Fifteen-year follow-up of all patients in a study of post-operative chemotherapy for bronchial carcinoma

The future of adjuvant chemotherapy for resected non-small cell lung cancer

Non-small cell lung cancer is a frequent type of cancer, with approximately 1.2 million cases per year expected worldwide. A total of 20-30% of patients with early stage non-small cell lung cancer are amenable to radical surgery, although only 40-50% of these patients are cured. An improvement in survival has never been demonstrated for postoperative radiotherapy. However, a major step forward is several recent large randomized studies that have demonstrated improved survival with postoperative chemotherapy. This review covers the historic data on adjuvant chemotherapy for non-small cell lung cancer, meta-analyses, modern studies with cisplatin-based or other chemotherapy, implications for current clinical practice and guidelines, some practical recommendations and, finally, the questions for future studies.

Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines

OBJECTIVES

Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents.

METHODS

Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline.

CONCLUSIONS

It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.

Combined Modality Treatment of Non-Small-Cell Lung Cancer

Among all nonmetastatic non-small-cell lung cancer (NSCLC) patients, the best survival rates are observed in patients who undergo surgery. Nevertheless, 5-year survival rates vary between 20% and 60% depending on the stage of the disease. Several combined modality treatments have been investigated to improve outcome in localized NSCLC. These include local treatment, systemic before local treatment, concomitant systemic and local treatments, and systemic after local treatment. Preoperative irradiation was shown to be of no benefit on local recurrence rates or overall survival. Even doses of radiation >/=40 grays (Gy) were associated with lower survival rates. Postoperative irradiation did not influence survival in stage III disease and seemed to be deleterious in stages I and II disease. Modern radiotherapy techniques might be of interest in this setting but have been insufficiently tested. The early phase III studies of preoperative chemotherapy versus primary surgery in stage III NSCLC showed a tremendous difference in favor of chemotherapy. A larger study did not confirm these results but suggested that preoperative chemotherapy might have a greater effect in stages I and II of the disease. In locally advanced disease, chemotherapy followed by radiotherapy was shown to increase survival when compared with radiotherapy alone. Studies comparing concurrent chemoradiation with radiotherapy only were in favor of the concomitant schedule, which improved local control. Promising results have been reported with chemoradiation followed by surgery in stage IIIa and even stage IIIb disease. Randomized studies of postoperative chemotherapy demonstrated a 5% improvement in 5-year survival over adjuvant-free treatment. Postoperative chemoradiation showed no advantage over postoperative radiotherapy. Several trials that are ongoing or whose accrual was recently completed should further define the role of perioperative chemotherapy in resectable NSCLC and of trimodality treatments in advanced disease. Targeted agents are being developed in the postoperative setting. New schedules of chemoradiation with higher therapeutic indexes are also being investigated in nonresectable stage III NSCLC.

Toxicity and monitoring of immunosuppressive therapy used in systemic autoimmune diseases

Systemic autoimmune diseases may be progressive and lead to organ system dysfunction and premature death. Current treatment paradigms are usually predominantly based on the administration of immunosuppressive and/or immunomodulatory drug therapy. Such therapy can stabilize systemic manifestations of connective tissue disease (CTD) and may put the disease into remission, and many of these agents are commonly used to treat CTD-associated interstitial lung disease (ILD). Although these agents have largely revolutionized the treatment of the systemic autoimmune diseases, adverse reactions, which can be serious and life threatening, to the various immunosuppressive agents used in the treatment of CTD can occur. Treating physicians must be aware of mechanisms of action of various immunosuppressive agents and be able to recognize the potential adverse reactions that may occur with therapy as well as potentially harmful effects on fetal development. Appropriate monitoring may prevent or limit toxicity from these agents, and knowledge of drug-drug interactions is essential when these agents are prescribed.

A critical appraisal of the adjuvant chemotherapy guidelines for patients with completely resected T3N0 non-small-cell lung cancer

BACKGROUND

A Joint Expert Panel recently published guidelines for adjuvant cisplatin-based chemotherapy, recommending routine use in patients with completely resected stage II (T1-2N1 and T3N0) non-small-cell lung cancer (NSCLC). However, these two tumor subgroups should be considered as different entities. While the efficacy of adjuvant chemotherapy has been established in patients with T1-2N1 NSCLC, its benefit in patients with T3N0 tumor remains questionable.

MATERIAL AND METHODS

We performed an extensive review of the literature using the Joint Expert Panel guidelines as a start point. Altogether, we identified 76 potentially relevant articles. Basing on inclusion and exclusion criteria, 23 of the 76 articles were eventually included in this review.

RESULTS

After careful evaluation of the selected articles, we found no information on the effect of adjuvant chemotherapy in patients with T3N0 NSCLC.

DISCUSSION

In the absence of evidence-based data, we recommend that the lack of information on the efficacy of adjuvant chemotherapy for T3N0 tumors be discussed with patients and propose chemotherapy as an individual option. While the efficacy of adjuvant chemotherapy will be difficult to assess prospectively through a large randomized clinical trial, a pooled-analysis of the existing data would quickly and with a limited effort provide a preliminary answer.

Les traitements adjuvants dans les cancers bronchiques non à petites cellules

If surgery remains the cornerstone for the curative treatment of non-small cell lung cancer, failures are common especially for stage III disease and adjuvant treatment (chemotherapy or radiotherapy) may be justified. After the two meta-analyses, new trials have showed a moderate but significant benefit from cisplatin based chemotherapy. The role of radiotherapy is still controversial but from some clinical observations, a new trial using the modern radiation technology should address the question.

Adjuvant chemotherapy for early-stage non-small cell lung cancer: the past, the present and the future

Complete resection is mandatory in order to achieve a cure in patients with early-stage non-small cell lung cancer (NSCLC). However, despite complete resection, a substantial proportion of patients have disease recurrence, with distant metastases being the primary sites of failure. Recent trials have conclusively demonstrated the benefit of platinum-based adjuvant therapy in patients with resected stage IB and II NSCLC. The role of adjuvant chemotherapy in resected stage III NSCLC is less clear, with trials showing conflicting results. The role of targeted agents in this setting is being investigated. Gene expression profiling studies should help direct chemotherapy to those who would actually benefit from it, thereby saving others from unnecessary toxicity.

Advances in our understanding of postoperative adjuvant chemotherapy in resectable non-small-cell lung cancer

PURPOSE OF REVIEW

After publication in 1995 of a meta-analysis of adjuvant chemotherapy in the treatment of NSCLC, a number of randomized trials investigated adjuvant chemotherapy using more active chemotherapeutic regimens and larger numbers of accrued patients per trial. This review will focus on recent clinical trials for adjuvant chemotherapy, and will help to interpret the applicability of these results to daily clinical practice.

RECENT FINDINGS

Four large-scale randomized trials that used platinum-based chemotherapy have reported positive results during the last 3 years. These trials included cisplatin-based chemotherapy [the International Adjuvant Lung Cancer (IALT) trial], cisplatin plus vinorelbine [the National Cancer Institute of Canada (NCIC) BR10 trial], and carboplatin plus paclitaxel [the Cancer and Leukemia Group B (CALGB) 9633 trial]. More recently, another adjuvant trial [Adjuvant Navelbine International Trialist Association (ANITA)] was reported, which has added greatly to our understanding of the potential role of adjuvant treatment. Regarding adjuvant UFT (tegafur and uracil) chemotherapy, an individual patient data-based meta-analysis demonstrated its significant effect on survival in selected patients with completely resected non-small-cell lung cancer.

SUMMARY

Recent trials indicate a survival benefit of postoperative adjuvant chemotherapy. These findings are anticipated to change the clinical management of patients with completely resectable non-small-cell lung cancer.

Adjuvant Chemotherapy in Early-Stage Non-Small Cell Lung Cancer

Approximately 80% of lung malignancies are non-small cell lung carcinoma (NSCLC). Patients diagnosed with early-stage disease (about 30% of patients) undergo surgery, but up to 50% develop local or distant recurrence. In an effort to improve survival for patients with resectable NSCLC, chemotherapy has been explored in the adjuvant setting. Several adjuvant trials were launched in the mid 1990s after an individual data-based meta-analysis suggested a 5% survival benefit at 5 years. Among those, the International Adjuvant Lung Cancer Trial (IALT) study, with 1,867 patients included, confirmed the benefit of postoperative chemotherapy in resected NSCLC. More recently, modern platinum-containing doublets showed a 10% to 15% overall benefit compared to no adjuvant treatment. In this article, the current status of adjuvant chemotherapy is reviewed, and future prospects are discussed.

Early-Stage Non–Small-Cell Lung Cancer: Current Perspectives in Combined-Modality Therapy

The most effective treatment for patients with early-stage non-small-cell lung cancer (NSCLC) remains complete surgical resection, providing the disease is medically operable and adequately staged. The effectiveness of surgical resection, however, is limited by high rates of distant recurrence caused by the presence of metastatic disease that is not apparent at the time of surgery. Thus, induction, adjuvant chemotherapy, and radiation therapy, as well as a combination of both, have been studied for their ability to reduce local and distant recurrence rates and to improve survival. Adjuvant chest radiation therapy following resection decreases local relapse rates but also decreases overall patient survival, with an increase in the hazard ratio of death. A previous metaanalysis of cisplatin-based adjuvant chemotherapy showed a 13% reduction in the hazard ratio of death and a 5% improvement in 5-year survival, but the differences in the small sample failed to reach statistical significance. Newer 2-drug combinations were shown to reduce the hazard ratio of death by 14%, with a 4.3% improvement in 5-year survival in the largest trial recently reported. These newer 2-drug combinations also have the benefits of reduced toxicity and improved delivery. Induction chemotherapy offers several potential advantages compared with adjuvant chemotherapy, such as improved delivery, early control of micrometastatic disease, and reduction of the primary tumor size prior to surgery, thus allowing for more conservative and possibly complete resection of the tumor. A number of clinical trials have shown that induction chemotherapy is safe and feasible, with no significant increase in surgical complications, and results in favorable survival rates in patients with resectable NSCLC. A number of phase III randomized trials are currently under way to confirm the benefits of induction chemotherapy in patients with stage IB-IIIA NSCLC and to compare induction chemotherapy versus adjuvant chemotherapy following surgery versus surgery alone. In addition, biologically targeted agents are currently under study for patients with advanced NSCLC.

The role of chemotherapy in early-stage (stage I and II) resectable non-small cell lung cancer

For patients with stage I or II non-small cell lung cancer (NSCLC), surgical resection is considered the standard of care. Although surgery achieves long-term survival in many patients, a significant proportion experience locoregional or distant recurrence. Five-year survival rates after resection for stage I and II NSCLC range from 38% (T3 N0) to 67% (T1 N0). Efforts at improving survival for early-stage NSCLC patients have focused on the use of chemotherapy administered postoperatively (adjuvant) or preoperatively (neoadjuvant or induction) to eradicate micrometastatic disease. The majority of trials examining adjuvant chemotherapy have not found a survival benefit. A meta-analysis examining the role of chemotherapy in the treatment of NSCLC found a 5% absolute improvement in 5-year survival associated with the use of adjuvant cisplatin-based chemotherapy (P =.08). Chemotherapy administered before surgery or definitive irradiation has improved survival rates in patients with stage III NSCLC. The role of induction chemotherapy in stage I and II NSCLC is currently under investigation.

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.

Results of pneumonectomy for non-small cell lung cancer

To assess the role of pneumonectomy for lung cancer and the factors affecting the prognosis, 107 patients who had undergone pneumonectomy for non-small cell lung cancer (NSCLC) between January, 1985 and March, 1996, were analyzed. They included 81 squamous cell carcinoma, 22 adenocarcinoma, 3 large cell carcinoma, and one adenosquamous cell carcinoma, with 8 patients in post-operative stage I, 15 in stage II, 51 in stage IIIA, and 33 in stage IIIB of the disease. The 5-year survival rate was 54.7% in stages I + II, 38.0% in stage IIIA, and <4% in stage IIIB. In stages I-IIIA, the patients with squamous cell carcinoma showed a significantly better prognosis than those with adenocarcinoma (50.6 vs. 0%, p < 0.01). The prognosis was also better, but not statistically significant, for patients with central type compared with those with peripheral type in both all histologic types (58.0 vs. 8.4%) and only squamous cell type (59.3 vs. 18.8%). A better prognosis observed in squamous histologic type or central type seemed to be related to a better N factor. Pneumonectomy remains the treatment of choice for lung cancer, but seems not to be justified for patients with stage IIIB due to their poor prognosis.

Adjuvant therapy for stage I and II non-small cell lung cancer

The ideal adjuvant program should utilize an effective chemotherapeutic drug (or drug combination) at a maximally tolerated dose for a sufficient time to eradicate all micrometastases. Currently, no such "ideal" program has been identified. Additionally, the optimal timing of a multimodal program has not yet been established (i.e., chemotherapy followed by radiotherapy, or vice versa, or concurrent radiotherapy and chemotherapy). Adjuvant therapy at this time for stage I or II NSCLC should be considered investigational and limited to clinical trials.

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.

Chemotherapy in non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer can no longer be regarded as resistant to chemotherapy, and there have recently been considerable improvements in the use of the older agents and advances in the identification of new drugs. Recent meta-analysis has also confirmed the view that chemotherapy can have small but modest survival benefits. Although in the treatment of stage IV disease the criteria of efficacy have concentrated on tumour response rates, more recently it has become obvious that these patients can also benefit in terms of improved symptom control.

RECENT ADVANCES

For patients with locally advanced stage III disease there have been important developments indicating the benefit of combined modality treatment with chemotherapy and thoracic irradiation. Furthermore, the use of neoadjuvant chemotherapy indicates that resection is possible in about half the patients, and on pathological examination of 15%-20% of the resected specimens there is no evidence of residual tumour. These results justify an increase in the use of systemic chemotherapy in this disease.

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.