Effective oral chemotherapy for breast cancer: pillars of strength

KDM5 family as therapeutic targets in breast cancer: Pathogenesis and therapeutic opportunities and challenges

Breast cancer (BC) is the most frequent malignant cancer diagnosis and is a primary factor for cancer deaths in women. The clinical subtypes of BC include estrogen receptor (ER) positive, progesterone receptor (PR) positive, human epidermal growth factor receptor 2 (HER2) positive, and triple-negative BC (TNBC). Based on the stages and subtypes of BC, various treatment methods are available with variations in the rates of progression-free disease and overall survival of patients. However, the treatment of BC still faces challenges, particularly in terms of drug resistance and recurrence. The study of epigenetics has provided new ideas for treating BC. Targeting aberrant epigenetic factors with inhibitors represents a promising anticancer strategy. The KDM5 family includes four members, KDM5A, KDM5B, KDM5C, and KDMD, all of which are Jumonji C domain-containing histone H3K4me2/3 demethylases. KDM5 proteins have been extensively studied in BC, where they are involved in suppressing or promoting BC depending on their specific upstream and downstream pathways. Several KDM5 inhibitors have shown potent BC inhibitory activity in vitro and in vivo, but challenges still exist in developing KDM5 inhibitors. In this review, we introduce the subtypes of BC and their current therapeutic options, summarize KDM5 family context-specific functions in the pathobiology of BC, and discuss the outlook and pitfalls of KDM5 inhibitors in this disease.

Predictors of community pharmacists' readiness to manage the effective and safe use of oral anticancer medicines in a developing setting

BACKGROUND

There is a paucity of studies about the readiness of community pharmacists to manage the safe and effective use of oral anticancer medicines (OAMs) in developing settings.

OBJECTIVES

Using the readiness component (knowledge and willingness) of the situational theory of leadership, the study assessed community pharmacists' readiness to manage the safe and effective use of OAMs in Qatar, and also identified its significant predictors.

METHODS

A cross-sectional assessment of 252 community pharmacists was conducted with a pre-tested 48-item questionnaire. Readiness was assessed with a 5-point Likert-type scale and the maximum obtainable score was 70. The mean was used as the cut-off point to categorize willingness and knowledge as either high (≥ mean) or low (< mean). Independent t-test, one-way analysis of variance and multiple linear regression was used for data analyses.

RESULTS

The mean SD score for the readiness of community pharmacists was 39.3 ± 11.2 (min = 11, max = 70). Only a minority of the respondents expressed an excellent understanding of the chemotherapy cycles (19.6%; 45/230), and familiarity with targeted anticancer therapy (14.3%; 33/230), side effects (22.2%; 51/230), and dosing of OAMs (14.4%; 33/230). Employment status, number of OAMs prescriptions dispensed per month and adequacy of the contents related to OAMs in undergraduate training were the significant predictors of readiness (R2 = 0.558, (F (11, 209) = 3.559, p = 0.0001).

CONCLUSIONS

Community pharmacists' readiness appear inadequate especially regarding its dosing, side effects, handling, and disposal of OAMs. These inadequacies probably underline community pharmacists' low familiarity and comfortability with dispensing and educating patients on the effective and safe use of OAMs.

A phase Ib trial of pembrolizumab plus paclitaxel or flat-dose capecitabine in 1st/2nd line metastatic triple-negative breast cancer

Chemoimmunotherapy with anti-programmed cell death 1/ligand 1 and cytotoxic chemotherapy is a promising therapeutic modality for women with triple-negative breast cancer, but questions remain regarding optimal chemotherapy backbone and biomarkers for patient selection. We report final outcomes from a phase Ib trial evaluating pembrolizumab (200 mg IV every 3 weeks) with either weekly paclitaxel (80 mg/m² weekly) or flat-dose capecitabine (2000 mg orally twice daily for 7 days of every 14-day cycle) in the 1st/2nd line setting. The primary endpoint is safety (receipt of 2 cycles without grade III/IV toxicities requiring discontinuation or ≥21-day delays). The secondary endpoint is efficacy (week 12 objective response). Exploratory aims are to characterize immunologic effects of treatment over time, and to evaluate novel biomarkers. The trial demonstrates that both regimens meet the pre-specified safety endpoint (paclitaxel: 87%; capecitabine: 100%). Objective response rate is 29% for pembrolizumab/paclitaxel (n = 4/13, 95% CI: 10-61%) and 43% for pembrolizumab/capecitabine (n = 6/14, 95% CI: 18-71%). Partial responses are observed in two subjects with chemo-refractory metaplastic carcinoma (both in capecitabine arm). Both regimens are associated with significant peripheral leukocyte contraction over time. Response is associated with clinical PD-L1 score, non-receipt of prior chemotherapy, and the H&E stromal tumor-infiltrating lymphocyte score, but also by a novel 27 gene IO score and spatial biomarkers (lymphocyte spatial skewness). In conclusion, pembrolizumab with paclitaxel or capecitabine is safe and clinically active. Both regimens are lymphodepleting, highlighting the competing immunostimulatory versus lymphotoxic effects of cytotoxic chemotherapy. Further exploration of the IO score and spatial TIL biomarkers is warranted. The clinical trial registration is NCT02734290.

Surface-modified nanoparticles of docetaxel for chemotherapy of lung cancer: An intravenous to oral switch

Despite being potent, the marketed formulations of Docetaxel (DX) are associated with numerous side effects and are meant for intravenous administration. Advanced pharmaceutical nanotechnology has a significant potential to facilitate the 'intravenous (i.v) to oral switch'. The present research work deals with the development of an orally administrable, folate-receptor-targeted Nanostructured lipid carriers (NLCs) of DX (FA-DX-NLCs) for facilitating oral chemotherapy of lung cancer while overcoming the bioavailability and toxicity issues. The nanoformulation prepared to employ high-pressure homogenization and lyophilization, was evaluated and statistically analyzed for various in-vitro and in-vivo formulation characteristics. The lyophilized nanoparticles were observed to be spherical with a particle size of 183.4 ± 2.13 (D90), Pdi of 0.358 ± 0.03, % EE of 82.41 ± 2.44, % DL of 4.41 ± 0.54 and a zeta potential of -3.3 ± 0.7 mv. The increased oral in-vivo bioavailability of DX was evident from the plasma-concentration area under the time curve (AUC_0-t), which was ∼ 27-fold greater for FA-DX-NLCs as compared to DX suspension. The orally administered FA-DX-NLCs exhibited excellent antitumor efficacy in a pre-clinical model of lung carcinoma. Tumor staging, histopathology, and immunostaining of the tumors suggested greater anti-proliferative, apoptotic, anti-metastatic, and anti-angiogenic potential as compared to DX-suspension. The pre-clinical toxicity studies affirmed the excellent safety and bio-compatibility of FA-DX-NLCs. The research work presents immense translational potential for switching the DX-based chemotherapy for lung cancer from 'hospital to home.'

Adherence to Oral Anticancer Medications Among Women With Breast Cancer in Africa: A Scoping Review

PURPOSE

Oral anticancer medications (OAMs) improve treatment outcomes and survival in women with breast cancer (BC). However, adherence to OAM therapy remains suboptimal. This scoping review provides evidence of adherence to OAMs among African women with BC.

METHODS

We searched four databases and gray literature, using guidance from the Joanna Briggs Institute. Thirteen studies on adherence rates, determinants, and interventions were included. NVivo 12 software was used to perform thematic analysis of the included studies. The determinants (barriers and facilitators) associated with adherence were analyzed according to the five dimensions of the WHO multidimensional adherence model.

RESULTS

Most studies (n = 11, 85%) focused on endocrine medication. Depending on the definition, measurements, and assessment period, the nonadherence rates ranged from 4.3% to 65.4% for endocrine medications, 80.9% for cytotoxic chemotherapies, and 32.7% for combined medications. The significant barriers associated with adherence include Islamic religion, concurrent comorbidities, mastectomy, anastrozole treatment, side effects, unawareness of treatment insurance coverage, and seeking treatment from traditional healers. Thorough therapeutic communication regarding treatment, neoadjuvant chemotherapy, and adequate social support significantly facilitate adherence. A randomized controlled trial of breast nursing interventions reported improved patient adherence.

CONCLUSION

The evidence mapped from studies that evaluated OAM adherence in women with BC indicates that nonadherence to OAMs is common. Applying context-specific standardized measures to assess adherence and facilitators or strategies targeting the identified barriers can optimize adherence and treatment outcomes. Effective interventions to improve adherence are limited. Therefore, further empirical and interventional studies in Africa are required to enhance the evidence.

Impact of pharmacogenetics on variability in exposure to oral vinorelbine among pediatric patients: a model-based population pharmacokinetic analysis

PURPOSE

Better understanding of pharmacokinetics of oral vinorelbine (VNR) in children would help predicting drug exposure and, beyond, clinical outcome. Here, we have characterized the population pharmacokinetics of oral VNR and studied the factors likely to explain the variability observed in VNR exposure among young patients.

DESIGN/METHODS

We collected blood samples from 36 patients (mean age 11.6 years) of the OVIMA multicentric phase II study in children with recurrent/progressive low-grade glioma. Patients received 60 mg/m² of oral VNR on days 1, 8, and 15 during the first 28-day treatment cycle and 80 mg/m², unless contraindicated, from cycle 2-12. Population pharmacokinetic analysis was performed using nonlinear mixed-effects modeling within the Monolix^® software. Fifty SNPs of pharmacokinetic-related genes were genotyped. The influence of demographic, biological, and pharmacogenetic covariates on pharmacokinetic parameters was investigated using a stepwise multivariate procedure.

RESULTS

A three-compartment model, with a delayed double zero-order absorption and a first-order elimination, best described VNR pharmacokinetics in children. Typical population estimates for the apparent central volume of distribution (V_c/F) and elimination rate constant were 803 L and 0.60 h^-1, respectively. Following covariate analysis, BSA, leukocytes count, and drug transport ABCB1-rs2032582 SNP showed a dramatic impact on V_c/F. Conversely, age and sex had no significant effect on VNR pharmacokinetics.

CONCLUSION

Beyond canonical BSA and leukocytes, ABCB1-rs2032582 polymorphism showed a meaningful impact on VNR systemic exposure. Simulations showed that the identified covariates could have an impact on both efficacy and toxicity outcomes. Thus, a personalized dosing strategy, using those covariates, could help to optimize the efficacy/toxicity balance of VNR in children.

Small Molecule Agents Targeting PD-1 Checkpoint Pathway for Cancer Immunotherapy: Mechanisms of Action and Other Considerations for Their Advanced Development

Pioneering success of antibodies targeting immune checkpoints such as programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) has changed the outlook of cancer therapy. Although these antibodies show impressive durable clinical activity, low response rates and immune-related adverse events are becoming increasingly evident in antibody-based approaches. For further strides in cancer immunotherapy, novel treatment strategies including combination therapies and alternate therapeutic modalities are highly warranted. Towards this discovery and development of small molecule, checkpoint inhibitors are actively being pursued, and the efforts have culminated in the ongoing clinical testing of orally bioavailable checkpoint inhibitors. This review focuses on the small molecule agents targeting PD-1 checkpoint pathway for cancer immunotherapy and highlights various chemotypes/scaffolds and their characterization including binding and functionality along with reported mechanism of action. The learnings from the ongoing small molecule clinical trials and crucial points to be considered for their clinical development are also discussed.

A Remote Monitoring System to Optimize the Home Management of Oral Anticancer Therapies (ONCO-TreC): Prospective Training-Validation Trial

Background

A platform designed to support the home management of oral anticancer treatments and provide a secure web-based patient–health care professional communication modality, ONCO-TreC, was tested in 3 cancer centers in Italy.

Objective

The overall aims of the trial are to customize the platform; assess the system’s ability to facilitate the shared management of oral anticancer therapies by patients and health professionals; and evaluate system usability and acceptability by patients, caregivers, and health care professionals.

Methods

Patients aged ≥18 years who were candidates for oral anticancer treatment as monotherapy with an Eastern Cooperative Oncology Group performance status score of 0 to 1 and a sufficient level of familiarity with mobile devices were eligible. ONCO-TreC consisted of a mobile app for patients and a web-based dashboard for health care professionals. Adherence to treatment (pill count) and toxicities reported by patients through the app were compared with those reported by physicians in medical records. Usability and acceptability were evaluated using questionnaires.

Results

A total of 40 patients were enrolled, 38 (95%) of whom were evaluable for adherence to treatment. The ability of the system to measure adherence to treatment was high, with a concordance of 97.3% (95% CI 86.1%-99.9%) between the investigator and system pill count. Only 60% (3/5) of grade 3, 54% (13/24) of grade 2, and 19% (7/36) of grade 1 adverse events reported by physicians in the case report forms were also reported in the app directly by patients. In total, 94% (33/35) of patients had ≥1 app launch each week, and the median number of daily accesses per patient was 2. Approximately 71% (27/38) and 68% (26/38) of patients used the app for messages and vital sign entering, respectively, at least once during the study period.

Conclusions

ONCO-TreC is an important tool for measuring and monitoring adherence to oral anticancer drugs. System usability and acceptability were very high, whereas its reliability in registering toxicity could be improved.

Trial Registration

ClinicalTrials.gov NCT02921724; https://www.clinicaltrials.gov/ct2/show/NCT02921724

A Concept Analysis of Oral Anticancer Agent Self-management

BACKGROUND

The rapid development and adoption of oral anticancer agents (OAAs) for cancer management have shifted patients' roles from recipient to owner of their care delivery, assuming their responsibilities for self-managing their OAA treatments at home, while the concept of oral anticancer agent self-management (OAA-SM) has not been well clarified and defined.

OBJECTIVE

This study was to clarify the concept of OAA-SM and identify major components, influential factors, and consequences of OAA-SM, as well as propose a representative conceptual model of OAA-SM.

METHODS

A literature review was conducted concerning the concept and application of OAA-SM. The Walker and Avant method for concept analysis was utilized to guide the examination of OAA-SM.

RESULTS

OAA-SM is a multifaceted and dynamic process that requires continuous adaptation by patients as multiple self-management challenges can emerge throughout OAA treatments. The defining attributes of OAA-SM include OAA adherence, adverse-effect self-management, patient-provider communication, and OAA safe storage, handling, and administration practices. Oral anticancer agent-SM is potentially influenced by a variety of patient-related, OAA-related, and healthcare system factors. Effective OAA-SM is associated with better patient and healthcare outcomes.

CONCLUSIONS

The clarification of the concept of OAA-SM and the identification of attributes of OAA-SM and their interrelationships contribute to the body of knowledge in OAA-SM.

IMPLICATIONS FOR PRACTICE

This concept analysis provides the foundation to increase healthcare providers' understanding of patients' needs for OAA-SM support and guides the development of patient-centered interventions to empower and engage patients and their families in effective OAA-SM, and improve patients' quality of life and care.

Preclinical meritorious anticancer effects of Metformin against breast cancer: An In vivo trial

OBJECTIVE

This research aims to evaluate the preclinical meritorious and anticancer effects of Metformin in a Xenograft model of breast cancer.

METHODS

This interventional trial was conducted during a defined period of 5 months (August 2016 January 2017). We used a Xenograft model of nude BALB/c mice. A sample size of 50 mice, allocated into two groups and designated as Group A and Group B for Metformin and negative control groups, respectively. The anticancer activity of Metformin has been evaluated by comparing the tumour volume, tumour weight, tumour regression ratio, percentage regression, and survival rate.

RESULTS

Compared with the control group, Metformin can significantly reduce the progression of tumour in the Xenograft model of breast cancer induced by MCF-7. This is reflected by significant differences in tumour volume at the final follow-up (p = <0.001). Our findings are further supported by a significant reduction of the tumour growth rate (p = <0.001) and tumour weight (p = <0.001) in the Metformin group than in the control group. Similarly, the total survival rate and tumour regression are more significantly correlated in the Metformin group.

CONCLUSION

This study demonstrates that Metformin can significantly reduce the tumour growth and can increase the survival rate in a Xenograft model of breast cancer.

Effect and mechanism of actionin vitroof cyclodextrin derivative nanoparticles loaded with tyroserleutide on hepatoma

In this study, a cyclodextrin derivative (R6RGD-CMβCD) nanoparticle with tumor targeting and cell penetration ability was successfully synthesized and loaded with tyroserleutide (YSL) to obtain YSL-loaded nanoparticles (YSL/R6RGD-CMβCD NPs). The characterization of these NPs revealed a smooth surfaces and an average diameter of approximately 170 nm. YSL/R6RGD-CMβCD NPs increased the NP uptake in Caco-2 cells. As regard the mechanism of action, the cell uptake was related to endocytosis mediated by reticulin and megacytosis. In addition, YSL/R6RGD-CMβCD NPs induced significantly higher cytotoxicity on tumor cells and better tumor targeting compared with the effect of CMβCD NPs. Most importantly, the good anti-cancer effect of YSL/R6RGD-CMβCD NPs might be due to the interference with the function of mitochondria. On the other hand, YSL/R6RGD-CMβCD NPs were not toxic for normal cells. Taken together, our results indicated that R6RGD-CMβCD could be considered as a nanopharmaceutical material with good tumor targeting abilities, and their combination with YSL could represent an effective anti-cancer system.

Finding an easy way to harmonize: a review of advances in clinical research and combination strategies of EZH2 inhibitors

Enhancer of zeste homolog 2 inhibitors (EZH2i) have garnered increased attention owing to their anticancer activity by targeting EZH2, a well-known cancer-promoting factor. However, some lymphomas are resistant to EZH2i, and EZH2i treatment alone is ineffective in case of EZH2-overexpressing solid tumors. The anti-cancer efficacy of EZH2i may be improved through safe and effective combinations of these drugs with other treatment modalities. Preclinical evidence indicates that combining EZH2i with other therapies, such as immunotherapy, chemotherapy, targeted therapy, and endocrine therapy, has complementary or synergistic antitumor effects. Therefore, elucidating the underlying mechanisms of the individual constituents of the combination therapies is fundamental for their clinical application. In this review, we have summarized notable clinical trials and preclinical studies using EZH2i, their progress, and combinations of EZH2i with different therapeutic modalities, aiming to provide new insights for tumor treatment.

Harnessing the therapeutic potential of anticancer drugs through amorphous solid dispersions

The treatment of cancer is still a major challenge. But tremendous progress in anticancer drug discovery and development has occurred in the last few decades. However, this progress has resulted in few effective oncology products due to challenges associated with anticancer drug delivery. Oral administration is the most preferred route for anticancer drug delivery, but the majority of anticancer drugs currently in product pipelines and the majority of those that have been commercially approved have inherently poor water solubility, and this cannot be mitigated without compromising their potency and stability. The poor water solubility of anticancer drugs, in conjunction with other factors, leads to suboptimal pharmacokinetic performance. Thus, these drugs have limited efficacy and safety when administered orally. The amorphous solid dispersion (ASD) is a promising formulation technology that primarily enhances the aqueous solubility of poorly water-soluble drugs. In this review, we discuss the challenges associated with the oral administration of anticancer drugs and the use of ASD technology in alleviating these challenges. We emphasize the ability of ASDs to improve not only the pharmacokinetics of poorly water-soluble anticancer drugs, but also their efficacy and safety. The goal of this paper is to rationalize the application of ASD technology in the formulation of anticancer drugs, thereby creating superior oncology products that lead to improved therapeutic outcomes.

Key elements for the education and counselling of patients treated with oral anticancer drugs

PURPOSE

The process of education and counselling of patients treated with oral anticancer drugs, aimed to achieve adequate self-management, involves different stakeholders (i.e. physicians, oncology nurses, pharmacists) from primary and secondary care. However, currently no guiding principles exist on how to organize and perform education and counselling for these patients. Therefore, the purpose of this study was to develop and build consensus on key elements for the education and counselling in patients on oral anticancer drugs.

METHODS

A multi-method approach combining a literature search, semi-structured interviews with patients and healthcare professionals, and input from experts were used to develop an initial list of key elements. Subsequently, consensus was built in a two-round Delphi-study, involving patients and healthcare professionals from primary and secondary care. Key elements were retained if at least 80% of respondents in all groups considered the element as important or if in at least one group 90% consensus was reached.

RESULTS

The initial list contained 110 key elements, divided in 7 themes: coordination of care, patient contacts: style and content, medication counselling at the start of the treatment and during follow-up, psychosocial support, and involvement of family and friends. After the first Delphi round, 80% consensus was reached for 23 elements; 6 new key elements were added. After the second round, 80% consensus was reached for 51 out of 116 elements; 31 elements were added following the 90%-rule, yielding a list of 82 elements.

CONCLUSION

The final list of 82 key elements, obtained in this study, could be used to develop clinical pathways that guide adequate education and counselling of patients on oral anticancer drugs. Due to the open description, the implementation of these elements can be adapted to the specific context and composition of the oncology team.

Current treatment of HER 2+ metastatic breast cancer

Historically, HER2-positive breast cancer had a poor prognosis. The development of molecul ar ther apies that target the HER2 receptor has TR ansformed outcomes. Here, the evidence on Anti-HER2 therapies is summarised.

Randomized phase II study evaluating weekly oral vinorelbine versus weekly paclitaxel in estrogen receptor-positive, HER2-negative patients with advanced breast cancer (NorBreast-231 trial)

BACKGROUND

Single-agent paclitaxel and vinorelbine are recommended treatments for advanced breast cancer (ABC) non-responsive to hormone therapy and without visceral crisis. This phase II trial compared first-line oral vinorelbine versus weekly paclitaxel for ABC.

METHODS

Eligible female patients had measurable locally recurrent/metastatic estrogen receptor-positive HER2-negative breast cancer and had received prior endocrine therapy (any setting) but no chemotherapy for ABC. Patients were stratified by prior taxane and visceral metastases and randomized to either oral vinorelbine 80 mg/m² (first cycle at 60 mg/m², escalated to 80 mg/m² in the absence of grade 3/4 toxicity) or intravenous paclitaxel 80 mg/m² on days 1, 8, and 15 every 3 weeks until disease progression or unacceptable toxicity. The primary endpoint was disease control rate (DCR; confirmed complete or partial response, or stable disease for ≥6 weeks).

RESULTS

The 131 randomized patients had received a median of 2 prior endocrine therapies; >70% had prior (neo)adjuvant chemotherapy and 79% visceral metastases. DCR was 75.8% (95% confidence interval: 63.6-85.5%) with vinorelbine and 75.4% (63.1-85.2%) with paclitaxel. The most common grade 3/4 adverse events were neutropenia (52%), fatigue (11%), and vomiting (5%) with vinorelbine, and neutropenia (17%), dyspnea (6%), hypertension (6%), and peripheral sensory neuropathy (5%) with paclitaxel. Grade 2 alopecia occurred in 2% of vinorelbine-treated and 34% of paclitaxel-treated patients. Neither arm showed relevant global health status changes.

CONCLUSION

Oral vinorelbine and paclitaxel demonstrated similar DCRs (∼75%). Safety profiles differed and, together with administration route and convenience, may influence treatment choice (EudraCT number, 2012-003530-16).

Pharmacoeconomics Evaluations of Oral Anticancer Agents: Systematic Review of Characteristics, Methodological Trends, and Reporting Quality

OBJECTIVES

To review literature characteristics, describe methodological trends, and assess the reporting quality of the economic evaluations of oral anticancer drugs (OACDs).

METHODS

The review included comparative economic evaluations of OACDs. The search was conducted via PubMed, Embase, EconLit, and Economic Evaluation Database, and studies till December 2017 were included. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, literature inclusion and data extraction were performed in duplicate by separate investigators. Outcome measures were literature characteristics, gaps and methodological trends, and reporting quality using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data were summarized on the basis of methodological themes of interest. Descriptive statistics and tabulations were used for result presentation.

RESULTS

Out of 241 found articles, 21 were included. There is a recent increasing interest in the economics of OACDs, whereby the cost per quality-adjusted life-year, via cost-utility analysis, is the most used for decision making. Most of the studies were from the payer perspective, and the primary sources of data were clinical trials, expert panels, and medical charts. The dominance status (higher effect, lower cost) was a commonly reported outcome. Decision-analytic modeling was used in most of the studies, mostly including Markov modeling. Studies were highly heterogeneous in methodological aspects, and the included studies did not meet most of the reporting quality criteria.

CONCLUSIONS

High heterogeneity in methods in studies may limit the robustness and transferability of results, potentially misleading decision makers toward wrong decisions on OACDs. The transferability and generalizability of results are further limited by a "less than ideal" adherence to current reporting standards.

pH-Responsive carriers for oral drug delivery: challenges and opportunities of current platforms

Oral administration is a desirable alternative of parenteral administration due to the convenience and increased compliance to patients, especially for chronic diseases that require frequent administration. The oral drug delivery is a dynamic research field despite the numerous challenges limiting their effective delivery, such as enzyme degradation, hydrolysis and low permeability of intestinal epithelium in the gastrointestinal (GI) tract. pH-Responsive carriers offer excellent potential as oral therapeutic systems due to enhancing the stability of drug delivery in stomach and achieving controlled release in intestines. This review provides a wide perspective on current status of pH-responsive oral drug delivery systems prepared mainly with organic polymers or inorganic materials, including the strategies used to overcome GI barriers, the challenges in their development and future prospects, with focus on technology trends to improve the bioavailability of orally delivered drugs, the mechanisms of drug release from pH-responsive oral formulations, and their application for drug delivery, such as protein and peptide therapeutics, vaccination, inflammatory bowel disease (IBD) and bacterial infections.

Foreword

Delivering multifaceted, quality care to women living with metastatic breast cancer (MBC) demands professional competence and an advanced level of practice. The breast cancer nursing community is evolving to meet this need as more nurses are appointed specifically for the advanced disease setting, while nurses who previously worked only in early stage disease are now delivering care across the disease trajectory, fulfilling a 'diagnosis to death' nursing model. The MBC nursing community, linked by UK charity Breast Cancer Care and the Roche Nursing Matters programme, offers forums for learning, and provides ongoing support to this group of nurses. This supplement has been commissioned by Roche Products Ltd to continue supporting nurses who treat patients with MBC by sharing learning and best practice, with a view to encouraging innovation in service delivery.

Improving patient care: expert nursing and service development

Early access to a clinical nurse specialist will ensure that patients receive the interventions and support they need. Optimum outcomes will be achieved if specialists work in collaboration with a wider team.

Introduction

Metastatic breast cancer (MBC), also known as secondary breast cancer (SBC), occurs when cells from the primary breast tumour metastasise from the breast to other parts of the body via the blood or lymphatic systems. The disease may range from limited bone metastases to widespread and life-threatening metastases in visceral organs such as the liver, lung and brain (National Institute for Health and Care Excellence (NICE), 2009; 2014). MBC is incurable, and the primary goal of treatment is to extend life and palliate symptoms, while preserving quality of life (NICE, 2009; 2014).

Defining what matters most to patients

Advanced communication skills are needed to identify patients' needs and provide the psychological and social support they require. Meanwhile, early access to palliative care will improve symptom control.

The oral education clinic: A pharmacist- and nurse-led clinic to support patients starting oral systemic anti-cancer treatments

With the increased number of oral systemic anti-cancer treatments available, patients need to be managed safely and effectively in line with national guidance. In response to guidance in 2011, Oxford University Hospitals NHS Foundation Trust implemented an 'Oral Education Clinic'. This nurse- and pharmacist-led clinic facilitates the delivery of patient education, highlighting key safety aspects of drug administration and management, and ensures follow-up is arranged as per protocol. Patients have found this service to be effective and it has had a positive impact on the running of outpatient units, the volume of triage calls, emergency admissions and workload associated with consenting patients to an oral systemic anti-cancer treatments.

National trends in use and costs of oral anticancer drugs in France: An 8-year population-based study

PURPOSE

During the last decade, many oral anticancer drugs (OAcDs) have been marketed, providing interesting but potentially costly pharmaceutical alternatives to intravenous treatments. This study aims to provide updated information on their use and costs.

METHODS

A cross-sectional yearly repeated study was conducted from 2006 to 2014 using the representative sample of the French national health care insurance system claims database (EGB). OAcD use was described for each year, among prevalent (ie, patients with at least 1 OAcD reimbursement) and incident users (ie, patients with no OAcD reimbursement within the prior year) and according to their pharmacological classes (Hormone Therapy [HT], Cytotoxic Therapy [CT], Targeted Therapy [TT], and others). Demographic characteristics were described for both users; comorbidities and direct medical costs were described for incident users only.

RESULTS

The yearly prevalence and incidence of OAcD use, mainly represented by HT, remained stable from 2006 to 2014 (1.2%; 0.4%). Compared with users of other OAcD classes, the proportion of TT users substantially increased over the 8-year study period (+9.3%), and TT incident users had more severe comorbidities at treatment initiation. The health expenditures were the most important in TT users with median monthly medical direct costs varying from 2995€ to 4968€ per patient between 2006 and 2014.

CONCLUSION

With the development of new OAcDs, the TTs use reaches a wider population of patients but is responsible for increasing health expenditures.

Adherence to oral cancer therapy in older adults: The International Society of Geriatric Oncology (SIOG) taskforce recommendations

There is an increasing trend towards using oral systemic therapy in patients with cancer. Compared to parenteral therapy, oral cancer agents offer convenience, have similar efficacy, and are preferred by patients, consequently making its use appealing in older adults. However, adherence is required to ensure its efficacy and to avoid compromising treatment outcomes, especially when the treatment goal is curative, or in case of symptomatic/rapidly progressing disease, where dose-intensity is important. This opens a new challenge for clinicians, as optimizing patient adherence is challenging, particularly due to lack of consensus and scarcity of available clinical evidence. This manuscript aims to review the impact of age-related factors on adherence, summarize the evidence on adherence, recommend methods for selecting patients suitable for oral cancer agents, and advise monitoring interventions to promote adherence to treatment.

Metronomic treatment of advanced non-small-cell lung cancer with daily oral vinorelbine - a Phase I trial

Micro-abstract

In a Phase I dose-finding study of metronomic daily oral vinorelbine in advanced non-small-cell lung cancer, a recommended dose was established for this therapeutic approach. In addition, this trial revealed promising efficacy data and an acceptable tolerability profile. The observed vinorelbine blood concentrations suggest continuous anti-angiogenic coverage.

Introduction

We present a Phase I dose-finding study investigating metronomic daily oral vinorelbine (Navelbine^® Oral, NVBo) in advanced non-small-cell lung cancer (NSCLC).

Patients and methods

Patients with stage III/IV NSCLC received daily NVBo at fixed dose levels of 20–50 mg/d for 21 days of each 4-week cycle. Primary end point was the maximum tolerated dose. Secondary end points included tumor response, time to progression (TTP), overall survival (OS) and tolerability.

Results

Twenty-seven patients with advanced NSCLC were enrolled. Most of them were extensively pretreated. Daily NVBo was well tolerated up to 30 mg/d. At 40 mg/d, two of five patients experienced dose-limiting toxicities (DLTs). Three of six patients had DLTs at the 50 mg/d level. The recommended dose was established at 30 mg/d in cycle 1, with escalation to 40 mg/d in cycle 2, if tolerated. Pharmacokinetic analyses showed continuous blood exposure over 21 days and only marginal accumulation. The tolerability profile was acceptable (all dose levels – all grades: decreased appetite 33%, diarrhea 33%, leukopenia 33%, nausea 30%, vomiting 26%; ≥grade 3: leukopenia 30%, lymphopenia 19%, neutropenia 19%, febrile neutropenia 15%). Disease control rate, OS and TTP signaled a treatment effect.

Conclusion

Daily metronomic NVBo therapy in extensively pretreated patients with advanced NSCLC is feasible and safe at the recommended dose of 30 mg/d. Escalation to 40 mg/d in the second cycle is possible. The blood concentrations of vinorelbine after daily metronomic dosing reached lower peaks than intravenous or oral conventional dosing. Blood concentrations were consistent with anti-angiogenic or immune modulating pharmacologic properties of vinorelbine. Further studies are warranted to evaluate the safety and efficacy of this novel approach in specific patient populations.

Inventory of oral anticancer agents: Pharmaceutical formulation aspects with focus on the solid dispersion technique

Dissolution from the pharmaceutical formulation is a prerequisite for complete and consistent absorption of any orally administered drug, including anticancer agents (oncolytics). Poor dissolution of an oncolytic can result in low oral bioavailability, high variability in blood concentrations and with that suboptimal or even failing therapy. This review discusses pharmaceutical formulation aspects and absorption pharmacokinetics of currently licensed orally administered oncolytics. In nearly half of orally dosed oncolytics poor dissolution is likely to play a major role in low and unpredictable absorption. Dissolution-limited drug absorption can be improved with a solid dispersion which is a formulation method that induces super-saturated drug dissolution and with that it enhances in vivo absorption. This review discusses formulation principles with focus on the solid dispersion technology and how it works to enhance drug absorption. There are currently three licensed orally dosed oncolytics formulated as a solid dispersion (everolimus, vemurafenib and regorafenib) and these formulations result in remarkably improved dissolution and absorption compared to what can be achieved with conventional formulations of the respective oncolytics. Because of the successful implementation of these three solid dispersion formulations, we encourage the application of this formulation method for poorly soluble oral oncolytics.

Effects of Lycopene Alone or Combined with Melatonin on Methotrexate-Induced Nephrotoxicity in Rats

Methotrexate (Mtx), used for its anticancer and immunsuppresive properties, is known to be a nephrotoxic agent. We aimed to investigate the effects of lycopene (Lyc) alone or combined with melatonin (Mel) on Mtx- induced nephrotoxicity since both of these agents have antioxidant and anti-inflammatory effects. Nephrotoxicity was induced by intraperitoneal administration of methotrexate at a dose of 20 mg/kg. Treatment both with Lyc alone and Lyc combined with Mel provided significant reduction in tumor necrosis factor-alpha, interleukin 1-beta and ceruloplasmin levels in Mtx administered rats. Hovewer, Lyc combined with Mel provided a significant reduction also in NO levels. Hstopathological examination showed that there was an obvious improvement in the degenerative changes compared to Mtx administrated group with the Lyc combined Mel group giving best protection. In conclusion Lyc alone and combined with Mel provided significant improvement against renal damage caused by Mtx, preseumably via antioxidant and anti-inflammatory activities.

Oral vinorelbine in combination with trastuzumab as a first-line therapy of metastatic or locally advanced HER2-positive breast cancer

PURPOSE

Vinorelbine-trastuzumab combination proved to be an effective first-line treatment for patients with locally advanced or metastatic breast cancer (MBC). Oral chemotherapy represents a step forward in MBC management. To improve patients' comfort using the oral form of vinorelbine, we conducted a multicenter phase II study to investigate the efficacy and safety of the oral vinorelbine-trastuzumab combination in women with MBC with human epidermal growth factor receptor 2 (HER2) overexpression.

METHODS

Main eligibility criteria: HER2-positive disease, no adjuvant chemotherapy within the last 6 months and no prior chemotherapy for MBC. Patients were treated with oral vinorelbine 80 mg/m(2) D1, D8, D15 (following first 3 administrations at 60 mg/m(2) during the first cycle) for a total of 8 cycles (1 cycle = 3 weeks), in combination with trastuzumab 6 mg/kg on D1 (loading dose: 8 mg/kg) every 3 weeks or 4 mg/kg (loading dose: 6 mg/kg) weekly. Response was evaluated every 2 cycles using RECIST 1.0.

PRIMARY ENDPOINT

objective response rate (ORR); secondary endpoints: duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

In the full population (n = 26), median age was 50.7 years and median WHO PS 0. Median disease-free interval was 50.7 months [95 % CI (43.6-57.9)]. In the evaluable patients population, ORR was 56 % [95 % CI (34.9-75.6)], including 3 complete responses (12 %) and 11 partial (44 %); 8 (32 %) patients had stable disease resulting in a clinical benefit (or disease control) rate of 88 % [95 % CI (68.8-97.5)]. Median DOR was 7.1 months [95 % CI (3.9-10.2)], median PFS 6.7 months (95 % CI 3.5-10), and median OS 27.9 months (95 % CI 17.4-38.3). Treatment was generally well tolerated with main observed grade 3/4 hematological toxicities being neutropenia (46 %) and anemia (4 %). Grade 3-4 nausea-vomiting were observed in 11.5 % of patients.

CONCLUSIONS

Our results confirm the efficacy of oral vinorelbine-trastuzumab combination as a first-line treatment in HER2-positive locally advanced or MBC patients with an acceptable safety profile. Oral vinorelbine-trastuzumab optimizes the convenience of this chemotherapy regimen, especially for patients receiving trastuzumab every 3 weeks.

A Systematic Review of Adherence to Oral Antineoplastic Therapies

BACKGROUND

Oral antineoplastic therapies not only improve survival but also reduce the burden of care for patients. Yet patients and clinicians face new challenges in managing adherence to these oral therapies. We conducted a systematic literature review to assess rates and correlates of adherence to oral antineoplastic therapies and interventions aimed at improving adherence.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive literature search of the Ovid MEDLINE database from January 1, 2003 to June 30, 2015, using relevant terminology for oral antineoplastic agents. We included observational, database, and intervention studies. At least two researchers evaluated each paper to ensure accuracy of results and determine risk of bias.

RESULTS

We identified 927 records from the search and screened 214 abstracts. After conducting a full-text review of 167 papers, we included in the final sample 51 papers on rates/correlates of adherence to oral antineoplastic therapy and 12 papers on intervention studies to improve adherence. Rates of adherence varied widely, from 46% to 100%, depending on patient sample, medication type, follow-up period, assessment measure, and calculation of adherence. Of the intervention studies, only 1 of the randomized trials and 2 of the cohort studies showed benefit regarding adherence, with the majority suffering high risk of bias.

CONCLUSIONS

Although no reliable estimate of adherence to oral antineoplastic therapies can be gleaned from the literature, a substantial proportion of patients struggle to adhere to these medications as prescribed. The few intervention studies for adherence have notable methodological concerns, thereby limiting the evidence to guide practice in promoting medication adherence among patients with cancer.

Treatment with oral anticancer agents: symptom severity and attribution, and interference with comorbidity management

PURPOSE/OBJECTIVES

To evaluate the prevalence, severity, and attribution of symptoms, as well as the interference with management of comorbidities, in patients who have been prescribed oral anticancer agents (OAs).

DESIGN

Descriptive exploratory study.

SETTING

A comprehensive cancer center and two community-based oncology programs in the midwestern United States.

SAMPLE

30 adults undergoing OA treatment.

METHODS

Five phone interviews were conducted during eight weeks. Linear mixed effects and generalized estimating equations were used to examine symptoms and interference over time.

MAIN RESEARCH VARIABLES

Symptoms and comorbid conditions.

FINDINGS

The mean age of participants was 65.1 years. Fifteen participants were female, 25 were Caucasian, and 23 had comorbidities. Twenty-one patients had late-stage cancer, and rates of adherence were 90%. Fatigue, sleep disturbance, and numbness or tingling in hands and feet were highly prevalent symptoms. Younger age was associated with higher symptom severity (p < 0.01) and interference (p = 0.01). Patients with more comorbidities tended to report higher symptom severity. Simultaneous IV chemotherapy was not a predictor of symptom severity or interference over age and comorbidity. Symptoms were most frequently attributed to cancer and its treatment. Patients with a greater number of comorbidities were more likely to include comorbidities in symptom attribution and reported interference from the OA with managing comorbid conditions.

CONCLUSIONS

Symptoms may be more severe in patients prescribed OAs who are younger and have comorbid conditions. More comorbidities and absence of simultaneous IV chemotherapy increased the likelihood of inclusion of chronic conditions in symptom attribution. Patients reported that OA treatment interfered with comorbidity management.

IMPLICATIONS FOR NURSING

Nurses need to take comorbidities into account when caring for patients prescribed OAs because the chronic conditions may influence symptom severity and the ability to manage symptoms.

Comparative adherence to oral hormonal agents in older women with breast cancer

We aim to (1) compare compliance of anastrozole, letrozole, exemestane, and tamoxifen in women and (2) identify clinical factors associated with medication non-adherence and non-persistence. Female Medicare beneficiaries who were new users of anastrozole, letrozole, exemestane, or tamoxifen between 2007 and 2010 were analyzed. Multivariate-modified Poisson and Cox regression models were constructed to compare non-adherence and non-persistence, respectively, across the different oral agents. A total of 5,150 women were included: mean age was 76.4 years, 2352 initiated anastrozole, 1401 letrozole, 248 exemestane, and 1149 tamoxifen. Non-adherence and non-persistence were 41 and 49% respectively, with exemestane being associated with the worst non-adherence and non-persistence (RR 1.57, 95% CI 1.37-1.80, p < 0.001; HR 1.93, 95% CI 1.63-2.30, respectively, p < 0.001), followed by letrozole (RR 1.39, 95% CI 1.26-1.53, p < 0.001; HR 1.47, 95% CI 1.32-1.64, respectively, p < 0.001), and anastrozole (RR 1.16, 95% CI 1.05-1.27, p = 0.003; HR 1.14, 95%CI 1.03-1.27, respectively, p = 0.011), whereas tamoxifen was associated with the best compliance. Use of statins and osteoporosis medications was correlated with improved adherence (RR 0.89, 95 % CI 0.82-0.96, p = 0.002 and RR 0.84, 95 % CI 0.76-0.92, p < 0.001, respectively, for non-adherence) and persistence (HR 0.86, 95 % CI 0.79-0.94, p < 0.001 and HR 0.86, 95 % CI 0.78-0.96, p = 0.005, respectively, for non-persistence), but chronic kidney disease was correlated with worse non-persistence (HR 1.15, 95 % CI 1.04-1.33, p = 0.04). Age ≥ 70 years was also associated with worse compliance. Compliance to oral hormonal therapy varied depending on the type of agent, age, and concurrent medications, highlighting specific opportunities to improve adherence and persistence in older women with breast cancer.

On and off Metronomic Oral Vinorelbine in Elderly Women with Advanced Breast Cancer

Background

Elderly patients with metastatic breast cancer (MBC) have more problems receiving chemotherapy than younger patients, especially with the presence of multiple comorbidities, adverse drug events and functional decline. Low-dose oral administration of cytotoxic agents such as vinorelbine, a semisynthetic vinca alkaloid that interferes with microtubule assembly, leading to arrest of cell division, is usually effective and well tolerated.

Methods

From February 2010 to February 2014, 32 patients with MBC, median age 76 years (range 69-83) were treated with oral vinorelbine 30 mg (total dose), one day on and one day off, until disease progression or unacceptable toxicity levels were reported. Toxicity, quality of life and clinical benefit were evaluated. Matched t-tests were conducted to discern whether quality-of-life indicator (p<0.05 was considered significant) differed before and 6 months after treatment. Statistical analysis was performed using Graph Pad Prism 5.0 (GraphPad Software Inc., San Diego, CA, USA).

Results

No grade 3 and 4 adverse events were reported. A clinical benefit of 50% was found in our cohort. On and off metronomic vinorelbine oral administration resulted in good tolerability and safe profile in our selected elderly population, and improved patient adherence to therapy.

Conclusions

The present study demonstrated that metronomic vinorelbine might be a potential treatment in elderly patients by reducing adverse effects and increasing quality of life, setting the stage for future extensive clinical trials.

Polymeric nanoparticle drug delivery technologies for oral delivery applications

INTRODUCTION

Many therapeutics are limited to parenteral administration. Oral administration is a desirable alternative because of the convenience and increased compliance by patients, especially for chronic diseases that require frequent administration. Polymeric nanoparticles (NPs) are one technology being developed to enable clinically feasible oral delivery.

AREAS COVERED

This review discusses the challenges associated with oral delivery. Strategies used to overcome gastrointestinal (GI) barriers using polymeric NPs will be considered, including mucoadhesive biomaterials and targeting of NPs to transcytosis pathways associated with M cells and enterocytes. Applications of oral delivery technologies will also be discussed, such as oral chemotherapies, oral insulin, treatment of inflammatory bowel disease, and mucosal vaccinations.

EXPERT OPINION

There have been many approaches used to overcome the transport barriers presented by the GI tract, but most have been limited by low bioavailability. Recent strategies targeting NPs to transcytosis pathways present in the intestines have demonstrated that it is feasible to efficiently transport both therapeutics and NPs across the intestines and into systemic circulation after oral administration. Further understanding of the physiology and pathophysiology of the intestines could lead to additional improvements in oral polymeric NP technologies and enable the translation of these technologies to clinical practice.

Plant natural products: from traditional compounds to new emerging drugs in cancer therapy

Natural products are chemical compounds or substances produced naturally by living organisms. With the development of modern technology, more and more plant extracts have been found to be useful to medical practice. Both micromolecules and macromolecules have been reported to have the ability to inhibit tumour progression, a novel weapon to fight cancer by targeting its 10 characteristic hallmarks. In this review, we focus on summarizing plant natural compounds and their derivatives with anti-tumour properties, into categories, according to their potential therapeutic strategies against different types of human cancer. Taken together, we present a well-grounded review of these properties, hoping to shed new light on discovery of novel anti-tumour therapeutic drugs from known plant natural sources.

Issues related to overadherence to oral chemotherapy or targeted agents

Use of oral chemotherapy or targeted agents is shifting how cancer treatment is administered, moving it from supervised office visits to self-administration at home. This study examines issues related to overadherence to oral agents that were noted during a trial conducted by the authors comparing an automated voice system to strategies to reduce symptom severity and improve adherence. Overadherence to oral agents may be a significant clinical problem, occurring more often in patients with complex dosing regimens, and may lead to increased symptom severity from side effects of treatment. Avoiding overadherence may be important for the reduction or prevention of symptoms and potentially life-threatening toxicity. Nurses need to discuss with their patients the importance of the timing of the administration of their oral oncolytic regimen, as well as to provide prompts to assist in self-administration as prescribed so that overadherence can be avoided.

Current practice patterns for oral chemotherapy: results of a national survey

PURPOSE/OBJECTIVES

To describe current nursing practices in the United States regarding care and safety of patients taking oral chemotherapy.

DESIGN

This three-phase study consisted of development, validation, and implementation of a national online survey.

SETTING

Survey of oncology nurses in outpatient settings.

SAMPLE

577 oncology nurses.

METHODS

Surveys were emailed to 5,000 members of the Oncology Nursing Society. The survey included 17 forced-choice items and one free-text item. Descriptive statistics and content analysis were obtained.

MAIN RESEARCH VARIABLES

Patient care practices, nursing resources, and barriers to medication adherence.

FINDINGS

Fifty-one percent of the respondents worked in practices that had developed specific policies, procedures, and resources for patients on oral chemotherapy. Barriers to treatment adherence included cost (81%) and adverse effects (72%). Practices with specific policies differed in clinical and statistical significance from practices without policies on almost every survey item. Free-text responses revealed that many practices have erratic procedures and inadequate interdisciplinary communication.

CONCLUSIONS

Systematic reliable policies and procedures for patient education, documentation, and interdisciplinary communication are urgently needed.

IMPLICATIONS FOR NURSING

Nurses should provide education and repeated teaching to improve patient safety, adherence to the medication, and self-monitoring for adverse effects.

Impact of the healthcare payment system on patient access to oral anticancer drugs: an illustration from the French and United States contexts

Background

Oral anticancer drugs (OADs) allow treating a growing range of cancers. Despite their convenience, their acceptance by healthcare professionals and patients may be affected by medical, economical and organizational factors. The way the healthcare payment system (HPS) reimburses OADs or finances hospital activities may impact patients’ access to such drugs. We discuss how the HPS in France and USA may generate disincentives to the use of OADs in certain circumstances.

Discussion

French public and private hospitals are financed by National Health Insurance (NHI) according to the nature and volume of medical services provided annually. Patients receiving intravenous anticancer drugs (IADs) in a hospital setting generate services, while those receiving OADs shift a part of service provision from the hospital to the community. In 2013, two million outpatient IADs sessions were performed, representing a cost of €815 million to the NHI, but positive contribution margin of €86 million to hospitals. Substitution of IADs by OADs mechanically induces a shortfall in hospital income related to hospitalizations. Such economic constraints may partially contribute to making physicians reluctant to prescribe OADs. In the US healthcare system, coverage for OADs is less favorable than coverage for injectable anticancer drugs. In 2006, a Cancer Drug Coverage Parity Act was adopted by several states in order to provide patients with better coverage for OADs. Nonetheless, the complexity of reimbursement systems and multiple reimbursement channels from private insurance represent real economic barriers which may prevent patients with low income being treated with OADs. From an organizational perspective, in both countries the use of OADs generates additional activities related to physician consultations, therapeutic education and healthcare coordination between hospitals and community settings, which are not considered in the funding of hospitals activities so far.

Summary

Funding of healthcare services is a critical factor influencing in part the choice of cancer treatments and this is expected to become increasingly important as economic constraints grow. Drug reimbursement systems and hospital financing changes, coupled with other accompanying measures, should contribute to improve equal and safe patient access to appropriate anticancer drugs and improve the management and care pathway of cancer patients.

Oral vinorelbine plus cisplatin as first-line chemotherapy in nonsquamous non-small-cell lung cancer: final results of an International randomized phase II study (NAVotrial 01)

BACKGROUND

The combination of oral vinorelbine plus cisplatin has been studied in numerous trials as first-line treatment of patients with non-small cell lung cancer (NSCLC) regardless of histologic subtype. NAVoTrial 01 is the first study that explores this combination specifically in nonsquamous (NS) NSCLC by assessing the feasibility of this doublet (ratio 1:2) in an investigational approach. A reference arm with pemetrexed plus cisplatin was included. Maintenance therapy with single-agent therapy after 4 cycles of combination therapy was included in the study schedules because it reflected a trend in first-line treatment of NSCLC.

PATIENTS AND METHODS

Stage IIIB/IV untreated/relapsed patients with NS NSCLC received a 3-week cycle of pemetrexed 500 mg/m(2) and cisplatin 75 mg/m(2) on day 1 (arm A) or oral vinorelbine 80 mg/m(2) on days 1 and 8 (first cycle 60 mg/m(2)) and cisplatin 80 mg/m(2) on day 1 (arm B). After 4 cycles, patients without disease progression received single-agent maintenance treatment with pemetrexed or oral vinorelbine.

RESULTS

Overall, 153 patients were randomized (arm A/arm B: 51/102). Disease control rate (%) for arm A was 76.5 (95% confidence interval [CI], 62.5-87.2) and for arm B it was 75.0 (95% CI, 65.3-83.1), Response rates for arm A were 31.4% (95% CI, 19.1-45.9) and for arm B were 24.0% (95% CI, 16.0-33.6). Median progression-free survival for arm A was 4.3 months (95% CI, 3.8-5.6) and for arm B it was 4.2 months (95% CI, 3.6-4.7). Median survival for arm A was 10.8 months (95% CI, 7.0-16.4) and for arm B it was 10.2 months (95% CI, 7.8-11.9). Main grade 3/4 hematologic toxicities were neutropenia 18.3% (arm A) and 44.0% (arm B), whereas febrile neutropenia was reported in 2% of patients in each arm.

CONCLUSION

Oral vinorelbine and cisplatin had an efficacy in line with that achieved with a standard treatment such as pemetrexed and cisplatin, coupled with an acceptable safety profile.

Oral anticancer drugs: mechanisms of low bioavailability and strategies for improvement

The use of oral anticancer drugs has increased during the last decade, because of patient preference, lower costs, proven efficacy, lack of infusion-related inconveniences, and the opportunity to develop chronic treatment regimens. Oral administration of anticancer drugs is, however, often hampered by limited bioavailability of the drug, which is associated with a wide variability. Since most anticancer drugs have a narrow therapeutic window and are dosed at or close to the maximum tolerated dose, a wide variability in the bioavailability can have a negative impact on treatment outcome. This review discusses mechanisms of low bioavailability of oral anticancer drugs and strategies for improvement. The extent of oral bioavailability depends on many factors, including release of the drug from the pharmaceutical dosage form, a drug's stability in the gastrointestinal tract, factors affecting dissolution, the rate of passage through the gut wall, and the pre-systemic metabolism in the gut wall and liver. These factors are divided into pharmaceutical limitations, physiological endogenous limitations, and patient-specific limitations. There are several strategies to reduce or overcome these limitations. First, pharmaceutical adjustment of the formulation or the physicochemical characteristics of the drug can improve the dissolution rate and absorption. Second, pharmacological interventions by combining the drug with inhibitors of transporter proteins and/or pre-systemic metabolizing enzymes can overcome the physiological endogenous limitations. Third, chemical modification of a drug by synthesis of a derivative, salt form, or prodrug could enhance the bioavailability by improving the absorption and bypassing physiological endogenous limitations. Although the bioavailability can be enhanced by various strategies, the development of novel oral products with low solubility or cell membrane permeability remains cumbersome and is often unsuccessful. The main reasons are unacceptable variation in the bioavailability and high investment costs. Furthermore, novel oral anticancer drugs are frequently associated with toxic effects including unacceptable gastrointestinal adverse effects. Therefore, compliance is often suboptimal, which may negatively influence treatment outcome.