Carboplatin equals cisplatin: but how do I prescribe it?

Prediction of progression-free survival and response to paclitaxel plus carboplatin in patients with recurrent or advanced cervical cancer

OBJECTIVE

The aim of this study was to identify predictors of the response to paclitaxel-carboplatin chemotherapy (TC) in recurrent or patients with advanced cervical cancer.

METHODS

The records of 61 consecutive women with recurrent or advanced cervical cancer who were treated with TC were retrospectively reviewed. Data regarding their primary disease, follow-up, recurrence, and the activity and toxicity of TC were collected. Multivariate analysis was performed using the Cox proportional hazards regression model to identify predictors of the response to TC. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Overall, TC was well tolerated and displayed a response rate of 60.7% (19 complete response and 18 partial response). The median progression-free survival was 14 months for all patients and 20 months for the responders. Grade 3 to grade 4 toxicities were observed in 51 patients (83.6%). Multivariate analysis revealed that performance status, symptom status, and prior chemotherapy were independent prognostic predictors of a poor response. Patient survival was inversely correlated with the number of these prognostic factors. When the patients were divided into 2 prognostic groups (low risk: patients with no or one poor prognostic factor; and high-risk: patients with 2 or more poor prognostic factors), the patients in the high-risk group had a significantly shorter progression-free survival than those in the low-risk group (4 vs 16 months, log-rank; P < 0.0001).

CONCLUSIONS

The combination of paclitaxel and carboplatin is effective in patients with recurrent or advanced cervical cancer. Our prognostic model composed of 3 clinical variables might enable physicians to identify patients who would not derive clinical benefit from TC and offer them the opportunity to receive other types of treatment.

Effect of age on systemic exposure and haematological toxicity of carboplatin in advanced non-small cell lung cancer patients

The aim of this study was to evaluate systemic exposure to carboplatin and its haematological toxicity in patients with advanced non-small cell lung cancer both older and younger than 70 years when the target area under the curve (AUC) in elderly patients was reduced by 20%. For this purpose, a population pharmacokinetic model was developed and the haematological toxicity of the drug was assessed. A total of 33 patients received carboplatin on day 1 and gemcitabine (1250 mg/m(2) ) on days 1 and 8. This schedule was repeated every 21 days. The Calvert-Crokcoft-Gault formula was employed to calculate a dose of carboplatin with a target AUC of 5 mg/min./mL in patients under 70 years and 4 mg/min./mL in patients aged 70 or older. The data of 24 patients were treated for population modelling performed with the nonmem (University of California, San Francisco, CA, USA) approach. Haematological toxicity was evaluated for all 33 patients enrolled in the study. The carboplatin systemic exposure measured by the AUC (mg/min./mL) was 5.98 (5.45; 6.51) and 5.36 (5.02; 5.69) for the younger patients and older groups, respectively. No significant differences were observed between the two groups with respect to rates of grade 3+ anaemia, neutropenia or thrombocytopenia. In clinical practice, a target AUC of 4 mg/min./mL carboplatin is applied to patients aged 70 and over, but the actual systemic exposure to the drug is higher. This supports a target AUC of 4 mg/min./mL carboplatin for patients older than 70 years when the dose is calculated by means of the Calvert-Crokcoft-Gault formula.

Factors affecting the completion of intraperitoneal chemotherapy in women with ovarian cancer

HYPOTHESIS

The use of intraperitoneal (IP) chemotherapy as treatment for ovarian cancer has been demonstrated to result in improved survival. However, it is associated with significant toxicity, resulting in the early discontinuation of therapy in many cases. This report quantifies and analyzes the reasons why patients discontinue therapy before completion and discusses strategies for improvement.

METHODS

One hundred seventy-seven women with ovarian cancer who received IP chemotherapy for a 10-year period at a regional cancer center were followed, and demographic and treatment data were collected. SigmaStat (v2.0) was used to make statistical calculations regarding the data.

RESULTS

One hundred seventy-seven subjects received 915 cycles of IP therapy. One hundred forty subjects received IP chemotherapy as initial treatment. Ninety-five (68%) of the 140 subjects completed 6 planned cycles. Thirty-seven subjects received IP for recurrent disease. Only 14 (38%) of the 37 subjects completed 6 cycles (P = 0.001). The most common reason for noncompletion of IP therapy was port occlusion (39/68 of the patients, 57%). Very few subjects refused treatment (9/68 of the patients, 13%). The rate of completion of therapy improved over time in this program (2001, 36%; 2009, 75%).

CONCLUSIONS

The rate of completion of IP chemotherapy was higher in this institution than in other reports, including randomized multicenter trials. Port occlusion was the most common reason why IP chemotherapy was not completed. Subjective reasons for stopping therapy were rare. The establishment of a comprehensive, coordinated IP administration program is likely to result in improved completion rates. Completion rates within an institution improve with experience as well.

Bodyweight change during the first 5 days of chemotherapy as an indicator of cisplatin renal toxicity

To determine whether bodyweight (BW) loss, daily urine volume (UV) or furosemide use are associated with cisplatin nephrotoxicity, performance status, serum chemistries before treatment, average daily UV, maximum BW loss and use of furosemide on days 1-5 of chemotherapy were evaluated retrospectively in chemotherapy-naive patients with thoracic malignancies who had received 80 mg/m(2) cisplatin. Associations between these parameters and the worst serum creatinine levels (group 1, grade 0-1; and group 2, grade 2-3) during the first cycle were evaluated. Of the 417 patients (327 men and 90 women; median age, 59 years), 390 were categorized into group 1 and 27 were categorized into group 2. More women and older patients were observed in group 2 than in group 1 (11.1 vs 5.2%, P = 0.044, and 65 vs 59 years, P = 0.041, respectively). The median average daily UV was 3902 mL in group 1 and 3600 mL in group 2 (P = 0.021). A maximum BW loss > or 2.1 kg was noted in 4.4% of patients in group 1 and 18.5% of patients in group 2 (P = 0.006). Furosemide was used in 206 (49.4%) patients. The median total dose of furosemide in groups 1 and 2 were 0 mg and 26 mg, respectively (P = 0.024). A multivariate analysis showed that a maximum BW loss > or = 2.1 kg and the total furosemide dose were significantly associated with group category. In conclusion, BW loss and total furosemide dose were associated with cisplatin nephrotoxicity.

Medical treatment of epithelial ovarian cancer

Epithelial ovarian carcinoma is still the most common cause of death from gynecologic cancer in the USA and Europe. Only 20-30% of patients are diagnosed at the initial stage where appropriate staging surgery can be curative. Patients with high-risk Stage I disease can benefit from adjuvant chemotherapy with platinum-based schedules. The treatment of patients with advanced disease consists of a staging surgery with maximum cytoreductive effort, followed by chemotherapy with a platinum-taxane combination. Unfortunately, the majority of patients with advanced disease will relapse and become candidates for additional chemotherapy. In those patients with recurrence over 6 months after initial therapy (platinum sensitive), combinations of paclitaxel plus carboplatin and carboplatin plus gemcitabine have shown a benefit over carboplatin alone. Patients with early relapse should be managed with supportive care and sequential monotherapy if chemotherapy is indicated.

Weekly carboplatin in a frail elderly woman with advanced peritoneal carcinoma

INTRODUCTION

Standard chemotherapy for ovarian, peritoneal and fallopian tube carcinoma has been a combination of carboplatin (AUC = 6) and paclitaxel 175 mg/m2 every 3 weeks. For frail and elderly patients who may not tolerate the toxicity associated with combination chemotherapy there is the option of omitting paclitaxel and giving carboplatin (AUC = 6) as a single agent every 3 weeks. The toxicity may be reduced further, without decreasing effectiveness, by giving single-agent carboplatin at a reduced dose (AUC = 2) every week.

CASE REPORT

A frail 79-year-old woman with advanced peritoneal carcinoma had first-line and second-line chemotherapy with single-agent carboplatin on day 1 every 7 days. This has resulted in disease stabilization, CA-125 partial response and improved quality of life. Toxicity has been negligible.

CONCLUSION

Weekly carboplatin is an attractive option for the treatment of frail and elderly patients with ovarian, peritoneal and fallopian tube carcinoma.

A study of sequential high dose cyclophosphamide and high dose carboplatin with peripheral stem-cell rescue in resistant or recurrent pediatric brain tumors

PURPOSE

To determine the maximum tolerated dose (MTD) of carboplatin with autologous hematopoietic stem-cell rescue, in children with poor-prognosis brain tumors.

PATIENTS AND METHODS

A previously determined dose of cyclophosphamide with stem-cell rescue was used as a first course. In a second course, carboplatin was given for 3 days with stem-cell rescue to 20 children. The starting dose of carboplatin was 400 mg/m2/day with increments of 75 mg/m2/day in subsequent cohorts. Toxicity and tumor response were recorded.

RESULTS

There were two grade IV toxicities at the dose level of 775 mg/m2/day. There were no toxic deaths. Thus, the MTD of carboplatin was 700 mg/m2/day for 3 days. There were six complete responses (33%, 95% confidence interval [CI], 13-59%), two partial responses (11%; 95% CI, 1-35%), four with stable diseases (22%; 95% CI, 6-48%) and six progressed (33%; 95% CI, 13-59%) out of 18 assessable. Seven of the eight responses were in primitive neuroectodermal tumors (PNETs) or Germinomas. One child with a metastatic anaplastic astrocytoma had a CR. The median duration of tumor response was 10 months (range: 1.5-87 months) with two children disease free at 66 and 87 months. Actuarial survival is 21%. Median follow-up of survivors is 35 months (range: 15-87 months).

CONCLUSION

The MTD of carboplatin with stem-cell rescue is 700 mg/m2/day for 3 days. Sequential stem-cell supported cyclophosphamide and carboplatin was tolerable in children with brain tumors and produced responses in PNETs and Germinomas.

Gemcitabine plus carboplatin versus mitomycin, ifosfamide, and cisplatin in patients with stage IIIB or IV non-small-cell lung cancer: a phase III randomized study of the London Lung Cancer Group

PURPOSE

This phase III randomized trial compared two chemotherapy regimens, gemcitabine plus carboplatin and mitomycin, ifosfamide, and cisplatin, in chemotherapy-naive patients with advanced non-small-cell lung cancer (NSCLC). The regimens were compared with regard to effects on survival, response rates, toxicity, and quality of life.

PATIENTS AND METHODS

Eligible patients had previously untreated stage IIIB or IV NSCLC suitable for cisplatin-based chemotherapy. Randomly assigned patients were to receive four cycles, each at 3-week intervals, of carboplatin area under the curve of 5 on day 1 plus gemcitabine 1,200 mg/m(2) on days 1 and 8 (GCa) or mitomycin 6 mg/m(2), ifosfamide 3g/m(2), and cisplatin 50 mg/m(2) on day 1 (MIC).

RESULTS

Between February 1999 and August 2001, 422 patients (GCa, n = 212; MIC, n = 210) were randomly assigned in the United Kingdom. The majority of patients received the intended four cycles (GCa, 64%; MIC, 61%). There was a significant survival advantage for GCa compared with MIC (hazard ratio, 0.76; 95% CI, 0.61 to 0. 93; P = .008). Median survival was 10 months with GCa and 7.6 months with MIC (difference, 2.4 months; 95% CI, 1.0 to 4.0), and 1-year survival was 40% with GCa and 30% with MIC (difference, 10%; 95% CI, 3% to 18%). Overall response rates were similar (42% for GCa v 41% for MIC; P = .84). More thrombocytopenia occurred with GCa (P = .03), but this was not associated with increased hospital admission or fatality. GCa caused less nausea, vomiting, constipation, and alopecia and was associated with fewer admissions for administration and better quality of life.

CONCLUSION

In patients with advanced NSCLC, GCa chemotherapy was shown to be a better-tolerated treatment that conferred a survival advantage over MIC.

Relevance of chemotherapy dose and schedule to outcomes in ovarian cancer

The current standard of care in ovarian cancer is complete surgical cytoreduction followed by adjuvant (postoperative) platinum-based chemotherapy. Taxanes are frequently combined with platinum compounds in the adjuvant chemotherapy setting and, whether they are given in combination or sequentially, they produce greater progression-free and overall survival than historical combination regimens. Because the treatment of ovarian cancer relies on chemotherapy, this article reviews the evidence for a correlation between chemotherapy delivered at full dose on schedule (FDOS) and patient outcomes. Meta-analyses have suggested that the dose intensities of cisplatin and carboplatin correlate with survival. However, the findings in these hypothesis-generating analyses have not been confirmed in prospective trials. In addition, increasing the dose of cisplatin above a certain threshold is not recommended in ovarian cancer because of the greater toxicity with higher doses of platinum compounds. The delivered dose intensities of taxanes used as single agents have not been shown to correlate with patient outcomes, but adding a taxane to platinum compounds appears both to attenuate the toxicity of the platinum compounds and to facilitate the delivery of FDOS chemotherapy. In the literature on ovarian cancer there is no clear consensus on the benefit of maintaining FDOS chemotherapy. Clinical studies, especially a proposed trial of a dose-dense carboplatin and paclitaxel combination, may provide stronger evidence for the effect of FDOS chemotherapy in ovarian cancer.