A randomised trial of cisplatin and vindesine versus supportive care only in advanced non-small cell lung cancer

Best first-line therapy for people with advanced non-small cell lung cancer, performance status 2 without a targetable mutation or with an unknown mutation status

BACKGROUND

Most people who are newly diagnosed with non-small cell lung cancer (NSCLC) have advanced disease. For these people, survival is determined by various patient- and tumor-related factors, of which the performance status (PS) is the most important prognostic factor. People with PS 0 or 1 are usually treated with systemic therapies, whereas people with PS 3 or 4 most often receive supportive care. However, treatment for people with PS 2 without a targetable mutation remains unclear. Historically, people with a PS 2 cancer are frequently excluded from (important) clinical trials because of poorer outcomes and increased toxicity. We aim to address this knowledge gap, as this group of people represents a significant proportion (20% to 30%) of the total population with newly diagnosed lung cancer.

OBJECTIVES

To identify the best first-line therapy for advanced lung cancer in people with performance status 2 without a targetable mutation or with an unknown mutation status.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 17 June 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared different chemotherapy (with or without angiogenesis inhibitor) or immunotherapy regimens, specifically designed for people with PS 2 only or studies including a subgroup of these people.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. overall survival (OS), 2. health-related quality of life (HRQoL), and 3. toxicity/adverse events. Our secondary outcomes were 4. tumor response rate, 5. progression-free survival, and 6. survival rates at six and 12 months' treatment. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included 22 trials in this review and identified one ongoing trial. Twenty studies compared chemotherapy with different regimens, of which 11 compared non-platinum therapy (monotherapy or doublet) versus platinum doublet. We found no studies comparing best supportive care with chemotherapy and only two abstracts analyzing chemotherapy versus immunotherapy. We found that platinum doublet therapy showed superior OS compared to non-platinum therapy (hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.57 to 0.78; 7 trials, 697 participants; moderate-certainty evidence). There were no differences in six-month survival rates (risk ratio [RR] 1.00, 95% CI 0.72 to 1.41; 6 trials, 632 participants; moderate-certainty evidence), whereas 12-month survival rates were improved for treatment with platinum doublet therapy (RR 0.92, 95% CI 0.87 to 0.97; 11 trials, 1567 participants; moderate-certainty evidence). PFS and tumor response rate were also better for people treated with platinum doublet therapy, with moderate-certainty evidence (PFS: HR 0.57, 95% CI 0.42 to 0.77; 5 trials, 487 participants; tumor response rate: RR 2.25, 95% CI 1.67 to 3.05; 9 trials, 964 participants). When analyzing toxicity rates, we found that platinum doublet therapy increased grade 3 to 5 hematologic toxicities, all with low-certainty evidence (anemia: RR 1.98, 95% CI 1.00 to 3.92; neutropenia: RR 2.75, 95% CI 1.30 to 5.82; thrombocytopenia: RR 3.96, 95% CI 1.73 to 9.06; all 8 trials, 935 participants). Only four trials reported HRQoL data; however, the methodology was different per trial and we were unable to perform a meta-analysis. Although evidence is limited, there were no differences in 12-month survival rates or tumor response rates between carboplatin and cisplatin regimens. With an indirect comparison, carboplatin seemed to have better 12-month survival rates than cisplatin compared to non-platinum therapy. The assessment of the efficacy of immunotherapy in people with PS 2 was limited. There might be a place for single-agent immunotherapy, but the data provided by the included studies did not encourage the use of double-agent immunotherapy.

AUTHORS' CONCLUSIONS

This review showed that as a first-line treatment for people with PS 2 with advanced NSCLC, platinum doublet therapy seems to be preferred over non-platinum therapy, with a higher response rate, PFS, and OS. Although the risk for grade 3 to 5 hematologic toxicity is higher, these events are often relatively mild and easy to treat. Since trials using checkpoint inhibitors in people with PS 2 are scarce, we identified an important knowledge gap regarding their role in people with advanced NSCLC and PS 2.

The need for speed in advanced non-small cell lung cancer: A population kinetics assessment

BACKGROUND

Systemic therapy prolongs overall survival (OS) in advanced non-small cell lung cancer (NSCLC), but diagnostic tests, staging and molecular profiling take time, and this can delay therapy initiation. OS approximates first-order kinetics.

METHODS

We used OS of chemo-naive NSCLC patients on a placebo/best supportive care trial arm to estimate % of patients dying while awaiting therapy. We digitized survival curves from eight studies, calculated OS half-life, then estimated the proportion surviving after different times of interest (t_n ) using the formula: X = exp - t n ∗ 0 .693 / t 1 / 2 , where EXP signifies exponential, * indicates multiplication, 0.693 is the natural log of 2, and t_1/2 is the survival half-life in weeks.

RESULTS

Across trials, the OS half-life for placebo/best supportive care in previously untreated NSCLC was 19.5 weeks. Hence, based on calculations using the formula above, if therapy were delayed by 1, 2, 3, or 4 weeks then 4%, 7%, 10%, and 13% of all patients, respectively, would die while awaiting treatment. Others would become too sick to consider therapy even if still alive.

CONCLUSIONS

This quantifies why rapid baseline testing and prompt therapy initiation are important in advanced NSCLC. It also illustrates why screening procedures for clinical trial inclusion must be faster. Otherwise, it is potentially hazardous for a patient to be considered for a trial due to risk of death or deterioration while awaiting eligibility assessment. It is also important to not delay initiation of systemic therapy for procedures that add relatively little value, such as radiotherapy for small, asymptomatic brain metastases.

Virtual randomized study comparing lobectomy and particle beam therapy for clinical stage IA non-small cell lung cancer in operable patients

To the best of our knowledge there have been no randomized controlled trials comparing lobectomy-a standard treatment for patients with early-stage non-small cell lung cancer (NSCLC)-and particle beam therapy (PBT), the best performing existing radiotherapy. We conducted a virtual randomized trial in medically operable patients with stage IA NSCLC to compare lobectomy and PBT effectiveness. A Markov model was developed to predict life expectancy after lobectomy and PBT in a cohort of patients with stage IA NSCLC. Ten thousand virtual patients were randomly assigned to each group. Sensitivity analyses were performed as model variables and scenarios changed to determine which treatment strategy was best for improving life expectancy. All estimated model parameters were determined using variables extracted from a systematic literature review of previously published articles. The preferred strategy differed depending on patient age. In young patients, lobectomy showed better life expectancy than that of PBT. The difference in life expectancy between lobectomy and PBT was statistically insignificant in older patients. Our model predicted lobectomy as the preferred strategy when operative mortality was under 5%. However, the preferred strategy changed to PBT if operative mortality post lobectomy was over 5%. For medically operable patients with stage IA NSCLC, our Markov model revealed the preferred strategy of lobectomy or PBT regarding operative mortality changed with varying age and comorbidity. Until randomized controlled trial results become available, we hope the current results will provide a rationale background for clinicians to decide treatment modalities for patients with stage IA NSCLC.

Involvement of selective GABA-A receptor subtypes in amelioration of cisplatin-induced neuropathic pain by 2'-chloro-6-methyl flavone (2'-Cl-6MF)

Cisplatin-induced peripheral neuropathic pain is a common adverse effect of chemotherapy. The present study evaluated the effects of 2'-chloro-6-methylflavone (2'-Cl-6MF) at recombinant α1β2γ2L, α2β1-3γ2L, and α3β1-3γ2L GABA-A receptor subtypes expressed in Xenopus oocytes and subsequently evaluated its effectiveness in cisplatin-induced neuropathic pain. The results showed that 2'-Cl-6MF potentiated GABA-elicited currents at α2β2/3γ2L and α3β2/3γ2L GABA-A receptor subtypes. The potentiation was blocked by the co-application of flumazenil (a benzodiazepine (BDZs) site antagonist). In behavioral studies, mechanical allodynia was induced by intraplantar injection of cisplatin (40 μg/paw) in Sprague Dawley rats, and behavioral assessments were made 24 h after injection. 2'-Cl-6MF (1, 10, 30, and 100 mg/kg, i.p.), was administered 1 h before behavioral evaluation. Administration of 2'-Cl-6MF (30 and 100 mg/kg, i.p) significantly enhanced the paw withdrawal threshold and decreased mechanical allodynia. The standard drugs, gabapentin (GBP) at the dose of 70 mg/kg, and HZ 166 (16 mg/kg), i.p. also significantly enhanced the paw withdrawal threshold in mechanical allodynia. Pretreatment with pentylenetetrazole (PTZ) (15 mg/kg, i.p.) and flumazenil reversed the antinociceptive effect of 2'-Cl-6MF in mechanical allodynia indicating GABAergic mechanisms. Moreover, the binding mechanism of 2'-Cl-6MF was rationalized by in silico modeling tools. The 3D-coordinates of α2β2γ2L and α2β3γ2L were generated after homology modeling of the α2 subtype and 2'-Cl-6MF was at predicted binding sites of the developed models. The α2 model was compared with the α1 and α3 subunits via structural and sequence alignment. Molecular docking depicted that the compound binds efficiently at the neuromodulator binding site of the receptors. The findings of this study revealed that 2'-Cl-6MF ameliorated the manifestations of cisplatin-induced neuropathic pain in rats. Furthermore, we also conclude that GABAergic mechanisms may contribute to the antinociceptive effect of 2'-Cl-6MF. The molecular docking studies also confirm the involvement of the BDZs site of GABA-A receptors. It was observed that Ile230 of α2 stabilize the chlorophenyl ring of 2'-Cl-6MF through hydrophobic interactions, which is replaced by Val203 in α1 subunit. However, the smaller side chain of Val203 does not provide hydrophobic interaction to the compound due to high conformational flexibility of α1 subunit.

Chemotherapy remains an essential element of personalized care for persons with lung cancers

Molecularly targeted and immunotherapies have improved the care of patients with lung cancers. These successes have rallied calls to replace or avoid chemotherapy. Yet, even in this era of precision medicine and exciting advances, cytotoxic chemotherapies remain an essential component of lung cancer treatment. In the setting of locoregional disease, chemotherapy is the only systemic therapy thus far proven to enhance curability when combined with surgery or radiation. In the metastatic setting, chemotherapy can improve the length and quality of life in many patients. Chemotherapy remains the mainstay of care for individuals whose cancers with oncogenic drivers have acquired resistance to targeted agents. Chemotherapy also has the potential to modulate the immune system to enhance the effectiveness of immune checkpoint inhibitors. In this context, chemotherapy should be framed as a critical component of the armamentarium available for optimizing cancer care rather than an unfortunate anachronism. We examine the role of chemotherapy with precision medicine in the current care of patients with lung cancers, as well as opportunities for future integration in combinations with targeted agents, angiogenesis inhibitors, immunotherapies, and antibody drug conjugates.

Influence of dosing times on cisplatin-induced peripheral neuropathy in rats

BACKGROUND

Although cis-diamminedichloro-platinum (CDDP) exhibits strong therapeutic effects in cancer chemotherapy, its adverse effects such as peripheral neuropathy, nephropathy, and vomiting are dose-limiting factors. Previous studies reported that chronotherapy decreased CDDP-induced nephropathy and vomiting. In the present study, we investigated the influence of dosing times on CDDP-induced peripheral neuropathy in rats.

METHODS

CDDP (4 mg/kg) was administered intravenously at 5:00 or 17:00 every 7 days for 4 weeks to male Sprague-Dawley rats, and saline was given to the control group. To assess the dosing time dependency of peripheral neuropathy, von-Frey test and hot-plate test were performed.

RESULTS

In order to estimate hypoalgesia, the hot-plate test was performed in rats administered CDDP weekly for 4 weeks. On day 28, the withdrawal latency to thermal stimulation was significantly prolonged in the 17:00-treated group than in the control and 5:00-treated groups. When the von-Frey test was performed to assess mechanical allodynia, the withdrawal threshold was significantly lower in the 5:00 and 17:00-treated groups than in the control group on day 6 after the first CDDP dose. The 5:00-treated group maintained allodynia throughout the experiment with the repeated administration of CDDP, whereas the 17:00-treated group deteriorated from allodynia to hypoalgesia.

CONCLUSIONS

It was revealed that the severe of CDDP-induced peripheral neuropathy was inhibited in the 5:00-treated group, whereas CDDP-treated groups exhibited mechanical allodynia. These results suggested that the selection of an optimal dosing time ameliorated CDDP-induced peripheral neuropathy.

Chemotherapy remains an essential element of personalized care for persons with lung cancers

Molecularly targeted and immunotherapies have improved the care of patients with lung cancers. These successes have rallied calls to replace or avoid chemotherapy. Yet, even in this era of precision medicine and exciting advances, cytotoxic chemotherapies remain an essential component of lung cancer treatment. In the setting of locoregional disease, chemotherapy is the only systemic therapy thus far proven to enhance curability when combined with surgery or radiation. In the metastatic setting, chemotherapy can improve the length and quality of life in many patients. Chemotherapy remains the mainstay of care for individuals whose cancers with oncogenic drivers have acquired resistance to targeted agents. Chemotherapy also has the potential to modulate the immune system to enhance the effectiveness of immune checkpoint inhibitors. In this context, chemotherapy should be framed as a critical component of the armamentarium available for optimizing cancer care rather than an unfortunate anachronism. We examine the role of chemotherapy with precision medicine in the current care of patients with lung cancers, as well as opportunities for future integration in combinations with targeted agents, angiogenesis inhibitors, immunotherapies, and antibody drug conjugates.

Treatment of non-small cell lung cancer (NSCLC)

Radical surgery is the standard of care for fit stage I non-small cell lung cancer (NSCLC) patients. Adjuvant treatment should be offered only as part of an investigation trial. Stage II and IIIA adjuvant cisplatin-based chemotherapy remains the gold standard for completely resected NSCLC tumors. Additionally radiotherapy should be offered in patients with N2 lymph nodes. In advanced stage IIIB/IV or inoperable NSCLC pts, a multidisciplinary treatment should be offered consisted of 4 cycles of cisplatin-based chemotherapy plus a 3(rd) generation cytotoxic agent or a cytostatic (anti-EGFR, anti-VEGFR) drug.

Chemotherapy plus best supportive care versus best supportive care in patients with non-small cell lung cancer: a meta-analysis of randomized controlled trials

BACKGROUND

The use of chemotherapy has been proposed to increase the effectiveness of best supportive care (BSC) in patients with non-small cell lung cancer (NSCLC). Previous trials reported inconsistent findings regarding the efficacy and safety of chemotherapy on overall survival (OS) and treatment-related mortality. We performed a systematic review and meta-analysis to evaluate the effects of chemotherapy plus BSC versus BSC alone on survival of patients with NSCLC.

METHODOLOGY AND PRINCIPAL FINDINGS

We systematically searched PubMed, EmBase, and the Cochrane Central Register of Controlled Trials for relevant literature. All eligible studies included patients with NSCLC who had received chemotherapy and BSC or BSC alone. All eligible studies measured at least 1 of the following outcomes: OS or treatment-related mortality. Overall, patients that received chemotherapy plus BSC had significant longer OS than those that received BSC alone (HR, 0.76; 95%CI, 0.69-0.84; P<0.001). Additionally, chemotherapy plus BSC as compared to BSC alone resulted in a 28% RR reduction (95%CI: 12-40; P = 0.001) in 6-month mortality, 11% RR reduction (95%CI: 8-15; P<0.001) in 12-month mortality, and 5% RR reduction (95%CI: 1-8; P = 0.02) in 2-year mortality. Toxicity was greater in patients that received chemotherapy plus BSC.

CONCLUSION/SIGNIFICANCE

Chemotherapy plus BSC increased the OS and reduced the 6-month, 12-month, and 2-year mortality of NSCLC patients.

Extended survival observed in adoptive activated T lymphocyte immunotherapy for advanced lung cancer: results of a multicenter historical cohort study

Purpose

To clarify the long-term effect of immunotherapy, the effect of adoptive activated T lymphocyte immunotherapy on advanced lung cancer was evaluated in terms of survival time. In addition, the performance status of cancer patients under immunotherapy was examined.

Experimental design

Over 5 × 10⁹ alpha–beta T lymphocytes cultured ex vivo with an immobilized anti-CD3 antibody and interleukin-2 were injected intravenously into patients, once every 2 weeks for 3 months or longer. Follow-up of these patients was carried out using clinical records and by telephone interview questionnaire. Patients undergoing immunotherapy in immunotherapy clinics and those undergoing other anticancer therapies without immunotherapy in seven hospitals in Tokyo were enrolled in this study. Data were analyzed by a third-party statistician. Performance status was studied on another series of various cancer patients who underwent immunotherapy.

Results

The overall median survival time of the patients with the best supportive care, which was obtained using Kaplan–Meier’s model, was 5.6 months, and those with immunotherapy alone, chemotherapy alone, and immuno-chemotherapy were 12.5, 15.7, and 20.8 months, respectively. Using Cox’ proportional hazard model, we examined the possible factors on survival time by univariate analysis. Then, the patients were stratified by gender and histological type for multivariate analysis. Significantly low hazard ratios were observed for immunotherapy and radiotherapy in males with squamous cancer; for chemotherapy and radiotherapy in male with adenocarcinoma; and for immunotherapy in females with adenocarcinoma. Addition of immunotherapy to chemotherapy resulted in a statistically significant decrease in hazard ratio in females with adenocarcinoma. Studies on the performance status (PS), determined according to the European Cooperative Oncology Group criteria, revealed a continuous high level of PS under immunotherapy until around 2 months before death, in contrast to the gradual increase of tumor marker level.

Conclusions

The effectiveness of immunotherapy on advanced lung cancer is limited but may extend life span under certain conditions. Immunotherapy itself provided no clinical benefit by itself as compared with chemotherapy, but a significant additive effect of immunotherapy on chemotherapy was observed in females with adenocarcinoma. Moreover, immunotherapy can maintain good quality of life of the patients until near the time of death.

Exponential decay nonlinear regression analysis of patient survival curves: preliminary assessment in non-small cell lung cancer

BACKGROUND

For processes that follow first order kinetics, exponential decay nonlinear regression analysis (EDNRA) may delineate curve characteristics and suggest processes affecting curve shape. We conducted a preliminary feasibility assessment of EDNRA of patient survival curves.

METHODS

EDNRA was performed on Kaplan-Meier overall survival (OS) and time to relapse (TTR) curves for 323 patients with resected NSCLC and on OS and progression-free survival (PFS) curves from selected publications.

RESULTS AND CONCLUSIONS

In our resected patients, TTR curves were triphasic with a "cured" fraction of 60.7% (half-life [t1/2] >100,000 months), a rapidly relapsing group (7.4%, t1/2=5.9 months) and a slowly relapsing group (31.9%, t1/2=23.6 months). OS was uniphasic (t1/2=74.3 months), suggesting an impact of co-morbidities; hence, tumor molecular characteristics would more likely predict TTR than OS. Of 172 published curves analyzed, 72 (42%) were uniphasic, 92 (53%) were biphasic, 8 (5%) were triphasic. With first-line chemotherapy in advanced NSCLC, 87.5% of curves from 2 to 3 drug regimens were uniphasic vs. only 20% of those with best supportive care or 1 drug (p<0.001). 54% of curves from 2 to 3 drug regimens had convex rapid-decay phases vs. 0% with fewer agents (p<0.001). Curve convexities suggest that discontinuing chemotherapy after 3-6 cycles "synchronizes" patient progression and death. With postoperative adjuvant chemotherapy, the PFS rapid-decay phase accounted for a smaller proportion of the population than in controls (p=0.02) with no significant difference in rapid-decay t1/2, suggesting adjuvant chemotherapy may move a subpopulation of patients with sensitive tumors from the relapsing group to the cured group, with minimal impact on time to relapse for a larger group of patients with resistant tumors. In untreated patients, the proportion of patients in the rapid-decay phase increased (p=0.04) while rapid-decay t1/2 decreased (p=0.0004) with increasing stage, suggesting that higher stage may be associated with tumor cells that both grow more rapidly and have a higher probability of surviving metastatic processes than in early stage tumors. This preliminary assessment of EDNRA suggests that it may be worth exploring this approach further using more sophisticated, statistically rigorous nonlinear modelling approaches. Using such approaches to supplement standard survival analyses could suggest or support specific testable hypotheses.

Chemotherapy and supportive care versus supportive care alone for advanced non-small cell lung cancer

BACKGROUND

Since our individual patient data (IPD) meta-analysis of supportive care and chemotherapy for non-small cell lung cancer (NSCLC), published in 1995, many trials have been completed. We have carried out an updated IPD meta-analysis to assess newer regimens and determine conclusively the effect of chemotherapy.

OBJECTIVES

To assess the effect on survival of supportive care and chemotherapy versus supportive care alone in advanced NSCLC.

SEARCH STRATEGY

All randomised controlled trials (RCTs), published or unpublished. We searched bibliographic databases, trials registers, conference proceedings and reference lists of relevant trials. Searches were completed to November 2009.

SELECTION CRITERIA

Trials had to have commenced accrual on or after 1 January 1965 and should have included patients with NSCLC who had received either chemotherapy and supportive care or supportive care alone. Patients should have not received any previous chemotherapy or had any prior malignancy.

DATA COLLECTION AND ANALYSIS

For trials included in 1995 we sought updated follow up. For new trials we sought survival and baseline characteristics for all patients. We combined results from RCTs to calculate individual and pooled hazard ratios (HRs).

MAIN RESULTS

We obtained data on 2714 patients from 16 RCTs. There were 1293 deaths among 1399 patients assigned supportive care and chemotherapy and 1240 among 1315 assigned supportive care alone. Results showed a significant benefit of chemotherapy (HR = 0.77; 95% CI 0.71 to 0.83, P < 0.0001), equivalent to a relative increase in survival of 23%, an absolute improvement in survival of 9% at 12 months, increasing survival from 20% to 29% or an absolute increase in median survival of 1.5 months (from 4.5 months to six months). There was no clear evidence that this effect was influenced by the drugs used (P = 0.63) or whether they were used as single agents or in combination (P = 0.40). Despite changes in patient demographics, the effect of chemotherapy in recent trials did not differ from those included previously (P = 0.77). There was no clear evidence of a difference in the relative effect of chemotherapy across patient subgroups. Quality of life could not be formally assessed.

AUTHORS' CONCLUSIONS

All trials were of good methodological quality with no risk of bias. This meta-analysis of chemotherapy in the supportive care setting demonstrates that chemotherapy improves overall survival in all patients with advanced NSCLC. Patients who are fit enough and wish to receive it should be offered chemotherapy.

Chemotherapy in addition to supportive care improves survival in advanced non-small-cell lung cancer: a systematic review and meta-analysis of individual patient data from 16 randomized controlled trials

PURPOSE

Since our individual patient data (IPD) meta-analysis (MA) of supportive care and chemotherapy for non-small-cell lung cancer (NSCLC), published in 1995, many trials have been completed. An updated, IPD MA has been carried out to assess newer regimens and determine conclusively the effect of chemotherapy.

METHODS

Systematic searches for randomized controlled trials (RCTs) were undertaken, followed by central collection, checking, and reanalysis of updated IPD. Results from RCTs were combined to calculate individual and pooled hazard ratios (HRs).

RESULTS

Data were obtained from 2,714 patients from 16 RCTs. There were 1,293 deaths among 1,399 patients assigned supportive care and chemotherapy and 1,240 among 1,315 assigned supportive care alone. Results showed a significant benefit of chemotherapy (HR, 0.77; 95% CI, 0.71 to 0.83; P

CONCLUSION

This MA of chemotherapy in the supportive care setting demonstrates conclusively that chemotherapy improves overall survival in all patients with advanced NSCLC. Therefore, all patients who are fit enough and wish to receive chemotherapy should do so.

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Key Words Collapse

MESH Headings

• Carcinoma, Non-Small-Cell Lung/drug therapy
• Carcinoma, Non-Small-Cell Lung/mortality
• Humans
• Lung Neoplasms/drug therapy
• Lung Neoplasms/mortality
• Palliative Care
• Randomized Controlled Trials as Topic
• Survival Analysis

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Grants

• MC_U105285807 Medical Research Council
• MC_U122861323 Medical Research Council

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Affiliation(s) Collapse

Comparison of vinorelbine-Cisplatin with gemcitabine-Cisplatin in patients with advanced non-small cell lung cancer

PURPOSE

The objective of this trial was to compare cisplatin-plus-vinorelbine regimen with cisplatin-plus-gemcitabine regimen in patients with stage IIIB-IV non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemonaive patients with stage IIIB-IV NSCLC received either vinoelbine 30 mg/m(2) (days 1 and 8) plus cisplatin 80 mg/m(2) (day 1) every 21 days (VC arm) or gemcitabine 1250 mg/m(2) (days 1 and 8) plus cisplatin 80 mg/m(2) (day 1) every 21 days (GC arm).

RESULTS

One hundred thirtyfour patients (67 VC and 67 GC) were included to the study. Overall response rates for the VC arm (31.2%) were not significantly different from that of the GC arm (34.3%). There were no differences in overall survival and one-year survival rates. Median survival and one-year survival rates for the VC and GC groups were 10.6 and 11.5 months, 45% and 46.8%, respectively. Grade 3-4 thrombocytopenia was significantly higher on the GC arm (VC 1.4% v GC 8.9%, p < 0.05), as was febrile neutropenia on the VC arm (VC 8.9% v GC 1.4%, p < 0.05).

CONCLUSION

VC and GC demonstrated similar efficacy but there were differences in toxicity profiles.

Phase I trial of oral talactoferrin alfa in refractory solid tumors

BACKGROUND

Lactoferrin is an iron-binding glycoprotein first identified in breast milk as a protein product of mammary epithelial cells. Its immunomodulatory functions include activation of NK and lymphokine-activated killer cells and enhancement of PMN and macrophage cytotoxicity. Studies in animal models have shown promising anti-cancer activity. The purpose of the present study was to evaluate the safety and tolerability of talactoferrin alfa (talactoferrin; TLF) in humans, as well as pharmacokinetics and pharmacodynamics.

METHODS

Ten adult patients with progressive advanced solid tumors who had failed conventional chemotherapy were administered oral TLF at doses from 1.5 to 9 g/day, using a 2 weeks on, 2 weeks off schedule. Patients were evaluated for drug toxicity, tumor growth rate, talactoferrin pharmacokinetics and cytokine markers.

RESULTS

Talactoferrin was very well tolerated. No hematological, hepatic, or renal toxicities were reported. A single patient had Grade 2 diarrhea, and there were no Grade 3 or 4 toxicities. Following oral administration, significant levels of talactoferrin were undetectable in circulation, but a statistically significant increase in circulating IL-18, a pharmacodynamic indicator of talactoferrin activity, was observed. Of the eight patients who were radiologically evaluable, five (63%) had stable disease by RECIST criteria two months after start of therapy, including one patient with a minor response. Seven patients (88%) had a decrease in their tumor growth rate. The three patients with non-small cell lung cancer (NSCLC) all survived for at least one year following the start of talactoferrin monotherapy.

CONCLUSIONS

Talactoferrin is a promising, well-tolerated new agent that should be evaluated further in patients with refractory metastatic cancer.

Gemcitabine and carboplatin in the treatment of locally advanced and metastatic non-small cell lung cancer

OBJECTIVE

The aim of the study was to evaluate the response, survival advantage and toxicity profile of gemcitabine-carboplatin combination cytotoxic chemotherapy in patients with locally advanced and metastatic non-small cell lung cancer (NSCLC).

METHODOLOGY

Patients who received gemcitabine-carboplatin combination chemotherapy over a 2.5-years period were analyzed. Carboplatin at a dose of 5 mg/mL/min (area under the concentration-time curve) was given on day 1 and gemcitabine (1000 mg/m(2)) on days 1 and 8, every 3 weeks.

RESULTS

Of 49 chemotherapy-naive patients (median age, 62 years) who received this treatment, 57% were males, 12% had stage IIIa, 39% stage IIIb and 49% metastatic disease. The Eastern Cooperative Oncology Group (ECOG) performance status of 70% of the patients was 1 at the time of commencement of chemotherapy and 2 for the remaining 30% of patients. The overall response rate, based on 33 evaluable patients, was 27.3%. The response rate was not affected by age, stage of disease or performance status. The median survival was 9 months. Median survival among patients with an ECOG performance status of 1 was 11 months, as compared with 4 months for patients with an ECOG performance status of 2 (P < 0.001). Toxicity was generally well tolerated and there were no treatment-related deaths.

CONCLUSIONS

Gemcitabine-carboplatin combination chemotherapy is an effective and well-tolerated cytotoxic regimen among Malaysian patients with advanced NSCLC. A performance status of 1 or less was associated with a better survival.

The care of the lung cancer patient in the 21st century: a new age

Lung cancer is by far the leading cause of cancer-related death within the United States and throughout the world, with a global incidence estimating 1,240,000 in 2001. While median survival has improved from 7 months in 1960 to 16.8 months in 2001 for all patients diagnosed with lung cancer, much of this progress relates to improved surgical techniques, combined modality therapy for locally advanced disease, improved symptom palliation, and moderate but real improvements in survival of stage IV disease. However, much work remains to be done in a field in which only 15% to 17% of patients live 5 years. The role of chemotherapy in the last decade has expanded substantially, with evidence for extension of median survival in stage IV from 4 months to 8 to 10 months, improvements in symptom control, as well as 1-year survival almost tripling from 11% to 14% to 32% to 37% with modern chemotherapy regimens. Furthermore, progress has also been seen in the use of concomitant chemoradiotherapy, which has become the mainstream approach for treating patients with locally advanced non-small cell lung cancer. Finally, trials with cisplatin-based chemotherapy suggest that for resectable non-small cell lung cancer, improvement in disease-free and overall survival at 5 years is in the range of 4% to 5%. With the development of multiple small molecules and monoclonal antibodies targeting important growth factor receptors, oncogenes and tumor-suppressor genes known to be aberrant in lung cancer, there is hope for further incremental improvements in the treatment of this deadly disease.

Are Chemotherapy Response Rates Related to Treatment-Induced Survival Prolongations in Patients With Advanced Cancer?

Purpose

Patients with incurable cancer are faced with difficult decisions regarding whether to take chemotherapy in an attempt to preserve the quality and/or prolong the quantity of their lives. The average prolongation in survival with chemotherapy compared with best supportive care has not been well described.

Methods

We performed a literature search using PUBMED combined with expert inquiry to identify trials comparing cytotoxic chemotherapy with best supportive care. Twenty-five randomized, controlled clinical trials comparing cytotoxic chemotherapy with best supportive care were identified. Sixteen trials (64%) were in patients with non–small-cell lung cancer (NSCLC). Data were extracted and analyzed.

Results

Sufficient data for statistical modeling were available for NSCLC trials. The mean sample size of the NSCLC trials was 175 patients. Response rates in the treatment arms for NSCLC ranged from 7% to 42%. A relationship between response rate and survival was observed for NSCLC. The estimated relationship for NSCLC suggested that each 3.3% increase in response rate correlated, on average, with a 1-week increase in median survival, and each 2% increase in response rate correlated, on average, with a 1% increase in 1-year survival. The mean increase in 1-year survival for trials of agents with at least a 20% response rate in NSCLC was 16%. Formulas are provided to help estimate how a given response rate may effect median and 1-year survival relative to best supportive care alone for NSCLC.

Conclusion

We found a relationship between response rate and both median and 1-year survival in NSCLC. This information may help oncologists estimate how an NSCLC chemotherapy regimen with a given response rate can, on average, impact survival relative to supportive care alone.

Placebo effects in oncology

BACKGROUND

Previous studies have suggested that placebo treatment can have positive effects on a variety of disorders and disease-related symptoms. However, the methodology used to collect and interpret the data may not have been ideal, because the studies were not double-blinded or the endpoints were not properly validated. The purpose of the present study was to determine the probability of improvement in symptoms or quality of life and tumor response in cancer patients treated with placebos in randomized controlled trials. We hypothesized that administration of placebos would improve symptom control and quality of life but would not lead to tumor response.

METHODS

We reviewed reports of randomized controlled trials in which there was a placebo arm (37 trials) or a best supportive care (BSC) arm (10 trials).

RESULTS

In trials that assessed average responses for patients in the placebo arm, improvements in average levels of pain were reported in two of six trials and in appetite, in one of seven trials. No improvements in average levels of weight gain (six trials), in quality of life (as assessed by patients; 10 trials), or in performance status (as assessed by physicians; nine trials) were reported. In trials that assessed response to a placebo in individual patients, 0%-21% of patients showed reduced pain or decreased analgesic intake, 8%-27% of patients showed appetite improvement, 7%-17% of patients showed weight gain, and 6%-14% of patients showed improvement in performance status. Quality of life for individual patients was not reported in any trial. Tumor response assessed by World Health Organization criteria was observed in 10 (2.7%) of 375 patients (seven trials total). Response as assessed by a serum marker was observed in 1 (1.7%) of 60 patients (two trials total). The probability of symptom improvement in patients receiving BSC was generally similar to that in patients receiving placebo, although no improvement in pain and only one tumor response among 191 patients (five trials) were reported.

CONCLUSION

In randomized double-blinded, placebo-controlled trials, presumably with minimum sources of bias, placebos are sometimes associated with improved control of symptoms such as pain and appetite but rarely with positive tumor response. Substantial improvements in symptoms and quality of life are unlikely to be due to placebo effects.

Chemotherapeutic management of stage IV non-small cell lung cancer

Stage IV non-small cell lung cancer (NSCLC) denotes the presence of metastatic disease and is largely incurable using present-day therapies. Chemotherapy remains a therapeutic option in this patient population, and there are many pertinent issues surrounding its use in patients with stage IV NSCLC. Eleven questions were framed by the American College of Chest Physicians Lung Cancer Guidelines Committee, and these were addressed by a systematic search of the available literature. The issues addressed included the identification of prognostic factors in selecting patients for chemotherapy and a critical analysis of the survival benefit provided by chemotherapy. Given the development of several new chemotherapy agents over the past decade, the impact that these agents have made was addressed as well as the definition of a standard of care regarding chemotherapeutic regimens. Given the fact that chemotherapy does not represent a curative option, other issues addressed were the optimal duration of treatment as well as its impact on symptom relief and quality of life, the role of second-line therapy, and the outcomes expectations from both first-line and second-line chemotherapy. The question of what specialty delivered the chemotherapy also was addressed. Once the data were identified, a critical analysis was undertaken attempting to objectively portray the data in support of answers for each of the questions posed. We believe the data support the fact that properly selected patients benefit from chemotherapy with regard to survival and palliation in both first-line and second-line settings. It appears that in trials addressing the duration of first-line therapy, this survival and palliative benefit occurs early, and prolonged therapy is not indicated. Therapy in this setting is cost-effective, and there are several regimens that can be considered to be "standard-of-care" options. Physicians involved in the diagnosis of these patients should be aware of the potential benefits of chemotherapy, allowing them to give recommendations to patients that are based on data derived from clinical trials. In addition, this awareness will allow them to make referrals, when appropriate, to physicians who are trained in the administration of chemotherapy and the management of patients undergoing such therapy.

Silence and cancer: why do families and patients fail to communicate?

This study examined the phenomenon of avoidance of family communication about cancer. Thirty-seven Stage III or IV lung cancer patients and 40 caregivers, including 24 primary and 16 secondary caregivers, were interviewed; a total of 26 families were studied. The interviews were audiotaped and transcribed. Analysis of the interviews indicated that two thirds of the families (65%) experienced communication problems. The avoidance of family communication was associated with several underlying thought processes: avoidance of psychological distress; desire for "mutual protection;" and belief in positive thinking. Family communication was further hindered by the increasing difficulty of issues inherent to late-stage cancer. The adverse impact of communication avoidance and the implications of our findings are discussed.

Chemotherapy in NSCLC: historical review

The use of chemotherapy in patients with advanced NSCLC has been under investigation for several years. It has evolved from administration in the palliative care setting to integration into combined-modality curative therapy settings in patients with locoregionally-advanced disease. Following the largest meta-analysis in 1995 it was suggested that platinum-based chemotherapy was effective in treating patients with advanced disease. The absolute improvement in survival was 10% at 1 year and an increased median survival of 1.5 months. Since this analysis, platinum-based chemotherapy is considered the gold standard of treatment in this disease.

Assessing outcomes in palliative chemotherapy

Patients with metastatic cancer are often offered systemic chemotherapy, although it is not usually curative in this situation. The impact of treatment on survival may be small and the intention is mainly to palliate symptoms and to improve the patient's quality of life. Traditional end points in clinical trials tend to focus on cancer outcomes, such as tumour shrinkage or survival. Trials of palliative chemotherapy should focus on patient outcomes that reflect the aims of treatment. There are now a large number of instruments available to measure quality of life and the difficulty lies in deciding which tools are appropriate and applying them consistently to give results that are robust enough to enable clinical decision making. This is particularly challenging in a population of patients with a high degree of morbidity. In addition, economic end points are becoming increasingly relevant in the current climate: as newer treatments become available, the ways in which costs may be balanced against the potential benefits in terms of gains in quality of life become important.

The Value of Platinum Compounds in Non—Small-Cell Lung Cancer

The value of platinum compounds has come into question with the advent of newer chemotherapy agents in the management of patients with advanced non-small-cell lung cancer. These newer agents, which include the taxanes, topoisomerase I inhibitors, gemcitabine, and vinorelbine, appear to have higher single-agent response rates and more favorable toxicity profiles when compared to the platinum compounds. However, the toxicity of the platinum compounds is now minimized with the advent of more effective antiemetics. In addition, phase III clinical trials have demonstrated that the strategy of cisplatin dose intensity and prolonged duration of therapy with platinum compounds does not improve overall survival; therefore, moderate doses of cisplatin and a shorter duration of therapy can be given to further decrease toxicity. Furthermore, while phase II trials utilizing nonplatinum-based combination chemotherapy appear to demonstrate superior response rates and survival in comparison to platinum-based doublets, results of phase III trials have demonstrated no improvement in survival. Platinum combination chemotherapy remains the standard approach for stage IV non-small-cell lung cancer. More substantial advances will likely be made with novel molecular targeted therapy, such as the epidermal growth factor receptor inhibitors, which demonstrate synergy with the platinum compounds.

Clinical-benefit response in advanced non-small-cell lung cancer: A multicentre prospective randomised phase III study of single agent gemcitabine versus cisplatin-vindesine

BACKGROUND

The modest improvement in median survival of advanced non-small-cell lung cancer (NSCLC) by cisplatin-based chemotherapy has led to the current opinion that clinical benefit for the patient is at least as important an end-point as objective response rate (ORR) or survival. Clinical benefit response was the primary end-point of this prospective randomised trial in symptomatic, advanced stage IIIB/IV NSCLC, comparing single agent gemcitabine (GEM) to cisplatin-based chemotherapy.

PATIENTS AND METHODS

Patients received either GEM (1000 mg/m2, days 1, 8 and 15) or cisplatin (100 mg/M2, day 1) plus Vindesine (3 mg/m2, days 1 and 15) (PV), both every four weeks. Clinical benefit was measured by a simple metric based on changes in a visual analogue symptom score list, the Karnofsky performance status and the weight.

RESULTS

One hundred sixty-nine patients were randomised (84 GEM, 85 PV). Prognostic factors and baseline symptoms were well balanced between the two arms. Most of the the objective responders and about half of the patients with disease stabilisation experienced clinical benefit. Compared to PV, a significantly larger number of GEM-treated patients experienced a clinical benefit (48.1 vs. 28.9%, P = 0.03) that lasted significantly longer (median duration 16 vs. 10 weeks, P = 0.01). No important differences in ORR, time-to-progression or median survival were observed. Grade 3 + 4 toxicity was significantly higher in the PV-group for leukopenia (P = 0.0003), neutropenia (P < 0.0001), nausea/vomiting (P = 0.0006), alopecia (P < 0.0001), and neurotoxicity (P = 0.04). Some severe pulmonary toxicity to GEM was noted.

CONCLUSION

Comparison of GEM with cisplatin-based therapy in symptomatic, advanced NSCLC demonstrates that GEM produces significantly a stronger and longer-lasting clinical benefit, probably due to its equal effectiveness in terms of ORR, time-to-progression or survival, combined with significantly less severe therapy-related toxicity.

Management of patients with advanced non-small-cell lung cancer

Lung cancer is one of the most lethal cancers, causing more deaths of men and women than any other cancer in the United States. Non-small-cell lung cancers account for most the newly diagnosed cases of lung cancer. Many patients with non-small-cell lung cancer present with advanced-stage disease and are not appropriate candidates for combined modality therapy. Although these patients have incurable disease, they have a chance of achieving improved 1-year survival rates and palliation of symptoms with chemotherapy. The performance status of patients with advanced non-small-cell lung cancer is the most important determinant of response to chemotherapy.

A Phase II study of docetaxel and carboplatin in the treatment of non-small cell lung cancer

We investigated the efficacy of docetaxel (D) in combination with carboplatin (C) in the treatment of non-small cell lung cancer (NSCLC) patients. Since 1996, 123 with inoperable NSCLC were enrolled in the study; 120 (108 males, 12 females; mean age 58.0+/-8.3 years) were evaluated. Of those, 46 patients had squamous carcinoma, 44 adenocarcinoma, 11 large cell carcinoma and 19 undifferentiated tumours. Eligibility criteria included, documented inoperable NSCLC, WHO performance status (PS) 0-1, age up to 70 years, and normal renal and hepatic function. A total of 622 cycles of chemotherapy (CHT) (median 7 (95% CI 6.2-7.47), courses per patient) were administered. Each cycle consisted of 100 mg/m(2) of docetaxel in a 2-h infusion with C at a dose of area under the curve (AUC) of 6 on day 1. This regimen was repeated every 28 days up to eight cycles. Of the patients, five (4%) achieved complete response, 49 (40%) partial response, 47 (39%) had stable disease and 19 (15%) had progressive disease. The median survival was 12 months for all patients, 12 for the four patients with stage IIb disease, 18 for the patients with stage IIIa disease, 20 for the 29 patients with stage IIIb disease, and 11 for the 65 stage IV patients. The median time to progression was 8 months (90 patients). Toxicity was, grade 3/4 neutropenia, 18 patients (15%); grade 3/4 anaemia, 6 patients (5%); and tolerable peripheral neuropathy, 16 patients (13.3%). Responders received radiotherapy (total dose, 50 Gy in 4 weeks) between the 6th and 8th cycle. Among responders with initial stage IIIb disease, 7 (5%) underwent surgical resection. Patients with early progression of the disease received the same dose of radiotherapy between 2nd and 3rd cycle. The study is ongoing, and six patients (5%) are still alive (after 3 years). Preliminary results indicate that the D/C combination is very active in the treatment of NSCLC with tolerable toxicity. It appears that this drug combination is also good as neoadjuvant therapy in inoperable NSCLC patients.

Single-agent mitomycin for advanced non-small cell lung cancer

In the treatment of patients with advanced non-small cell lung cancer with chemotherapy, there is no consensus concerning the optimum regimen. Survival is poor and the activity of drugs has to be balanced against toxicity. There is therefore continued interest in the use of single-agent chemotherapy for this condition. I report the treatment of non-small cell lung cancer with mitomycin. In 20 patients, four responses were observed, giving a response rate of 20% (95% confidence interval (CI) 3-37); median survival was 26 weeks (95% CI 13-30). One patient who presented with bone and liver metastases survived for 27 months after treatment.

Chemotherapy versus best supportive care in stage IV non-small cell lung cancer, non metastatic to the brain

Stage IV non-small cell lung cancer is a fatal disease, with a median survival of 14 months. Systemic chemotherapy is the most common approach. However the impact in overall survival and quality of life still a controversy.

OBJECTIVES

To determine differences in overall survival and quality of life among patients with stage IV non-small cell lung cancer non-metastatic to the brain treated with best supportive care versus systemic chemotherapy.

PATIENTS

From February 1990 through December 1995, 78 eligible patients were admitted with the diagnosis of stage IV non-small cell lung cancer. Patients were divided in 2 groups: Group A (n=31 - treated with best supportive care ), and Group B (n=47 - treated with systemic chemotherapy).

RESULTS

The median survival time was 23 weeks (range 5 - 153 weeks) in Group A and 55 weeks (range 7.4 - 213 weeks) in Group B (p=0.0018). In both groups, the incidence of admission for IV antibiotics and need of blood transfusions were similar. Patients receiving systemic chemotherapy were also stratified into those receiving mytomycin, vinblastin, and cisplatinum, n=25 and those receiving other combination regimens (platinum derivatives associated with other drugs, n=22). Patients receiving mytomycin, vinblastin, and cisplatinum, n=25 had a higher incidence of febrile neutropenia and had their cycles delayed for longer periods of time than the other group. These patients also had a shorter median survival time (51 versus 66 weeks, p=0.005).

CONCLUSION

In patients with stage IV non-small cell lung cancer, non-metastatic to the brain, chemotherapy significantly increases survival compared with best supportive care.

Controlling malignant pericardial effusion by intrapericardial carboplatin administration in patients with primary non-small-cell lung cancer

Malignant pericarditis, when associated with massive pericardial effusion, presents a critical condition in lung cancer patients. Because this condition often arises in terminally ill patients, intensive therapy such as multi-drug combination chemotherapy is rarely appropriate. This study evaluated the clinical relevance of intrapericardial administration of carboplatin for controlling malignant pericardial effusions associated with non-small-cell lung carcinoma (NSCLC). The method used for 10 eligible patients consisted of draining the pericardial effusion and infusing 300 mg/body of carboplatin in 50 ml of saline through an in-place catheter into the pericardial space and clamping the catheter for 40 min. Nine of the 10 patients showed satisfactory results, and 8 experienced complete regression of the effusion. No major or minor adverse effects were observed. Pharmacokinetics analysis revealed that the concentration of free platinum in the pericardial fluid was very high while that of total platinum in the circulating plasma was very low, assuring the usefulness of the intrapericardial instillation of carboplatin in terminally ill patients for controlling malignant pericardial effusion when the systemic delivery of cytotoxic agents is inappropriate.

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.

Decision framework for chemotherapeutic interventions for metastatic non-small-cell lung cancer

BACKGROUND

Best supportive care has long been considered to be the standard therapy for metastatic non-small-cell lung cancer (NSCLC). There is now evidence from randomized trials that a number of chemotherapy regimens can palliate cancer-related symptoms and modestly improve survival. We show how cost-effectiveness analyses can be used to make choices between different (ambulatory) chemotherapy regimens.

METHODS

Clinical algorithms describing the diagnosis, staging, and treatment of metastatic NSCLC were incorporated into Statistics Canada's Population Health Model. Using consistent methodology, we assessed the cost-effectiveness of several chemotherapeutic interventions: a combination of vindesine (VDS) plus cisplatin, etoposide (VP-16) plus cisplatin, vinblastine (VLB) plus cisplatin, vinorelbine (Navelbine; NVB) plus cisplatin, paclitaxel (Taxol) plus cisplatin, and gemcitabine (GEM) and NVB alone. We calculated the total chemotherapy costs in 1995 Canadian dollars, the cost per case, the average life-years saved, and the cost per life-year saved. Using the Population Health Model, we then constructed an advanced decision framework that rank-ordered the various treatment regimens so as to optimize benefit below various cost-effectiveness thresholds.

RESULTS

One regimen (VLB plus cisplatin) appears to result in better survival and lower health care expenditures than best supportive care. By use of cost-effectiveness thresholds of $25,000 and $50,000 per life-year gained, NVB plus cisplatin is the preferred regimen. When quality of life is considered, however, GEM is preferred to NVB plus cisplatin at a threshold value of $50,000. At thresholds of $75 000 and $100,000, paclitaxel plus cisplatin at a dose of 135 mg/m(2) is the preferred regimen. At thresholds of $50,000 and above, best supportive care is the least preferred regimen.

CONCLUSIONS

This decision framework allows the comparison of different treatment regimens based on various cost-effectiveness thresholds. Our analysis also supports the use of chemotherapy regimens and the abandonment of best supportive care as the standard of care for patients with advanced NSCLC. [J Natl Cancer Inst 2000;92:1321-9].

Natural history of untreated head and neck cancer

This paper describes the characteristics and natural history of the largest reported group of patients with untreated head and neck cancer. From 1953 to 1990, 808 untreated head and neck cancer patients were followed-up until their death. All patients were given supportive care, but specific oncological treatment was not pursued secondary to advanced tumour stage, poor performance status and/or patients' refusal of any treatment. The overall survival ranged from 1 day to 53.8 months (median 3.82 months). Performance status was the most significant predictor of survival (P < 0.001). A subgroup of 357 patients with good performance status and aged less than 70 years old had a 12.9% 1-year survival. Approximately 50% of untreated head and neck cancer patients will die within 4 months of their diagnosis. However, the remaining patients can survive up to 4 or more years, depending on their tumour location, extent, performance status and level of supportive care.

Evolution of cisplatin-based chemotherapy in non-small cell lung cancer: a historical perspective and the eastern cooperative oncology group experience

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death in most industrialized nations, including the United States. Frequently, patients with unresectable disease are treated with symptomatic care alone or, in the case of locally advanced, unresectable lesions, with radiotherapy alone. In general, chemotherapy is viewed as ineffective, and therefore rarely recommended except by medical oncologists. Over the past 2 decades, however, it has become clear that chemotherapy, and in particular cisplatin-based chemotherapy, provides a modest survival advantage. In addition, recent studies indicate that chemotherapy can improve tumor-related symptoms and quality of life. With modern chemotherapy, median survival averages around 9 to 10 months in advanced NSCLC, a figure comparable to that achieved with treatment of extensive-stage small cell lung cancer, a malignancy generally viewed as chemotherapy sensitive. Importantly, existing data indicate that chemotherapy is also cost-effective. Given these observations, it is appropriate today for patients with advanced NSCLC to receive chemotherapy.

A multicenter, randomized, phase III study of docetaxel plus best supportive care versus best supportive care in chemotherapy-naive patients with metastatic or non-resectable localized non-small cell lung cancer (NSCLC)

This was an open-label randomized Phase III study of 207 patients with either unresectable or metastatic non-small cell lung cancer (NSCLC) who were treated with docetaxel plus best supportive care (BSC) or best supportive care alone. Patients in the chemotherapy arm of the study received docetaxel 100 mg/m(2) as a 1 h intravenous infusion every 21 days until they showed evidence of progressive disease, or estimated maximum benefit obtained or unacceptable side effects. Patients who received docetaxel were pretreated with oral dexamethasone. Patients in the BSC arm should not receive chemotherapy or anticancer therapy except for palliative radiotherapy. Overall survival obtained in the docetaxel arm was significantly longer than in the BSC arm (P=0.026). Two-year survival in the docetaxel arm was 12%, whereas none of the BSC patients survived after 20 months. The response rate was 13.1% (95% CI, 7.5-18.8%). There was a significantly longer time to progression in the docetaxel versus the BSC arm (P<0.001), and statistically significant improvement of clinical symptoms with docetaxel compared to BSC. The quality-of-life descriptors were in favor of docetaxel, and the difference was significant for pain, dyspnea and emotional functioning. The safety profile of docetaxel for this study was similar to that already reported in this patient population.

Evidence-based medicine in the treatment of non-small-cell lung cancer

Treatment decisions for non-small-cell lung cancer require accurate initial staging of patients. Typically surgical resection is recommended for early stage disease, while chemotherapy in conjunction with radiotherapy and possibly surgical resection is recommended for selected patients with locally advanced disease. Chemotherapy clearly has been demonstrated to improve survival and quality of life in metastatic disease. Surgical, chemotherapeutic, and radiotherapy treatment options as well as the role of multi-modality therapy will be discussed focusing on the evidence for various stages of non-small-cell lung cancer.

Phase III trial of gemcitabine plus cisplatin versus cisplatin alone in patients with locally advanced or metastatic non-small-cell lung cancer

PURPOSE

The Hoosier Oncology Group has previously reported the results of its phase II trial of the combination of cisplatin plus gemcitabine. In that study of 27 assessable patients with advanced or metastatic non-small-cell lung cancer (NSCLC), the response rate was 33%, with a median survival of 8.4 months. Based on such favorable results, the Hoosier Oncology Group designed this randomized phase III study of gemcitabine plus cisplatin compared with cisplatin alone in chemotherapy-naive patients with advanced NSCLC.

PATIENTS AND METHODS

Patients were randomized to receive either cisplatin (100 mg/m(2) intravenously on day 1 of a 28-day cycle) or the combination of cisplatin (100 mg/m(2) intravenously on day 1) plus gemcitabine (1,000 mg/m(2) administered intravenously on days 1, 8, and 15 of a 28-day cycle).

RESULTS

From August 1995 to February 1997, 522 assessable chemotherapy-naive patients were randomized. Toxicity was predominantly hematologic and was more pronounced in the combination arm, with grade 4 neutropenia occurring in 35.3% of patients compared with 1.2% of patients on the cisplatin monotherapy arm. The incidence of neutropenic fevers was less than 5% in both arms. Grade 4 thrombocytopenia occurred in 25. 4% of patients on the combination arm compared with 0.8% of patients on the cisplatin monotherapy arm. No serious hemorrhagic events related to thrombocytopenia were reported for either arm. The combination of gemcitabine plus cisplatin demonstrated a significant improvement over single-agent cisplatin with regard to response rate (30.4% compared with 11.1%, respectively; P <.0001), median time to progressive disease (5.6 months compared with 3.7 months, respectively; P =.0013), and overall survival (9.1 months compared with 7.6 months, respectively; P =.004).

CONCLUSIONS

For the first-line treatment of NSCLC, the regimen of gemcitabine plus cisplatin is superior to cisplatin alone in terms of response rate, time to disease progression, and overall survival.

Phase I/II study of gemcitabine plus vinorelbine as first-line chemotherapy of non-small-cell lung cancer

PURPOSE

To determine the maximum-tolerated dose of gemcitabine when combined with a fixed dose of vinorelbine in the treatment of non-small-cell lung cancer (NSCLC) and to evaluate in a phase II trial the activity of this combination.

PATIENTS AND METHODS

Sixty-eight patients with stage IIIB/IV NSCLC were treated with vinorelbine at fixed dose of 30 mg/m(2) intravenously and gemcitabine at increasing dose levels from 800 to 1,500 mg/m(2) intravenously on days 1 and 8 every 3 weeks.

RESULTS

In phase I, dose-limiting toxicity occurred at the dosage of 1,500 mg/m(2) gemcitabine, with three of five patients developing grade 4 thrombocytopenia. In phase II, with gemcitabine at 1,200 mg/m(2), 19 (36%) of 52 assessable patients responded. Objective response was observed in 11 (39%) of 28 patients with stage IIIB disease and in eight (33%) of 24 patients with stage IV. The median time to progression was 29 weeks (range, 2 to 41 weeks; 35 weeks and 16 weeks for stages IIIB and IV, respectively), and median survival was 54 weeks (range, 2 to 84+ weeks; 63 weeks and 42 weeks for stages IIIB and IV, respectively). One-year survival was 64% for patients with stage IIIB disease and 29% for those with stage IV. Clinical benefit response was observed in 29 (59%) of 49 assessable patients. Grade 4 leukopenia and thrombocytopenia were uncommon (6% and 8% of cases, respectively); however, grade 3/4 leukothrombocytopenia occurred more frequently in patients aged more than 70 years (52% and 24%, respectively).

CONCLUSION

The combination of vinorelbine and gemcitabine is effective and tolerable in the treatment of NSCLC, thus deserving randomized trials with cisplatin combination regimens.

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.

Paclitaxel-based therapy in non-small-cell lung cancer: improved third generation chemotherapy

The newer or 'third generation' chemotherapeutic agents (paclitaxel, docetaxel, vinorelbine, gemcitabine, irinotecan, topotecan) have all recently been shown to have substantial activity against non-small-cell lung cancer (NSCLC). Many of these agents are now being incorporated into the therapy for patients with advanced disease. Paclitaxel was the first 'third generation' drug to be studied. The use of paclitaxel and carboplatin has proven to be a well tolerated and quite active regimen with one-year survival in patients with stage IV disease of about 40% and two-year survival of about 20%. These survival rates are at least twice as good as previous platinum-based regimens. We have simplified the administration of paclitaxel by using a one-hour infusion and many other investigators and clinicians have followed suit. The results are equivalent to a three-hour infusion schedule. Given the degree of activity in patients with stage IV disease, it is imperative to begin neoadjuvant and adjuvant trials with the newer drugs and drug combinations. We and others have started a neoadjuvant strategy which has proven to be feasible and most patients tolerate surgery well. While the results are quite preliminary, we have seen some complete pathologic responses (about 20%) and are encouraged by these early data. In addition, we have routinely used adjuvant paclitaxel and carboplatin in patients with stage IB-IIIA disease who have been previously resected. Radiotherapy and a weekly schedule of paclitaxel and carboplatin have been incorporated for patients with stages II-IIIB (selected IIIB patients). Randomized comparisons are certainly needed in the neoadjuvant and adjuvant arena and the other 'third generation' drugs need to be quickly evaluated. We have chosen to add a third agent to paclitaxel and carboplatin. The evaluation of several triple combinations including the addition of gemcitabine, vinorelbine and topotecan, respectively to the paclitaxel-carboplatin combination has been completed. Preliminary results from these trials will be briefly summarized and plans for additional studies of the newer agents will also be discussed. Studies to learn the appropriate combinations, doses and schedules of the newer drugs in concert with radiotherapy and/or resection are also urgently needed. Since the newer 'third generation' drugs appear to genuinely improve the survival of patients with stage IV disease, it is likely that incorporation of these more active agents into therapy for lower stages of disease will make an even greater impact on overall survival for patients with this common neoplasm.