Pemetrexed for treatment of advanced non-small cell lung cancer

Serum Homocysteine and Vitamin B12 as Biomarkers for Haematological Toxicity in Lung Adenocarcinoma Treated With Pemetrexed

Background Serum homocysteine (Hcy) and vitamin B12 (VitB12) were investigated as serological markers for the prediction of pemetrexed induced haematological toxicity in patients with adenocarcinoma of the lung.

Material and Methods A total of 35 lung adenocarcinoma patients who received pemetrexed chemotherapy as first-line treatment were included in the present study. The patients received pemetrexed 500 mg/m2 once every three weeks until disease progression. Serum Hcy and VitB12 levels were analysed prior to chemotherapy. Haematological toxicities (leucopenia, neutropenia and thrombocytopenia) were graded for each cycle of chemotherapy. Serum Hcy and VitB12 concentrations were compared between grades 0-1 and 2-4 haematological toxicity groups.

Results A total of 151 chemotherapy cycles were administered to 35 lung adenocarcinoma patients. However, the serum Hcy and VitB12 concentration were only examined and recorded in 61 out of the 151 chemotherapy cycles. For the 61 cycles, grade 2-4 leucopenia, neutropenia and thrombocytopenia were observed in 21, 20 and 10 cases, respectively. Serum Hcy levels were 14.91±4.67 μg/ml, 15.50±4.35 μg/ml and 16.04±4.90 μg/ml for grade 2-4 leucopenia, neutropenia and thrombocytopenia, respectively, which were significantly higher than those of grade 0-1 groups (p<0.05). However, serum VitB12 were not statistically different between grade 0-1 and 2-4 haematological toxicity groups (p>0.05). The area under the ROC curve (AUC) were 0.73 (0.58-0.88), 0.80 (0.66-0.94), 0.75 (0.57-0.93) for serum Hcy and 0.65 (0.50-0.79), 0.64 (0.49-0.78), 0.68 (0.49-0.87) for serum VitB12 as predictive biomarkers of grade 2-4 leucopenia, neutropenia and thrombocytopenia, respectively.

Conclusion Pre-chemotherapy serum Hcy appeared to correlate with haematological toxicity and may be a useful biomarker for predicting severity of pemetrexed induced haematological toxicity.

Predictive role of erythrocyte macrocytosis during treatment with pemetrexed in advanced non-small cell lung cancer patients

OBJECTIVES

Pemetrexed has been approved for the treatment of advanced non-small cell lung cancer (NSCLC) non-squamous histology, both as first- and second-line therapy. Pemetrexed is an antimetabolite drug, that inhibits enzymes involved in nucleotides bio-synthesis arresting cancer cells cycle. The aim of this study was the evaluation of the impact of pemetrexed on erythrocyte mean corpuscular volume (MCV) change and its possible correlation with disease control rate (DCR), progression free (PFS) and overall survival (OS) in NSCLC patients.

MATERIALS AND METHODS

A retrospective collection of clinical and laboratory data (including basal MCV and maximum MCV occurred during therapy) in advanced NSCLC patients treated with pemetrexed at seven Italian centers was performed. Nonparametric tests, univariate and multivariate analysis were used to assess correlation between variables and to identify predictors of outcomes.

RESULTS

191 patients were enrolled: median age 62, 60% male, 61% performance status (PS) 0, 91% stage IV, 88% adenocarcinoma histotype, 25% never smoker, 62% received pemetrexed as first-line. Mean MCV significantly increased from basal (89fL) to during treatment (94fL), with mean ΔMCV=4fL. The median time from therapy start to maximum MCV was 2.2 months. Median PFS was 7 [CI95% 6-8] and 3 [CI95% 2-4] months [P=0.0016], and median survival was 17 [CI95% 12-23] and 10 [CI95% 8-12] months [P=0.02], in patients with ΔMCV>5fL (n=80) and ΔMCV≤5fL (n=111), respectively. Multivariate analysis identified age ≥62, PS 0, adenocarcinoma histology and ΔMCV>5fL as independent predictors of longer PFS. A ΔMCV>5fL significantly correlates with DCR.

CONCLUSION

Pemetrexed induces macrocytosis. ΔMCV>5fL on pemetrexed therapy correlated with better DCR, PFS and OS. These results deserve further validation in prospective studies.

Pemetrexed Versus Pemetrexed and Carboplatin As Second-Line Chemotherapy in Advanced Non–Small-Cell Lung Cancer: Results of the GOIRC 02-2006 Randomized Phase II Study and Pooled Analysis With the NVALT7 Trial

Purpose

To compare efficacy of pemetrexed versus pemetrexed plus carboplatin in pretreated patients with advanced non–small-cell lung cancer (NSCLC).

Patients and Methods

Patients with advanced NSCLC, in progression during or after first-line platinum-based chemotherapy, were randomly assigned to receive pemetrexed (arm A) or pemetrexed plus carboplatin (arm B). Primary end point was progression-free survival (PFS). A preplanned pooled analysis of the results of this study with those of the NVALT7 study was carried out to assess the impact of carboplatin added to pemetrexed in terms of overall survival (OS).

Results

From July 2007 to October 2009, 239 patients (arm A, n = 120; arm B, n = 119) were enrolled. Median PFS was 3.6 months for arm A versus 3.5 months for arm B (hazard ratio [HR], 1.05; 95% CI, 0.81 to 1.36; P = .706). No statistically significant differences in response rate, OS, or toxicity were observed. A total of 479 patients were included in the pooled analysis. OS was not improved by the addition of carboplatin to pemetrexed (HR, 90; 95% CI, 0.74 to 1.10; P = .316; P heterogeneity = .495). In the subgroup analyses, the addition of carboplatin to pemetrexed in patients with squamous tumors led to a statistically significant improvement in OS from 5.4 to 9 months (adjusted HR, 0.58; 95% CI, 0.37 to 0.91; P interaction test = .039).

Conclusion

Second-line treatment of advanced NSCLC with pemetrexed plus carboplatin does not improve survival outcomes as compared with single-agent pemetrexed. The benefit observed with carboplatin addition in squamous tumors may warrant further investigation.

Chemotherapy Given Near the End of Life by Community Oncologists for Advanced Non‐Small Cell Lung Cancer

PURPOSE

To characterize the chemotherapy given near the end of life to advanced non-small cell lung cancer (NSCLC) patients treated in the community oncology setting using a medical records database.

METHODS

We conducted a retrospective chart review of expired advanced (stage IIIb/IV) NSCLC patients treated with chemotherapy. Patients who initiated chemotherapy in 2000-2003 were eligible. Patient demographics, all chemotherapy including dose and schedule, and disease-related events were collected.

RESULTS

We report data from 10 community practices including 417 patients treated for advanced NSCLC in 2000-2003. The mean age was 67 years (median, 62 years) and 54% were male. Forty percent of patients were >69 years of age and 35% had an Eastern Cooperative Oncology Group performance status score of > or =2. First-line chemotherapy included combination therapy in 84% of patients. Second-line therapy was given to 56% of patients. Twenty-six percent of patients received third-line therapy, while 10% received fourth-line therapy and 5% received fifth-line therapy or greater. Patients received a mean of 6.1 cycles of chemotherapy. For patients receiving chemotherapy at the time of death, the mean line of therapy being given was second line. Chemotherapy was given within 1 month and 2 weeks of death to 43% and 20% of patients, respectively.

CONCLUSION

The availability of new chemotherapeutic agents has caused a subsequent increase in the length of time patients are receiving chemotherapy with advanced NSCLC. This would suggest an increased use of chemotherapy near the end of life, which was identified in this study.

Combination treatment of CC531-lac-Z rat liver metastases by chemoembolization with pemetrexed disodium and gemcitabine

PURPOSE

The aim of this study was to evaluate the combination effect of pemetrexed disodium (MTA; Alimta; LY 231514) and gemcitabine (GEM) administered by hepatic artery and portal vein chemoembolization (HACE and PVCE) in a colorectal cancer rat liver metastasis model.

MATERIALS AND METHODS

Proliferation studies on CC531-lac-Z rat colon cancer cells were performed using the MTT assay to obtain the optimal combination schedule of the two antineoplastic agents. To generate diffuse liver metastasis, 4 x 10(6) tumor cells were implanted into the portal vein of male WAG/Rij rats. MTA (30 mg/kg, 60 mg/kg, and 90 mg/kg) was administered locoregionally by portal vein chemoembolization (PVCE) and compared with repeated systemic intravenous injection. GEM (50 mg/kg) was also given locoregionally by hepatic artery chemoembolization (HACE) as well as systemically. All routes of administration were examined alone as well as in combination. Efficacy of treatment in terms of liver metastases burden was determined at the end of the experiment by measuring the beta-galactosidase activity of CC531-lac-Z cells with a chemoluminescence assay.

RESULTS

Combination experiments in vitro showed a more than additive tumor cell reduction after sequential exposure to MTA preceding GEM (observed/expected ratio [O/E] = 0.73). Experiments with the reverse sequence (GEM-->MTA) resulted only in additive combination effects (O/E ratio = 1.08). Simultaneous drug exposure showed less than additive combination effects (O/E ratios > or = 1.25). In vivo, locoregional administration by HACE with GEM was significantly more effective than systemic intravenous bolus treatment (P = 0.03). Portal vein chemoembolization with MTA performed immediately after tumor cell inoculation was ineffective. Repeated systemic treatment with MTA yielded a slight reduction in tumor cell load that was significant versus control at the medium and high doses (60 mg/kg, P = 0.009; 90 mg/kg, P = 0.046) but not versus intraportal chemoembolization. The combination treatment of systemic (60 and 90 mg/kg) or locoregional (60 mg/kg) MTA with HACE using GEM (50 mg/kg) resulted in more than 80% tumor growth inhibition; this antineoplastic combination effect was maximally additive.

CONCLUSION

A regimen-dependent synergistic combination effect of both drugs was found in vitro. In animals, hepatic artery chemoembolization with GEM was superior to systemic intravenous bolus treatment. Portal vein chemoembolization with MTA was ineffective. The optimal in vitro regimen of MTA (intravenous or PVCE) preceding GEM (HACE) resulted in a maximally additive tumor growth inhibition. The results indicate that MTA and GEM can successfully be combined and favor further evaluation in patients.

Treatment approaches in patients with advanced non-small cell lung cancer and poor performance status

It is estimated that 30% to 40% of patients with advanced non-small cell lung cancer (NSCLC) have a poor performance status (PS)-defined as a score of 2 or higher on the Eastern Cooperative Oncology Group scale-because of their disease burden, comorbidities, or both. Survival is shorter in these patients than in those with a better PS, and they do not tolerate chemotherapy as well. There is now evidence that PS2 patients with advanced NSCLC can benefit from single-agent chemotherapy with drugs such as vinorelbine, gemcitabine, paclitaxel, pemetrexed, and docetaxel and that combination chemotherapy may have additional advantages. The optimal treatment for PS2 patients with NSCLC, however, has yet to be determined. The case histories in this article demonstrate that PS2 patients are a heterogeneous group and that selecting the chemotherapy for each patient must take into consideration comorbidities and disease-related symptoms, as well as the potential toxicity of treatment. Large prospective clinical trials are needed to determine whether, and in which patients, combination chemotherapy or novel agents, such as the epidermal growth factor receptor inhibitors or paclitaxel poliglumex, have advantages. Three large phase III trials-Selective Targeting for Efficacy in Lung Cancer, Lower Adverse Reactions trials (STELLAR)-are now being conducted in PS2 patients with NSCLC. It is hoped that their findings will aid in determining the best treatment options for these patients.

Overview of the Current Status of Human Epidermal Growth Factor Receptor Inhibitors in Lung Cancer

Although chemotherapy remains the standard of care for lung cancer, new less toxic drugs are urgently needed. Targeted agents represent a new era in cancer therapy, and non-small-cell lung cancer (NSCLC) is at the forefront of many development programs. An exciting target is the human epidermal growth factor receptor (EGFR, ie, HER1), and agents targeting this receptor, including gefitinib, cetuximab, and erlotinib (OSI-774; Tarceva), are being investigated. These agents have antitumor activity and are less toxic than most therapies. Based on phase II data, gefitinib received US approval for third-line treatment of patients with locally advanced or metastatic NSCLC. Cetuximab is licensed in the United States for patients with metastatic colorectal carcinoma. However, erlotinib, recently approved in the United States for second- and third-line treatment of patients with locally advanced or metastatic NSCLC, is the only agent of this class to improve survival as monotherapy in patients with advanced, refractory NSCLC, as shown in a phase III placebo-controlled trial. Phase III trials of erlotinib and gefitinib combined with chemotherapy were disappointing, which could be the result of drug scheduling, chemotherapy combinations, or other factors. Patient characteristics may also affect outcome, and research is ongoing to identify predictive markers of response to enable patient selection and improve outcome. Recently identified mutations within the HER1/EGFR tyrosine kinase (TK) domain may provide insight into why some patients respond rapidly to HER1/EGFR tyrosine kinase inhibitors. Surrogate markers of efficacy are also being investigated, including rash, which could be used to monitor and optimize antitumor activity. Therefore, although more work is required, data indicate that HER1/EGFR inhibitors will play an important role in treating patients with NSCLC.