Phase III randomized trial comparing moderate-dose cisplatin to combined cisplatin and carboplatin in addition to mitomycin and ifosfamide in patients with stage IV non-small-cell lung cancer

Objective Measurements of Physical Function to Predict Survival in Patients with Metastatic Cancer

BACKGROUND/OBJECTIVES

Physician-reported performance status (PS) constitutes the established method for stratifying oncologic patients in therapeutic decision-making. Objective measurements of physical function may further refine prognostication.

SUBJECTS/METHODS

In this prospective observational study, 103 patients with metastatic cancer who were referred for systemic therapy initiation were evaluated. PS was evaluated using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and five objective physical function measurements (handgrip strength [HGS], chair stand test [CST], timed up and go [TUG] test, 4-m gait speed [GS] test, and short physical performance battery [SPPB] test). Overall survival and treatment complications were recorded from the medical records.

RESULTS

Patients with low PS according to ECOG-PS (hazard ratio [HR]: 3.80, 95% confidence interval [CI]: 1.84, 7.80), HGS (HR: 2.37, 95% CI: 1.24, 4.55), SPPB (HR: 3.43, 95% CI: 1.55, 7.57), GS (HR: 3.03, 95% CI: 1.44, 6.38), and TUG (HR: 5.16, 95% CI: 2.19, 12.14) had shorter overall survival after adjustment for sex, age, symptomatology, comorbidity, percentage of weight loss, and tumor localization.

CONCLUSIONS

Among the studied objective physical function measurements, HGS, SPPB, GS, and TUG were independent predictors of survival in a sample of patients with metastatic cancer, with TUG showing the highest effect size.

Chemotherapy of lung cancer: A global perspective of the role of ifosfamide

The oxazaphosphorine cytostatic ifosfamide (IFO) has been successfully integrated in the treatment of various hematological and solid tumors. The purpose of this review is to summarize the evidence for its use in lung cancer starting from basic data of preclinical studies followed by a global summary of the phase III and seminal phase II clinical studies. Global in double respect: first covering both the small cell as well as the non-small cell indications, and, second tracing those studies performed in Europe and the United States as well as those from Asian countries.

A phase III randomised trial comparing sequential chemotherapy using cisplatin-based regimen and paclitaxel to cisplatin-based chemotherapy alone in advanced non-small-cell lung cancer

BACKGROUND

The purpose of this study is to determine whether in advanced non-small-cell lung cancer (NSCLC), the sequential administration of cisplatin-based chemotherapy and paclitaxel (Taxol) is superior to a cisplatin-based chemotherapy, followed by paclitaxel as salvage treatment.

PATIENTS AND METHODS

A total of 485 chemotherapy naive patients with advanced NSCLC were treated with three courses of GIP (gemcitibine + ifosfamide + cisplatin), consisting of cisplatin 50 mg/m(2) on day 1, ifosfamide 3 g/m(2) on day 1 and gemcitabine 1 g/m(2) on days 1 and 8. Patients with nonprogressive disease were then randomised to further similar courses of GIP or courses of paclitaxel (225 mg/m(2) over 3 h every 3 weeks).

RESULTS

Objective response or nonprogression after induction GIP occurred in 174 and 115 patients, respectively. After randomisation, there were 140 patients in the GIP arm and 141 in the paclitaxel arm. In terms of postrandomisation survival, there was no statistically significant difference (P = 0.17) between the two arms. Median times were 9.7 [95% confidence interval (CI) 7.8-11.6] and 11.9 (95% CI 9.4-14.3) months for paclitaxel and GIP, respectively. Multivariate analysis demonstrated that sex and haemoglobin were independent prognostic factors. After adjustment for these factors, the observed hazard ratio was 0.81 (95% CI 0.63-1.04) in favour of GIP (P = 0.10). Toxicity was tolerable; there was a significantly higher rate of grades III/IV thrombocytopenia with GIP and more alopecia with paclitaxel.

CONCLUSION

Sequential chemotherapy using cisplatin-based regimen followed by paclitaxel does not result in better outcome than cisplatin-based chemotherapy using taxane as salvage treatment.

Randomized Phase II Designs in Cancer Clinical Trials: Current Status and Future Directions

Purpose

Randomized phase II (RPh2) designs are popular in cancer clinical trials because of the smaller sample size requirements when multiple treatments are being evaluated. We reviewed the use of RPh2 designs and give comments on future directions.

Design

The trial design, statistical properties, conduct, data analysis, results, and reporting were examined in RPh2 trials reported from 1986 to 2002.

Results

A statistical design was reported in only 46% of the 266 cancer trials, and approximately half of those provided inadequate information. Most studies applied randomization to achieve patient comparability, while embedding a one-sample phase II design within each treatment arm. Seventy-five percent of the trials’ accruals were within ± 10% of their targets. The average accrual rate was 3.3 patients per month. Planned interim analyses were reported in 27% of the trials, and 56% of the trials were stopped early; 69%, 13%, 13%, and 4% of the trial discontinuations were because of lack of efficacy, efficacy, toxicity, and slow accrual, respectively. Thirty-nine trials (14%) recommended or started phase III evaluations, with four positive reports in six phase III studies identified.

Conclusion

There is a trend of increasing use of RPh2 designs in cancer research. Continued improvement in study design, conduct, analysis, and reporting is required to enhance the quality of RPh2 designs. The accrual rate and success rate of the trials remain low, and therefore, futility stopping rules to terminate ineffective treatment arm(s) should be implemented more frequently. More innovative, flexible RPh2 designs are needed to facilitate the development of effective cancer treatments.

A phase III randomised study comparing two different dose-intensity regimens as induction chemotherapy followed by thoracic irradiation in patients with advanced locoregional non-small-cell lung cancer

PURPOSE

The aim of this study was to determine the role of chemotherapy dose intensity in patients with initially unresectable non-metastatic non-small-cell lung cancer (NSCLC), with survival as primary end point, by testing two different regimens as induction chemotherapy followed by thoracic irradiation.

PATIENTS AND METHODS

Patients had pathologically proven NSCLC, an initially unresectable non-metastatic tumour without homolateral malignant pleural effusion, no prior history of malignancy and had received no prior therapy. Treatment was randomised for chemotherapy between three courses of MIP (mitomycin C 6 mg/m2; ifosfamide 3 g/m2; cisplatin 50 mg/m2) or SuperMIP (mitomycin C 6 mg/m2; ifosfamide 4.5 g/m2; cisplatin 60 mg/m2, carboplatine 200 mg/m2), followed by chest irradiation (60 Gy; five times per week, for 6 weeks). If the tumour became resectable after chemotherapy, surgery was performed, followed by mediastinal irradiation.

RESULTS

A total of 351 patients were eligible: 176 in the MIP arm and 175 in the SuperMIP arm, with 43% and 51% stages IIIA and IIIB, respectively. There was a significantly higher objective response rate with SuperMIP (46%) compared with MIP (35%) (P=0.03) [95% confidence interval (CI) for the difference between the response rates, 1% to 22%]. After induction chemotherapy, surgery was performed in 54 (15%) patients (27 per arm) and chest irradiation in 203 (57%) patients (102 in the MIP arm and 101 in the SuperMIP). In terms of survival, there was no statistically significant difference between the two study arms (P=0.16), with median survival times of, for MIP and SuperMIP, respectively, 12.5 (95% CI 10.1-14.9) and 11.2 (95% CI 9.7-12.8) months. Haematological toxicity and dosage reductions were higher with SuperMIP, which was nevertheless associated with a significantly increased absolute dose intensity.

CONCLUSIONS

High dose-intensity induction chemotherapy does not improve survival in initially unresectable non metastatic NSCLC.

Combined intrapleural and intravenous chemotherapy, and pulmonary irradiation, for treatment of patients with lung cancer presenting with malignant pleural effusion. A pilot study

OBJECTIVES

Patients with non-small-cell lung cancer (NSCLC) and malignant pleural effusion (MPE) are difficult to manage clinically and have a short life expectancy. In this pilot study, we designed a protocol of combined intrapleural (i.p.) and intravenous (i.v.) chemotherapy and pulmonary irradiation to enhance local as well as systemic control of the disease.

METHODS

From April 1998 to April 2000, 27 patients with NSCLC and symptomatic MPE were eligible for the study. Patients received pre-radiation chemotherapy (cisplatin 60 mg/m(2) i.p. on day 1; gemcitabine 1,000 mg/m(2) i.v. on days 1, 8, and 15, q4week x 3) after surgical implantation of i.p. and i.v. port-A, followed by radiotherapy (7,020 cGy/39fr), and, finally, post-radiation chemotherapy (docetaxel 60 mg/m(2) q3week x 3-6 i.v.).

RESULTS

Grade 1/2 nausea/vomiting and impaired renal function were more common from pre-radiation than post-radiation chemotherapy; however, grade 3/4 toxicities from pre-radiation chemotherapy were minimal. Conversely, grade 3/4 leukopenia and grade 1/2 alopecia, diarrhea, elevation of SGOT/SGPT, and sensory impairment were more common following post-radiation chemotherapy. Only two patients experienced recurrence of pleural effusion. The overall response rate was 55% with 7% complete remission, 48% partial remission, 22% stable disease, and 22% progressive disease. The median failure-free and overall survival was 8 and 16 months, respectively. The one-year survival rate was 63% (95% confidence interval, 45-80%).

CONCLUSIONS

We conclude that the combination of i.p. and i.v. chemotherapy and pulmonary irradiation is feasible and should be tested in a larger clinical trial to determine whether survival can be improved for this cohort of patients.

Lung cancer--where are we today? Current advances in staging and nonsurgical treatment

Lung cancer remains the commonest cause of cancer death in both men and women in the developed world, although mortality rates for men are dropping. Spiral computed tomography (CT) of the chest in middle-aged, smoking subjects may identify two to four times more lung cancers than a chest X-ray, with more than 70% of tumors being Stage I. The incidence of benign nodules is high, making interpretation difficult. Randomized controlled trials are required to determine whether spiral CT detects lung cancer early enough to improve mortality. Preoperative staging has relied on CT scans, but positron emission tomography scanning has greater sensitivity, specificity, and accuracy than CT and is recommended as the final confirmatory investigation when the CT shows resectable disease. In locally advanced non-small cell lung cancer, there is a small advantage for the addition of chemotherapy to radiotherapy, but no advantage for postoperative radiotherapy. Chemotherapy gives no benefit when given as neoadjuvant or adjuvant treatment around surgery. In advanced disease, newer cytotoxic agents confer a small survival advantage over older combinations, but the advantage in median survival over best supportive care remains a few months with modest improvements in quality of life. Survival with small cell lung cancer has shown little increase over the last 15 years despite multiple attempts to manipulate the timing, dose intensity of chemotherapy, and the potential of radiotherapy. Novel therapies are urgently needed for all cell types of lung cancer.

A phase II randomised trial comparing the cisplatin-etoposide combination chemotherapy with or without carboplatin as second-line therapy for small-cell lung cancer

BACKGROUND

A phase II randomised trial was performed with patients with SCLC to determine if the addition of carboplatin to cisplatin-etoposide might improve the response rate in second-line therapy.

PATIENTS AND METHODS

Sixty-five eligible patients were randomised: 31 for CE (cisplatin 20 mg/m(2) and etoposide 100 mg/m(2) on days 1-3) and 34 for CCE (carboplatin 200 mg/m(2) on day 1, cisplatin 30 mg/m(2) on days 2-3, etoposide 100 mg/m(2) on days 1-3).

RESULTS

Eighty-two per cent of these patients had an objective response to first-line therapy and, among responders, 63% had a treatment-free interval of >3 months after previous therapy. The best response rates were 29% [95% confidence interval (CI) 13-45] and 47% (95% CI 30-64) for CE and CCE, respectively, with median survival times of 4.3 and 7.6 months. Dose-intensity analysis revealed a significant improvement in the relative dose-intensity and etoposide absolute dose-intensity for CE. Toxicity was tolerable and comparable between the two study arms.

CONCLUSION

CCE appears to be associated with a high objective response rate. The phase II randomised study design suggests that a comparison between the two regimens in a phase III trial would be interesting, but will probably be difficult to perform for reasons of accrual.

A three-arm phase III randomised trial comparing combinations of platinum derivatives, ifosfamide and/or gemcitabine in stage IV non-small-cell lung cancer

OBJECTIVE

To determine, in stage IV non-small-cell lung cancer (NSCLC), if the combination of gemcitabine-a new active drug-with ifosfamide (IG) or with the cisplatin-carboplatin association (CCG) will improve survival (primary end point) in comparison with a first-generation regimen, cisplatin-carboplatin-ifosfamide (CCI).

PATIENTS AND METHODS

A total of 284 chemotherapy-naïve patients with metastatic NSCLC were randomised. Four were ineligible and 16 were not assessable for responses. Cisplatin was given at 60 mg/m2 on day 1, carboplatin AUC 3 mg.min/ml on day 1, ifosfamide 4.5 g/m2 on day 1 and gemcitabine 1 g/m2 on days 1, 8 and 15. Courses were repeated every 4 weeks. Response was assessed after three courses and chemotherapy was continued in responding patients until best response. There were 94 eligible patients in the CCI arm, 92 in CCG and 94 in the IG arm.

RESULTS

The objective response rates for CCI, CCG and IG were 23% [95% confidence interval (CI) 15% to 32%], 29% (95% CI 20% to 39%) and 25% (95% CI 16% to 33%), respectively ( P = 0.61). Median survival time was 24, 34 and 30 weeks, respectively (P = 0.20). One-year survival was 23, 33 and 35%, and 2-year survival was 11, 14 and 17%, respectively. In some subgroups (older patients, women), there was a significant survival advantage for CCG and IG compared with CCI. Toxicity was tolerable: severe alopecia was less frequent in the CCG arm, and IG was associated with significantly more thrombopenia while CCG was associated with more leucopenia.

CONCLUSION

In stage IV NSCLC, treatment with regimens including the new drug gemcitabine were associated with a better but not statistically significant observed survival compared with a classical first-generation cisplatin-containing regimen. The non-platinum combination of gemcitabine was as effective as its combination with platinum.

Is weekly paclitaxel superior to paclitaxel given every 3 weeks? Results of a phase II trial

Twenty-four patients previously treated with platinum containing regimens with stage IIIB-IV non-small-cell lung cancer (NSCLC) participated in the study. Sequential cohorts of patients were treated with 60 and 90 mg/m(2) of Paclitaxel per week. Paclitaxel was administered weekly over 1 h infusion for 6 consecutive weeks followed by 2 weeks without treatment (8-week cycle). A total of 252 treatments were administered to the 24 patients. In 29 (12%) of 252 treatments grade 2 granulocytopenia was observed while four patients (17%) developed grade 2 neuropathy. Seven patients (29%) achieved a partial response and five (21%) had stable disease. Paclitaxel 90 mg/m(2) per week as salvage treatment is well tolerated and has shown promising activity in patients with NSCLC who progress after platinum treatment.

Chemotherapy in advanced nonsmall cell lung cancer: indication, intensity, and duration

Platinum-based combination and single-agent chemotherapy have become accepted as treatments for locally advanced and metastatic nonsmall cell lung cancer as a consequence of improved survival, quality of life, and symptom control compared with best supportive care. However, it is clear that a therapeutic plateau has been reached with current combinations requiring a re-evaluation of strategies to improve clinical outcomes. Dose intensification may offer one way in which to achieve better results, as may extension of the duration of treatment. The evidence suggests that dose intensification is a useful tool, and that its use in combination with markers of treatment duration and cumulative dose may help to maximize results from current active drug combinations.