisplatin established that 75 mg/m2 of each agent could be administered with reasonable safety and appeared to be active in non small-cell lung cancer (NSCLC). We evaluated the docetaxel/cisplatin combination in patients with advanced NSCLC. The response rate was 32%, and the median survival was 11.5 months. Efficacy was comparable to that observed in the Australian and French trials with the same combination. This is now being evaluated further in two large randomized trials for patients with advanced NSCLC and has been incorporated into the combined modality programs for early-stage disease. Carboplatin, devoid of the nephrotoxicity and neurotoxicity associated with the parent cis-platin, was then combined with docetaxel. The recommended dose of docetaxel for further evaluation in combination with carboplatin (AUC=6 mg/mL.min) was 90 mg/m2 with filgrastim support and 80 mg/m2 without filgrastim support. Our phase II trial of the combination of docetaxel and carboplatin in advanced NSCLC demonstrated an overall response rate of 36%; median survival was 13.9 months, and 1-year survival was 52%. Comparable activity has been seen by other investigators, and the regimen is being evaluated in two randomized trials. The combination of docetaxel with either of the two platinum agents has reasonable activity in NSCLC, though the carboplatin/docetaxel doublet appears to have a better therapeutic index.

Advanced non-small cell lung carcinoma: the emerging role of docetaxel

The treatment of advanced non-small cell lung carcinoma (NSCLC) has improved greatly over the past decade. With the advent of new agents, in particular taxanes, gemcitabine, vinorelbine, and topoisomerase I inhibitors, response rates have improved from 15-20% to 25-35%, with commensurate improvement in median and one year survival rates to 8-10 months and 35-45%, respectively. These improvements have proven statistically significant in multiple studies [1-4]. Docetaxel, either alone or in combination with platinols, has shown particular promise; and, in some arenas, it has become a standard component of our therapeutic armamentarium. We will review the preclinical data and single agent activity of docetaxel in treatment-naive and previously treated NSCLC patients, its activity in combination with cisplatin and carboplatin, as well as other new agents, and finally focus on ongoing studies evaluating its role in locally advanced disease.