Symptom relief with MVP (mitomycin C, vinblastine and cisplatin) chemotherapy in advanced non-small-cell lung cancer

Non-small cell lung cancer (NSCLC): A review of risk factors, diagnosis, and treatment

Lung cancer remains the leading cause of cancer deaths. Non-small cell lung cancer (NSCLC) is the most frequent subtype of lung cancer. Surgery, radiation, chemotherapy, immunotherapy, or molecularly targeted therapy is used to treat NSCLC. Nevertheless, many patients who accept surgery likely develop distant metastases or local recurrence. In recent years, targeted treatments and immunotherapy have achieved improvement at a breakneck pace. Therapy must be customized for each patient based on the specific medical condition, as well as other variables. It is critical to have an accurate NSCLC sub-classification for tailored treatment, according to the latest World Health Organization standards.

Everything Old Is New Again: Drug Repurposing Approach for Non-Small Cell Lung Cancer Targeting MAPK Signaling Pathway

Non-small cell lung cancer (NSCLC) is a prominent subtype of lung carcinoma that accounts for the majority of cancer-related deaths globally, and it is responsible for about 80% to 85% of lung cancers. Mitogen-Activated Protein Kinase (MAPK) signaling pathways are a vital aspect of NSCLC, and have aided in the advancement of therapies for this carcinoma. Targeting the Ras/Raf/MEK/ERK pathway is a promising and alternative method in NSCLC treatment, which is highlighted in this review. The introduction of targeted medicines has revolutionized the treatment of patients with this carcinoma. When combined with current systems biology-driven stratagems, repurposing non-cancer drugs into new therapeutic niches presents a cost-effective and efficient technique with enhancing outcomes for discovering novel pharmacological activity. This article highlights the successful cutting-edge techniques while focusing on NSCLC targeted therapies. The ultimate challenge will be integrating these repurposed drugs into the therapeutic regimen of patients affected with NSCLC to potentially increase lung cancer cure rates.

The role of palliative care in the management of patients with lung cancer

Palliative care (PC) is the care of patients and their families with serious illness and is rapidly becoming an important part of the care of cancer patients. Patients with advanced lung cancer are a highly symptomatic population of patients and clearly experience benefits in quality of life and potentially benefits in overall survival when PC is incorporated early on after diagnosis. However, referrals to PC are still reliant on clinical judgment of patient prognosis and symptom burden. Moving forward, improving the integration of PC and lung cancer care will require more efficient real-time screening of patient symptoms, which may be accomplished through the use of patient-reported outcomes.

Plant-derived glucose transport inhibitors with potential antitumor activity

Glucose, a key nutrient utilized by human cells to provide cellular energy and a carbon source for biomass synthesis, is internalized in cells via glucose transporters that regulate glucose homeostasis throughout the human body. Glucose transporters have been used as important targets for the discovery of new drugs to treat cancer, diabetes, and heart disease, owing to their abnormal expression during these disease conditions. Thus far, several glucose transport inhibitors have been used in clinical trials, and increasing numbers of natural products have been characterized as potential anticancer agents targeting glucose transport. The present review focuses on natural product glucose transport inhibitors of plant origin, including alkaloids, flavonoids and other phenolic compounds, and isoprenoids, with their potential antitumor properties also discussed.

Antitumor effect of hyaluronic-acid-modified chitosan nanoparticles loaded with siRNA for targeted therapy for non-small cell lung cancer

Purpose: Nanoparticle (NP)-mediated targeted delivery of therapeutic genes or siRNAs to tumors has potential advantages. In this study, hyaluronic acid (HA)-modified chitosan nanoparticles (CS NPs-HA) loaded with cyanine 3 (Cy3)-labeled siRNA (sCS NPs-HA) were prepared and characterized. Methods: Human non-small cell lung cancer (NSCLC) A549 cells expressing receptor CD44 and tumor-bearing mice were used to evaluate the cytotoxic and antitumor effects of sCS NPs-HA in vitro and in vivo. Results: The results showed that noncytotoxic CS NPs-HA of small size (100-200 nm) effectively delivered the Cy3-labeled siRNA to A549 cells via receptor CD44 and inhibited cell proliferation by downregulating the target gene BCL2. In vivo experiment results revealed that sCS NPs-HA directly delivered greater amounts of Cy3-labeled siRNA to the tumor sites, resulting in the inhibition of tumor growth by downregulating BCL2, as compared to unmodified NPs loaded with siRNA (sCS NPs) and to naked Cy3-labeled siRNA. Conclusion: The HA-modified NPs based on chitosan could serve as a promising carrier for siRNA delivery and targeted therapy for NSCLC expressing CD44.

A Career in Lung Cancer: Pushing Beyond Chemotherapy

The landscape of treatments for non-small cell lung cancer (NSCLC) has evolved dramatically over the past 3 decades. A better understanding of the disease biology and identification of actionable genetic alterations heralded an era of targeted therapies that has led to unprecedented survival benefits in patients with oncogene-driven NSCLC. More recent breakthroughs in immunotherapy led to the development of immune checkpoint inhibitors that have changed the treatment paradigm for patients with advanced NSCLC because of their ability to produce durable responses, resulting in improved survival outcomes. Despite the unparalleled success of these agents, primary and acquired resistance to these therapies pose a formidable challenge. In this article, we provide an overview of the therapeutic advances in the treatment of NSCLC, mechanisms of resistance, and potential strategies to overcome resistance to targeted therapies and immune checkpoint inhibitors.

Lung cancer: Biology and treatment options

Lung cancer remains the leading cause of cancer mortality in men and women in the U.S. and worldwide. About 90% of lung cancer cases are caused by smoking and the use of tobacco products. However, other factors such as radon gas, asbestos, air pollution exposures, and chronic infections can contribute to lung carcinogenesis. In addition, multiple inherited and acquired mechanisms of susceptibility to lung cancer have been proposed. Lung cancer is divided into two broad histologic classes, which grow and spread differently: small-cell lung carcinomas (SCLCs) and non-small cell lung carcinomas (NSCLCs). Treatment options for lung cancer include surgery, radiation therapy, chemotherapy, and targeted therapy. Therapeutic-modalities recommendations depend on several factors, including the type and stage of cancer. Despite the improvements in diagnosis and therapy made during the past 25 years, the prognosis for patients with lung cancer is still unsatisfactory. The responses to current standard therapies are poor except for the most localized cancers. However, a better understanding of the biology pertinent to these challenging malignancies, might lead to the development of more efficacious and perhaps more specific drugs. The purpose of this review is to summarize the recent developments in lung cancer biology and its therapeutic strategies, and discuss the latest treatment advances including therapies currently under clinical investigation.

50 Years of progress in the systemic therapy of non-small cell lung cancer

Non-small cell lung cancer constitutes 85% to 90% of lung cancer and is the most common cause of cancer death. Over the past 50 years, substantial progress has been made in all aspects of lung cancer including screening, diagnostic evaluation, surgery, radiation therapy, and chemotherapy. This review focuses on the advances in systemic therapy during this half century.

Anticancer therapies in specialized palliative care--a multicenter survey

INTRODUCTION

Anticancer therapies gain increasing attention and discussion in specialized palliative care institutions. Frequency, indication, attitude of team members, and modes of these therapies implemented in specialized palliative care settings are still under investigation.

METHODS

Descriptive analysis of the nationwide Hospice and Palliative Care Evaluation 2007 that collected data from palliative medicine, hospice care, and oncology institutions concerning the use of anticancer therapies.

RESULTS

Three thousand one hundred eighty-four patients from 67 palliative care units, eight oncology wards, and other in- and outpatient institutions were registered. Two hundred eleven therapeutic interventions, mostly i.v. chemotherapy (28.9%), have been documented in all institutions except from inpatient hospices. Although all institutions were asked to keep records from "palliative patients", those patients treated in oncology services differed from patients on palliative care units with respect to prognosis, therapeutic intention (symptom control versus tumor remission), and team attitude.

DISCUSSION

Anticancer therapies are incorporated into palliative care concepts. The described differences in palliative patients that are treated in specialized palliative care as compared to oncology services will have to be discussed with regard to selection of patients for specialized palliative care and the range of suitable treatment modalities in palliative care concepts.

A phase II study of ¹⁸F-fluorodeoxyglucose PET-CT in non-small cell lung cancer patients receiving erlotinib (Tarceva); objective and symptomatic responses at 6 and 12 weeks

BACKGROUND

The aim of this study was to assess if (18)F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)-CT scanning could minimise the time non-responding patients were exposed to erlotinib (Tarceva).

METHODS

Patients were selected for clinical factors that would predict response to erlotinib. A FDG PET-CT and diagnostic contrast-enhanced (traditional) CT scan were carried out at baseline, and then a FDG PET-CT at 6 weeks and a traditional CT at 12 weeks were repeated. The primary end-point was rate of early progression in patients after 6 weeks, of which a minimum 12 out of 35 were required to make the study worthwhile. The responses at 6 (PET-CT) and 12 weeks (traditional CT) were compared and correlated with symptomatic response at both these time points.

RESULTS

Forty seven patients were recruited with 38 and 33 patients assessable by FDG PET-CT at 6 weeks and traditional CT at 12weeks, respectively. There was good correlation between Partial response (PR) at both time points and all 10 patients who had a PR at 12 weeks had a PR at 6 weeks. Of the 13 patients with progressive disease (PD) at 12 weeks, seven had PD at 6 weeks and could have had their treatment stopped early. No evaluable patient with stable disease (SD) (8/38) or PD (9/38) on FDG PET-CT at 6 weeks went on to have a later response. Symptomatic response at 6 or 12 weeks did not correlate well with objective response on scanning at either time point.

CONCLUSIONS

The primary end-point of this study was met as >12 (15/38) patients could have stopped treatment early on the basis of the FDG PET-CT scan result. A FDG PET-CT evaluable response of SD or PD at 6 weeks does predict future lack of response. No correlation was found between response and symptomatic response at either 6 or 12 weeks.

Outcomes of patients with advanced non-small cell lung cancer treated in a phase I clinic

BACKGROUND

The outcomes of patients with advanced non-small cell lung cancer (NSCLC) treated in phase I clinical trials have not been systematically analyzed.

METHODS

We reviewed the records of consecutive patients with advanced/metastatic NSCLC who were treated in the Phase I Clinical Trials Program at MD Anderson from August 2004 to May 2009.

RESULTS

Eighty-five patients (51 men, 34 women) treated on various phase I protocols were identified. The median age was 62 years (range, 30-85). The median number of previous systemic therapies was two (range, 0-5). A partial response was observed in eight patients (9.5%) and stable disease lasting >4 months was observed in 16 patients (19%). The median overall survival time was 10.6 months and median progression-free survival (PFS) time was 2.8 months, which was 0.6 months shorter than the median PFS of 3.4 months following prior second-line therapy. Factors predicting longer survival in the univariate analysis were an Eastern Cooperative Oncology Group performance status (PS) score of 0-1, no prior smoking, two or fewer organ systems involved, a hemoglobin level ≥ 12 g/dL, liver metastases, a history of thromboembolism, and a platelets count > 440 × 10(9)/L. In the multivariate analysis, a PS score of 0-1 and history negative for smoking predicted longer survival. Sixty-two (73%) patients had grade ≤ 2 toxicity, and there were no treatment-related deaths.

CONCLUSION

Phase I clinical trials were well tolerated by selected patients with advanced NSCLC treated at M.D. Anderson. Nonsmokers and patients with a good PS survived longer. PFS in our population was shorter in smokers/ex-smokers and patients with a PS score of 2. It is reasonable to refer pretreated patients with a good PS to phase I clinical trials.

Targeted therapy in non-small-cell lung cancer--is it becoming a reality?

Treatment outcomes in advanced or metastatic non-small-cell lung cancer (NSCLC) remain unsatisfactory, with low long-term survival rates. Palliative chemotherapy offers a median survival not exceeding 1 year. To date, various combinations of cytotoxic drugs have not improved treatment results beyond what has been observed with platinum doublets. By contrast, molecular targeted drugs may block important pathways that drive cancer progression and achieve long-term disease control. Conflicting results have demonstrated marginal benefit with EGFR inhibitors, anti-EGFR monoclonal antibodies and antiangiogenic strategies in unselected populations of patients with advanced NSCLC. However, patients with an EGFR mutation are likely to respond to agents that target this gene. Novel targeted therapies that interfere with insulin-like growth factor 1 receptor, or the EML4-ALK fusion protein have shown promising activity. Aberrations in other key signaling pathways and molecules, such as RAS/RAF/MEK, PI3K/AKT/mTOR, or MET kinase, have been identified as crucial targets, especially in resistant patients. Novel drugs aimed at these abnormalities are already in the clinic. This Review outlines the current state-of-the-art research for targeted therapy in NSCLC.

Advanced non-small-cell lung cancer in the elderly

Systemic chemotherapy provides improvement in both survival and quality of life for patients with advanced non-small-cell lung cancer (NSCLC). Elderly patients have more comorbidities and tend to tolerate more poorly aggressive chemotherapy and radiation therapy than younger individuals. Our purpose in this article is to summarize recent studies of single-agent chemotherapy and combination regimens with cytotoxic or targeted therapies in the management of elderly patients with advanced NSCLC. We have reviewed the available evidence in the literature to gauge the results of therapy for elderly patients with lung cancer. We found that single-agent chemotherapy remains the standard of care for nonselected elderly patients. Retrospective analyses suggest that the efficacy of platinum-based combination chemotherapy is similar in fit older and younger patients, with increased but acceptable toxicity for elderly patients. Therefore, the outcomes in the fit elderly mirror results observed in younger patients, although toxicity is generally greater.

A randomized phase II trial assessing in advanced non-small cell lung cancer patients with stable disease after two courses of cisplatin-gemcitabine an early modification of chemotherapy doublet with paclitaxel-gemcitabine versus continuation of cisplatin-gemcitabine chemotherapy (GFPC 03-01 Study)

BACKGROUND

There is no consensus on the optimal treatment for patients with advanced non-small cell lung cancer and stable disease after cisplatin-based chemotherapy. The objective of the trial was to evaluate a switch to a different dual-agent chemotherapy.

METHODS

Patients with stage IV non-small cell lung cancer and stable disease after two cycles of cisplatin (P) and gemcitabine (G) (P day1 (d(1)): 75 mg/m(2), G: 1250 mg/m(2) d(1) and d(8) every 3 weeks) were randomized to receive either two further cycles of PG (arm A) or paclitaxel (100 mg/m(2) d(1), d(8), d(15)) plus gemcitabine (1250 mg/m(2) d(1) and d(8), every 4 weeks) (arm B).

RESULTS

Two-hundred-twenty-eight patients were enrolled between October 2003 and August 2006. After two cycles of PG, 98 patients (43%) had stable disease; 87 were randomized: 45 to arm A and 42 to arm B. The objective response rates were 15.6% (6.5-29.4) and 21.4% (10.3-36.8) in arms A and B. Overall survival after randomization was 9.6 months (7.0-13.8) in arm A and 9.3 months (7.4-13.3) in arm B. Adverse events were similar in the two arms for hematological and non hematological toxicities.

CONCLUSIONS

Sequential first-line chemotherapy in these patients is feasible with no difference in response rates. These results do not warrant a phase III trial.

NCIC Clinical Trials Group experience of employing patient-reported outcomes in clinical trials: an illustrative study in a palliative setting

In this article we briefly review the experience of the National Cancer Institute of Canada (NCIC) Clinical Trials Group (CTG) with respect to the assessment of patient reported outcomes in clinical trials, and illustrate issues important to assessing symptom palliation in clinical trials of cancer therapy. We highlight a standard approach taken by the NCIC CTG, and illustrate how this approach may be applied to the complex problem of symptom control analysis in patients with locally advanced NSCLC. We further illustrate how variations in this analysis yield different apparent rates of palliation. Apparent rates of palliation critically depended on the outcome measures used: single symptom response across patients (5-32%, depending on the symptom of interest), symptom response in specific symptomatic patients (37-100%), symptom control (45-82%), index symptom response (60%), proportion of patients experiencing improvement in all symptoms (21%), or health-related quality of life (HRQoL) improvement (23%, global). Rates also varied substantively depending on which cohort of patients was considered relevant to each analysis (i.e., was included in the respective denominator). Substantive discordance in patients' apparent palliation was seen when HRQoL data were compared with symptom diary data. Appropriate and valid descriptions of palliative outcomes in clinical trials are complex undertakings. We conclude that several measures are required for a textured clinical description of outcome, and recommend reporting palliation according to individual symptom response rates and HRQoL response rates, in order to address each construct of palliation success.

Local control of regional and metastatic lesions and indication for systemic chemotherapy in patients with non-small cell lung cancer

Systemic chemotherapy is the mainstay of treatment in patients with advanced non-small cell lung cancer. Local control of regional and metastatic lesions may be needed before systemic therapy can be started in patients with pleural effusions or bone or brain metastases. The indication for systemic chemotherapy depends on the symptoms and performance status of the patient. In addition, a risk assessment considering complications such as hemodynamic and respiratory compromise by effusions, pathological bone fractures, and neurologic deterioration caused by brain metastases is critical in selecting which patients should receive first-line systemic chemotherapy before local therapy, although predictive factors for these complications have not yet been established. Chemotherapy has been considered to have only a limited role in the treatment of patients with pleural effusions and brain and bone metastases, but recently developed anticancer agents have shown substantial antitumor effects in these types of patients with a good general condition.

Shrinkage of Locally Advanced Non–Small-Cell Lung Cancers in Response to Induction Chemotherapy: Implications for Radiotherapy Treatment Planning

PURPOSE

To quantify the impact that changes in tumor volume after induction chemotherapy have on radiotherapy treatment planning for locally advanced non-small-cell lung cancer.

METHODS AND MATERIALS

An analysis of coregistered pre- and postchemotherapy tumor volumes in a Phase II study of induction chemotherapy delivered before radical radiotherapy.

RESULTS

Using the Response Evaluation Criteria In Solid Tumors measurement, 35% of patients had a partial response and 62% had stable disease after chemotherapy. Conversely, volumetric decreases in tumor size were seen in 95% of patients. Mean decreases in gross tumor volume and planning target volume were 37% and 26%, respectively. Using the smaller postchemotherapy tumor volume to plan radiotherapy treatment leads to a mean decrease in volume of lung receiving 20 Gy or greater of 3% (p < 0.005). Targeting the postchemotherapy volume also results in the delivery of a significant, although inhomogeneous, incidental dose of radiation to the rind of tissue formed around the shrinking tumor. Disease shrinkage is anisotropic, with greater displacements observed along anterior, posterior, and lateral margins. After chemotherapy, there is measurable blurring of the tumor's radiologic edge.

CONCLUSIONS

Modest decreases in tumor volume that are not reflected by the Response Evaluation Criteria In Solid Tumors measurement occur in most patients. Although targeting the postchemotherapy tumor may decrease lung toxicity, the magnitude of the benefit is small. Because this strategy runs the risk of increasing the marginal recurrence rate, it should be used with caution. Quantification of tumor shrinkage and margin blurring permits more accurate reconstruction of the prechemotherapy target volume.

Use of chemotherapy at the end of life in a Portuguese oncology center

GOALS OF WORK

Chemotherapy plays a major role in the treatment of cancer. However, it is sometimes thought of as being taken too far, being used in many cases close to death. The purpose of this study is to determine the proximity of chemotherapy use to the patient's death in our hospital.

MATERIALS AND METHODS

This study comprised the analysis of the charts of 1,064 patients aged over 16 years with solid tumors who died in 2002 and were treated at the Porto Section of the Portuguese Institute of Oncology.

MAIN RESULTS

Four hundred ten of the 1,064 patients (39%) underwent chemotherapy. Fifty-two percent of those that underwent chemotherapy did so in the last 6 months of their lives, 31% in the last 3 months, 13% in the last month, and 3% in the last week. In the context of the total cohort of 1,064, the percentages of those that underwent chemotherapy was 20, 12, 5, and 1%, respectively. By multivariate analysis, age <65 years, breast and lung cancers, and metastases were positively associated with chemotherapy; kidney cancer and comorbidity were associated with a lower probability of undergoing chemotherapy. Three hundred sixty-one patients (34%) were admitted to the palliative care unit of the hospital.

CONCLUSION

It was concluded that in this hospital, chemotherapy is not used as close to death as often as most professionals feel and the literature reports. There are various possible explanations for this discrepancy; one of them may be the influence of health care systems. It would be useful to see what is happening in other countries with different health care systems.

A novel triplet regimen with paclitaxel, carboplatin and gemcitabine (PACCAGE) as induction chemotherapy for locally advanced unresectable non small cell lung cancer (NSCLC)

Phase II study of 3 cycles of triplet induction chemotherapy (response, toxicity) followed by radiotherapy in locally advanced non small cell lung cancer (NSCLC).

BACKGROUND

Patients with locally advanced inoperable non-small cell lung cancer are currently treated with concomitant or sequential chemotherapy and radiotherapy. However, the outcome of existing treatment modalities is unsatisfactory. Development of new strategies including more efficient systemic chemotherapy is warranted.

OBJECTIVE

To study the antitumour activity and toxicity of a triplet combination of paclitaxel, carboplatin and gemcitabine as induction chemotherapy before radiotherapy, in locally advanced NSCLC and to evaluate time to progression and survival.

METHODS

Three cycles of paclitaxel (175 mg/m(2) by 3h infusion on day 1), carboplatin (AUC 5mg/(mlmin) by IV bolus on day 1) and gemcitabine (1000 mg/m(2) by IV bolus on day 1 and 8) were administered every 3 weeks in reasonably fit patients. Fractionated radiotherapy with curative intent was initiated 4 weeks after the last chemotherapy administration. Toxicity was assessed weekly during cycle 1 and on day 1 and 8 in cycles 2 and 3. Response evaluation was performed at the end of cycle 3.

RESULTS

Forty-eight patients (20 stage IIIA and 28 stage IIIB) received a total of 134 cycles of chemotherapy. Forty-two patients received the intended 3 cycles. Thirty patients obtained an objective response (1 complete and 29 partial response) or 62.5% on the intent to treat analysis (95% confidence interval: 49-76%). None of the responders became eligible for surgery. The median time to progression and survival for all patients was 10.1 and 15.7 month, respectively. A significant difference was observed in survival parameters between stage IIIA and stage IIIB patients. Haematological toxicity grade 3/4, mainly neutropenia and thrombocytopenia, was most prominent on day 15 of the treatment cycles. Haematological support by means of recombinant erythropoietin, red blood cell or platelet transfusion, filgrastim administration or a combination was needed in 21 patients. None of the patients discontinued chemotherapy because of haematotoxicity. Grade 3/4 non-haematological toxicity leading to chemotherapy withdrawal occurred early during induction (2 and 1 in cycles 1 and 2, respectively).

CONCLUSION

Three cycles of the novel triplet combination of paclitaxel, carboplatin and gemcitabine (PACCAGE) is an active and feasible induction regimen for patients with locally advanced inoperable NSCLC. Neutropenia and to a lesser extent thrombocytopenia represent the main haematological toxicity. Whether this triplet regimen can improve outcome when compared to specific cisplatin doublet regimens should be evaluated in a phase III study.

Management of cancer from an unknown primary

Treatment of cancer is reliant on identifying the organ of origin. However, in a significant minority of cases, the primary site is never identified. This paper reviews the diagnostic work-up and therapeutic management for patients presenting with unknown primary cancer, including the role of tumour markers, conventional pathology and positron emission tomography imaging. It is important to identify atypical presentations of known tumour types, such as extragonadal germ cell tumours, lymphomas and breast cancer. The results from chemotherapy trials performed in patients with unknown primary cancer are summarised. Few trials have included > 100 patients, and most are non-randomised. There is no clear standard of care from the available data, and no trials of chemotherapy versus best supportive care have been performed. Platinum is the mainstay of treatment regimens, and from the regimens tested, a taxane seems to be among the best of the cytotoxics to combine with platinum in terms of both tolerability and efficacy. There is no data to favour a three-drug combination over a two-drug combination. To improve on existing treatment, molecular techniques may provide a means to identify the organ of origin, and/or to select appropriate targeted therapies. Further research is needed to improve knowledge on the biology of cancer from an unknown primary and to develop more effective treatment.

The aggressiveness of cancer care in the last three months of life: a retrospective single centre analysis

BACKGROUND

There is concern that terminally ill cancer patients are over treated with chemotherapy, even when such treatment is unlikely to palliate symptoms. The study objective was to evaluate the use of chemotherapy in the last three months of life in a cohort of adult patients with advanced solid tumours.

METHODS

All adult patients with solid tumours who died in our hospital in 2003 and received chemotherapy for advanced cancer, were included. Detailed data concerning chemotherapy and toxicity, in the last three months of life, were collected from patients' clinical charts.

RESULTS

A total of 319 patients were included. Median age was 61 years. Median time from diagnosis of metastatic disease to death was 11 months. The proportion of patients who received chemotherapy in the last three months of life was 66% (n = 211), in the last month 37% and in the last two weeks 21%. Among patients who received chemotherapy in the last three months of life, 50% started a new chemotherapy regimen in this period and 14% in the last month. There was an increased probability of receiving chemotherapy in the last three months of life in younger patients and in patients with breast, ovarian and pancreatic carcinomas.

CONCLUSION

There was a large proportion of patients who received chemotherapy in the last three months of life, including initiation of a new regimen within the last 30 days. Thus, further study is needed to evaluate if such aggressive attitude results in better palliation of symptoms at the end of life.

Update in Cancer Pain Syndromes

Cancer pain assessment and management are integral to palliative medicine. This paper reviews recent publications in the period 1999-2004 in the broad categories of epidemiology, pain assessment, nonpharmacologic approaches to cancer pain (radiation therapy, anesthetic blocks, palliative surgery and chemotherapy, complementary and alternative medicine), and in nociceptive pain, neuropathic pain, visceral pain, and bone pain.

Cisplatin plus gemcitabine on days 1 and 4 every 21 days for solid tumors: Result of a dose-intensity study

BACKGROUND

Three and 4-week cisplatin-gemcitabine schedules have shown similar dose-intensity (DI) and activity in non-small-cell lung cancer (NSCLC). The 3-week schedule is generally preferred because it enables better treatment compliance. To improve DI and compliance further, we delivered gemcitabine plus cisplatin over 4 days every 21 days.

METHODS

Patients with any stage NSCLC or epithelial neoplasms and an ECOG PS < or = 2 were given gemcitabine 1000 mg/m(2) on days 1 and 4 plus cisplatin 70 mg/m(2) on day 2 of a 21-day cycle. Minimax design was used and a received DI for gemcitabine of > or = 580 mg/m(2)/wk was considered successful.

RESULTS

Thirty-nine patients (34 NSCLC, 5 epithelial neoplasias) were enrolled. SWOG grade 3-4 neutropenia and thrombocytopenia were observed in 17.9% and 12.8% of patients, respectively. Nonhematological toxicity was minimal. Twenty-eight (18%) of 158 cycles required dose modifications and/or delays. Twenty-five patients received a gemcitabine dose intensity of > or = 580 mg/m(2)/wk. The received DIs were 601.8 mg/m(2)/wk for gemcitabine and 21.0 for cisplatin, with a relative DIs of 90.3% and 90.1%, respectively. The response rate of 27 evaluable patients with NSCLC was 44% (95% confidence interval [CI], 25.3 to 62.7%).

CONCLUSIONS

The shorter schedule of gemcitabine on days 1 and 4 plus cisplatin on day 2 produces an effective DI and a toxicity profile comparable to that of weekly regimens.

Metaanalysis of the correlation between radiographic tumor response and patient-reported outcomes

BACKGROUND

The primary aim of the current study was to determine whether radiographic tumor response is associated with patient-reported outcomes such as symptom response or health-related quality of life.

METHODS

A metaanalysis was conducted of 21 available studies from 1995-2003 that provided data sufficient for examining the association between tumor response and patient-reported outcomes, including symptom response and health-related quality of life. A second aim was to examine the influence of possible moderating study variables on effect size variation.

RESULTS

As hypothesized, patient-reported outcome improvement rates were most frequently associated with patients classified as a complete or partial response (CR/PR), followed by those with stable disease (SD) and progressive disease (PD). Moderate effect sizes were observed between the CR/PR and SD (effect size of 0.35) and CR/PR and PD categories (effect size of 0.43). A weak effect size was found between SD and PD (effect size of 0.16), raising concern over the meaningfulness of the SD category. No significant correlations were found between effect size and patient or study characteristics. Significant associations existed between treatment duration and age, study duration, survival, and symptom response rates, especially among PD patients.

CONCLUSION

Despite significant study-to-study heterogeneity, an important association exists in the correlation between tumor response and formal measures of change in patient-reported outcomes. A better understanding of this relation would be enhanced if future reports included estimates of effect size in patient-reported outcome change by tumor response category. Practical implications, limitations, and directions for future research are provided.

State of the art in therapy for non-small cell lung cancer

The treatment of lung cancer has changed rapidly over the last few years and now more than ever a multi-disciplinary approach is vital to patient care. Surgical resection remains the mainstay of treatment for patients with operable disease. Recent studies have clearly demonstrated the survival benefits of adjuvant chemotherapy and this is now considered the standard of care. Despite efforts to improve early detection the majority of patients present with advanced lung cancer. The combination of radiation and chemotherapy should be considered for patients with locally advanced disease. Chemotherapy and the newer generation of molecularly targeted agents, provide quality of life benefits and modest gains in survival for patients with metastatic disease. Though there is room for improvement there is no justification for the therapeutic nihilism once surrounding the treatment of lung cancer.

Mitomycin C, vinblastine and cisplatin (MVP): an active and well-tolerated salvage regimen for advanced breast cancer

This phase II study assessed the clinical efficacy and tolerability of a combination of mitomycin C, vinblastine and cisplatin in patients with metastatic breast cancer (MBC) previously treated with chemotherapy. A total of 87 patients with MBC, most of whom had been exposed to anthracyclines (92%) and/or taxanes (29%) in the adjuvant and/or metastatic setting, were treated with mitomycin C (8 mg m⁻² day 1 cycles 1, 2, 4 and 6), vinblastine (6 mg m⁻² day 1) and cisplatin (50 mg m⁻² day 1) repeated each 21 days for a maximum of six cycles. The overall response rate (ORR) was 32% (95% CI: 22–42%) with 31% partial response (PR) and one complete response (CR). Stable disease (SD) rate was 21% (95% CI: 12–29%). There was no statistically significant difference in the ORR when MVP was given as the first-line treatment for MBC vs second or subsequent line (38 vs 30%, P=0.6), or between patients with an early (<6 months) vs late (>6 months) relapse post-anthracyclines (30 vs 52%, P=0.3). Toxicity profile was mild. This platinum-based chemotherapy is an effective, well-tolerated and low-cost regimen for patients with MBC, including those pretreated with anthracyclines.

The palliative benefits of MVP (mitomycin C, vinblastine and cisplatin) chemotherapy in patients with malignant mesothelioma

BACKGROUND

With the rising incidence of malignant mesothelioma (MM), it is important to optimise treatment to control symptoms, maintain quality of life and, if possible, prolong life. We have analysed prospectively collected data to evaluate a frequently used palliative chemotherapy regimen.

PATIENTS AND METHODS

Between October 1986 and May 2002 all patients with inoperable pleural mesothelioma were considered for treatment with MVP (mitomycin C 8 mg/m2 every 6 weeks, vinblastine 6 mg/m2 every 3 weeks and cisplatin 50 mg/m2 every 3 weeks) chemotherapy. Symptoms were assessed by physician assessment at baseline and after each cycle of chemotherapy.

RESULTS

One hundred and fifty patients were treated with MVP for mesothelioma. Forty-three per cent had a performance status (PS) 2 or worse. The response rate was 15.3%, with 68.6% having stable disease. Sixty-nine per cent reported an improvement in symptoms; in particular there were good responses for pain (71%), cough (62%) and dyspnoea (50%). The most common grade 3/4 toxicity was neutropenia (22%). Median overall survival was 7 months, with 1-year survival 31% and 2-year survival 11%. Median survival for patients with PS 0/1 was 10 months, and was 6 months for patients with PS 2/3. Poor prognostic factors in univariate analysis included poor PS, weight loss, mixed or sarcomatoid histology, low haemoglobin and high white blood cell count. Excluding pathological subtype, the prognostic significance of poor PS and weight loss were retained in multivariate analysis.

CONCLUSIONS

Palliation of symptoms in MM is achievable with current cisplatin-based treatments.

Patients preferences in chemotherapy for advanced non-small-cell lung cancer

OBJECTIVE

To determine how Japanese patients with lung cancer weigh potential survival, chemotherapy response rate, and symptom relief against the potential toxicity of different treatments in cancer chemotherapy.

METHODS AND PATIENTS

We used a questionnaire describing a hypothetical situation about stage IV non-small-cell lung cancer. Seventy-three patients with lung cancer who had received chemotherapy and 120 patients with other respiratory disease as the control group were asked to rate the minimal benefit that would make two hypothetical treatments acceptable. For "chance of cure," "response but not cure," and "symptom relief," the subjects could give answers from 1% to 100% and for prolonging life could give answers from 1 to 60 months.

RESULTS

Patients with lung cancer were significantly more likely than were patients with other respiratory diseases to accept either intensive or less-intensive treatments for a potentially small benefit for "chance of cure," "response but not cure," and "symptom relief". The degree of survival advantage that patients require before accepting cancer treatment with its associated toxicity varied widely. If their lives were prolonged 3 months, 19% and 21% of patients with lung cancer would choose to receive intensive and less-intensive treatment, respectively. When the chance of symptom relief was 70%, 73% of patients with lung cancer were willing to choose intensive chemotherapy. Factor associated with patients' choice of chemotherapy in both groups was age.

CONCLUSION

Oncologists must consider the substantial range of attitudes to chemotherapy among patients when making treatment decisions and they must give patients the opportunity to be included in this process.

Lung cancer

Lung cancer is the leading cause of cancer-related mortality. Since tobacco smoking is the cause in vast majority of cases, the incidence of lung cancer is expected to rise in those countries with high or rising incidence of tobacco smoking. Even though populations at risk of developing lung cancer are easily identified, mass screening for lung cancer is not supported by currently available evidence. In the case of non-small cell lung cancer, a cure may be possible with surgical resection followed by post-operative chemotherapy in those diagnosed at an early stage. A small minority of patients who present with locally advanced disease may also benefit from pre-operative chemotherapy and/or radiation therapy to down stage the tumor to render it potentially operable. In a vast majority of patients, however, lung cancer presents at an advanced stage and a cure is not possible with currently available therapeutic strategies. Similarly, small cell lung cancer confined to one hemi-thorax may be curable with a combination of chemotherapy and thoracic irradiation followed by prophylactic cranial irradiation, if complete remission is achieved at the primary site. Small cell lung cancer that is spread beyond the confines of one hemi-thorax is, however, considered incurable. In this era of molecular targeted therapies, new agents are constantly undergoing pre-clinical and clinical testing with the aim of targeting the molecular pathways thought be involved in etiology and pathogenesis of lung cancer.

Quality‐of‐Life Considerations in Patients with Advanced Lung Cancer: Effect of Topotecan on Symptom Palliation and Quality of Life

Key goals in the treatment of lung cancer are to improve both survival and quality of life (QOL). While formal techniques are frequently used to evaluate survival and response, such rigor is used less often in assessing the impact of treatment on quality of life. Many patients with lung cancer are elderly and have complex medical histories and a myriad of comorbidities. In these patients, with limited survival expectations, symptom palliation, quality of life, and convenience of therapy are especially important end points. Indeed, clinical trials are now incorporating symptom scores and QOL outcomes in their designs (now combined as "patient reported outcomes" or PROs). Moreover, symptom palliation correlates well with QOL and survival duration, providing further rationale for therapy selection based on these parameters. The potential palliative and QOL benefits of chemotherapy have been investigated for several agents in lung cancer trials. Of these, topotecan (Hycamtin; GlaxoSmithKline; Philadelphia, PA) is the best characterized in relapsed small cell lung cancer (SCLC). In a phase III trial of topotecan versus cyclophosphamide, doxorubicin (Adriamycin; Bedford Laboratories; Bedford, OH), and vincristine (Oncovin; Eli Lilly and Company; Indianapolis, IN) (CAV) in patients with recurrent SCLC, topotecan was associated with statistically significant (p < 0.05) improvements in general symptoms (e.g., fatigue and interference with daily activity) and disease-specific symptoms (e.g., dyspnea and hoarseness). Moreover, the introduction of oral therapies, such as oral topotecan, may increase the convenience of therapy by reducing the time needed for therapy and the need for frequent venipuncture. This review summarizes the role of chemotherapy in symptom palliation, with an emphasis on the impact of topotecan therapy on symptom parameters in patients with relapsed SCLC and the emerging role of oral therapy in this setting.

Differences of Opinion

STUDY OBJECTIVES

To quantify clinician knowledge and bias regarding the role of chemotherapy for stage IV non-small cell lung cancer (NSCLC).

DESIGN, SETTING, AND PARTICIPANTS

A 16-question, multiple-choice questionnaire was sent to all Australian general internists, pulmonary and palliative care physicians, medical and radiation oncologists, and thoracic surgeons to assess beliefs concerning the role of chemotherapy in metastatic NSCLC. An overall assessment of "pessimism" and "optimism" regarding the role of chemotherapy in metastatic NSCLC was made, and knowledge of specific outcome measures was evaluated.

MEASUREMENTS AND RESULTS

A total of 1,325 questionnaires were mailed, with 679 replies (51%) received and 544 replies (41%) assessable. Overall, 60% of respondents were deemed to have good knowledge. There was a wide variation in knowledge between specialist groups (p < 0.0001), with more medical oncologists (76%) but fewer thoracic surgeons (35%) and general internists (50%) with good knowledge. Fewer medical oncologists (6%) were classified as pessimistic compared with palliative care physicians (31%), radiation oncologists (28%), or pulmonary physicians (22%). Sixty-eight percent of respondents agreed that most patients receiving chemotherapy have symptomatic improvement. More medical oncologists (77%) and pulmonary physicians (73%), but fewer general internists (55%) and palliative care physicians (57%) agreed with this. Medical oncologists were far more likely to agree that chemotherapy was of benefit in patients aged > or = 70 years compared with any of the other specialist groups.

CONCLUSIONS

There were significant differences regarding the perceived role of chemotherapy in metastatic disease between the various specialty groups involved in the treatment of NSCLC. Many clinicians had a poor understanding of contemporary data regarding the use of chemotherapy in metastatic NSCLC. This study raises substantial issues regarding the beliefs of clinicians treating NSCLC and emphasizes the importance of multidisciplinary assessment.

Chimiothérapie en pratique de routine des cancers bronchiques non à petites cellules (CBNPC) localement avancés ou métastasés

BACKGROUND

Patients in ANCCLC chemotherapy-trials are not representative of the general lung cancer population. The purpose of this study was to describe the ANCCLC population routinely treated by chemotherapy in a general hospital, and to assess the results of chemotherapy in this population.

METHODS

All newly diagnosed IIIB/IV ANCCLC chemotherapy-treated patients over a three-year period were prospectively assessed for response rate, toxicity and survival.

RESULTS

Seventy seven patients (70% stage IV, 69% PS 1/0, 30% with cerebral metastases, 60% ineligible for major lung trials) received first-line chemotherapy (cisplatine or paraplatine with vinorelbine) with tumor control in 31 (40%) and symptom improvement in 20 (26%) patients. 17 (22%) patients experienced febrile neutropenia. 33 (43%) patients received second line chemotherapy (gemcitabine) with tumor control in 12 (36%) and symptom improvement in 9 (27%) patients. Overall median survival was 7 months and 30% patients were alive at 1 year.

CONCLUSIONS

Routinely ANCCLC chemotherapy-treated patients in our center have poor prognostic factors and many comorbidities. Chemotherapy results in tumor control in 43% patients, - of whom two thirds have symptom improvement -, with a high rate of febrile neutropenia.

Do patients with weight loss have a worse outcome when undergoing chemotherapy for lung cancers?

To examine whether weight loss at presentation influences outcome in patients who received chemotherapy for lung cancer or mesothelioma. Multivariate analysis of prospectively collected data 1994–2001. Data were available for age, gender, performance status, histology, stage, response, toxicity, progression-free and overall survival. The outcomes of patients with or without weight loss treated with chemotherapy for small cell lung cancer (SCLC; n=290), stages III and IV non-small-cell lung cancer (NSCLC; n=418), or mesothelioma (n=72) were compared. Weight loss was reported by 59, 58 and 76% of patients with SCLC, NSCLC and mesothelioma, respectively. Patients with weight loss and NSCLC (P=0.003) or mesothelioma (P=0.05) more frequently failed to complete at least three cycles of chemotherapy. Anaemia as a toxicity occurred significantly more frequently in NSCLC patients with weight loss (P=0.0003). The incidence of other toxicities was not significantly affected by weight loss. NSCLC patients with weight loss had fewer symptomatic responses (P=0.001). Mesothelioma patients with weight loss had fewer symptomatic (P=0.03) and objective responses (P=0.05). Weight loss was an independent predictor of shorter overall survival for patients with SCLC (P=0.003, relative risk (RR)=1.5), NSCLC (P=0.009, RR=1.33) and mesothelioma (P=0.03, RR=1.92) and an independent predictor of progression-free survival in patients with SCLC (P=0.01, RR=1.43). In conclusion, weight loss as a symptom of lung cancer predicts for toxicity from treatment and shorter survival.

Chemotherapy for cancer patients who present late

Doctors should not overlook the potential benefits of chemotherapy in patients with incurable cancer

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.

Nucleotide-based therapies targeting clusterin chemosensitize human lung adenocarcinoma cells both in vitro and in vivo

Introduction: Lung cancer is highly lethal and resistant to most anticancer interventions. Treatment resistance is mediated, in part, by enhanced expression of cell survival proteins that help facilitate tumor progression. Clusterin is a stress-associated cytoprotective protein up-regulated by various apoptotic triggers in many cancers and confers treatment resistance when overexpressed. The objectives in this study were to evaluate clusterin expression levels in human lung cancer tissue, and to test effects of clusterin silencing using antisense oligonucleotides (ASOs) and short interfering double-stranded RNAs (siRNAs) on chemosensitivity in human lung cancer A549 cells. Methods: Clusterin immunostaining was evaluated in a tissue microarray of 149 spotted human lung cancers. The effects of clusterin ASO or siRNA treatment on clusterin expression and chemosensitivity to paclitaxel was examined in A549 cells in vitro while the ability of clusterin ASO to chemosensitize in vivo was evaluated in immunocompromised mice bearing A549 tumors. Results: More than 80% of human non-small cell lung cancers are immunoreactive for clusterin. Clusterin ASO or siRNA decreased clusterin mRNA expression in A549 cells &gt;75% in a dose-dependent, sequence-specific manner, and significantly enhanced chemosensitivity to paclitaxel in vitro. Characteristic apoptotic DNA laddering was observed after combined treatment with ASO plus paclitaxel, but not with either agent alone. In vivo administration of clusterin ASO, compared to mismatch control oligonucleotide, synergistically enhanced the effects of paclitaxel or gemcitibine to significantly delay A549 tumor growth. Conclusion: These findings identify clusterin as a valid therapeutic target in strategies employing novel multimodality therapy for advanced lung cancer.

Clinical Issues in the Management of Non–Small-Cell Lung Cancer and the Role of Platinum-Based Therapy

Although the benefits of chemotherapy have been established for treating non-small-cell lung cancer (NSCLC), several clinical issues remain. Currently, doublets offer the maximum benefit in terms of balancing efficacy with tolerability to patients with advanced-stage disease. The optimal duration of therapy continues to be evaluated, and several agents have emerged for treating patients with recurrent advanced NSCLC. Chemotherapy benefits for populations underrepresented in clinical trials, such as elderly patients and patients with poor performance status, also need to be established. Although combination therapy with carboplatin/paclitaxel is one regimen of choice for treating advanced NSCLC, there may be ways to optimize its delivery schedule including use of weekly administration of paclitaxel and monthly administration of carboplatin. In addition, biologic approaches are being investigated to determine if these agents may be appropriate for treating patients with advanced NSCLC and how best to administer them. In resectable stage IIIA disease, benefits of preoperative chemotherapy and chemotherapy/radiation therapy followed by surgery continue to be evaluated. Although associated with esophageal toxicity, in non-resectable stage IIIA/IIIB disease, concurrent chemotherapy/radiation therapy has emerged as the schedule of choice. Yet, benefits of higher radiation dosage need evaluation. Based on phase II studies, preoperative chemotherapy with or without radiation may benefit patients with early-stage disease, but studies have been inconclusive, yielding mixed results. Recent trials of adjuvant chemotherapy following surgical resection in early-stage NSCLC have yielded conflicting results, with some trials showing no benefit to adjuvant therapy. Trials under way will determine the future of adjuvant or induction chemotherapy in treating this patient population.

Docetaxel and cisplatin in patients with advanced non small-cell lung cancer (NSCLC): a multicenter phase II trial

We examined the safety and efficacy of the docetaxel/cisplatin combination in patients with advanced, previously untreated NSCLC and evaluated changes in quality of life over time. Docetaxel was administered before cisplatin (both 75 mg/m2, 1-hour infusions) every 3 weeks to 47 patients with stage IIIB or stage IV NSCLC. Patients also received premedication of oral dexamethasone. The median age (range) of patients was 62 (45-78) years and 26 patients (55.3%) had adenocarcinoma. Of the 40 patients evaluable for response, one achieved a complete response and 14 had partial responses; the response rate was 37.5% (95% confidence intervals; 22.5, 52.5). In the intent-to-treat population the overall response rate was 31.9%. Time to response ranged from 3 to 20 weeks, and the median duration of response was 34.6 weeks. Median survival and median time to progression were 11.3 months and 18.9 weeks, respectively. One-year survival was 40%. Grade 3 or 4 neutropenia and febrile neutropenia were observed in 74.4% and 12.8% of patients, respectively. Severe asthenia was seen in 14.9% of patients. Other grade 3 or 4 toxicities included nausea (eight patients), vomiting (five), neurosensory effects (six), neuromotor effects (five), diarrhea (four), and infection (three). There was an improvement in emotional well-being; however, the overall quality of life score did not change with treatment. Docetaxel administered in combination with cisplatin is an active regimen in patients with NSCLC. This regimen of docetaxel (75 mg/m2) and cisplatin (75 mg/m2) repeated at 3-week intervals is being evaluated in an ongoing Eastern Cooperative Oncology Group (ECOG) randomized study in patients with advanced and metastatic NSCLC.