Relationship between miR-7 expression and treatment outcomes with gefitinib in non-small cell lung cancer

The aim of the present study was to assess the effects of gefitinib chemotherapy on the serum levels of miR-7 in patients with non-small cell lung cancer (NSCLC). A total of 126 patients were enrolled in the present study (stage I-II, n=54 and stage III-IV, n=72). Patients with stage I-II NSCLC underwent surgery in combination with gefitinib chemotherapy, whereas only gefitinib chemotherapy was administered to patients with stage III-IV disease. Serum levels of miR-7 before and after treatment were measured with quantitative polymerase chain reaction using fluorogenic probes, and miR-7 positivity and scoring in resected specimens were determined by immunohistochemistry. The number of miR-7-positive cases and the number of cases with higher miR-7 scores were significantly lower among patients with stage I-II NSCLC than those with stage III-IV disease. Additionally, serum levels of miR-7 before and after intervention were lower in stage I-II than in stage III-IV NSCLC cases. Serum levels of miR-7 after treatment were significantly lower than those before intervention in the two groups. The treatment success rate was significantly higher in miR-7-negative patients than in miR-7-positive patients in the two patient groups. Adverse event rates in miR-7-negative and -positive patients were comparable between the groups. Among those with stage III-IV NSCLC, the survival rate of miR-7-positive patients was significantly lower than that of miR-7-negative patients. Conversely, among those with I-II NSCLC, the progression-free survival and median survival time of miR-7-positive patients were significantly lower than those of miR-7-negative patients. Our findings suggest that serum and expression levels of miR-7 in the tissue were closely associated with tumor staging and the therapeutic effects of gefitinib in NSCLC.

Carcinoembryonic antigen-related cell adhesion molecules as surrogate markers for EGFR inhibitor sensitivity in human lung adenocarcinoma

Background:

Lung adenocarcinoma (LADCA) patients with epidermal growth factor receptor (EGFR) mutations are in general associated with relatively high clinical response rate to EGFR-tyrosine kinase inhibitors (TKIs) but not all responded to TKI. It has therefore become important to identify the additional surrogate markers regarding EGFR-TKI sensitivity.

Methods:

We first examined the effects of EGFR-TKIs, gefitinib and erlotinib, upon cell proliferation of lung adenocarcinoma cell lines. We then evaluated the gene profiles related to EGFR-TKI sensitivity using a microarray analysis. Results of microarray analysis led us to focus on carcinoembryonic antigen-related cell adhesion molecule (CEACAM) family, CEACAM 3, 5, 6, 7, and 19, as potential further surrogate markers of EGFR-TKI sensitivity. We then examined the correlation between the status of CEACAM 3, 5, 6, 7, and 19 immunoreactivity in LADCA and clinicopathological parameters of individual cases.

Results:

In the cases with EGFR mutations, the status of all CEACAMs examined was significantly higher than that in EGFR wild-type patients, but there were no significant differences in the status of CEACAMs between TKI responder and nonresponder among 22 patients who received gefitinib therapy. However, among 115 EGFR mutation-negative LADCA patients, both CEACAM6 and CEACAM3 were significantly associated with adverse clinical outcome (CEACAM6) and better clinical outcome (CEACAM3).

Conclusion:

CEACAMs examined in this study could be related to the presence of EGFR mutation in adenocarcinoma cells but not represent the effective surrogate marker of EGFR-TKI in LADCA patients. However, immunohistochemical evaluation of CEACAM3/6 in LADCA patients could provide important information on their clinical outcome.

First- or second-line gefitinib therapy in unknown epidermal growth factor receptor mutants of non-small-cell lung cancer patients treated in Taiwan

Gefitinib is effective in treating patients with non-small-cell lung cancer (NSCLC). The response rate and improvement in survival are related to several aspects, including race, gender, smoking status, and histology; however, little is known about the relationship between survival and length of gefitinib treatment. We conducted this retrospective study to examine this relationship and identify the predictive factors influencing survival and tumor response in chemonaive and chemotherapy patients who had stage IIIb or IV NSCLC with unknown epidermal growth factor receptor mutants. This analysis was aimed to clarify the difference between first- and second-line gefitinib therapy. Among the 918 newly diagnosed, inoperable NSCLC patients from March 2003 to December 2006, 437 (47.6%) had ever received gefitinib therapy. One hundred forty-nine patients (34.0%) who selected gefitinib as first- or second-line therapy were included in the analysis. The overall survival rates of first- and second-line gefitinib therapy were 12.8 months and 20.7 months, respectively (P = .110). The shorter overall survival may be caused by the omission of platinum-based doublet chemotherapy in 37 patients from the first-line group (39.4%). There was also no significant difference in progression-free survival (6.8 months versus 4.9 months; P = .415), and the objective tumor response and disease control rates were similar. Better prognosis and tumor response was associated with female gender, adenocarcinoma, nonsmokers, and good performance status. The difference in overall survival between patients undergoing second-line treatment compared with those undergoing first-line treatment preceding chemotherapy was significant (P = .041). The overall survival, progression-free survival, and tumor response rates were similar in the patients who received gefitinib as initial therapy or after conventional chemotherapy.

Analysis of Somatic Mutations in Cancer: Molecular Mechanisms of Activation in the ErbB Family of Receptor Tyrosine Kinases

The ErbB/EGFR/HER family of kinases consists of four homologous receptor tyrosine kinases which are important regulatory elements in many cellular processes, including cell proliferation, differentiation, and migration. Somatic mutations in, or over-expression of, the ErbB family is found in many cancers and is correlated with a poor prognosis; particularly, clinically identified mutations found in non-small-cell lung cancer (NSCLC) of ErbB1 have been shown to increase its basal kinase activity and patients carrying these mutations respond remarkably to the small tyrosine kinase inhibitor gefitinib. Here, we analyze the potential effects of the currently catalogued clinically identified mutations in the ErbB family kinase domains on the molecular mechanisms of kinase activation. Recently, we identified conserved networks of hydrophilic and hydrophobic interactions characteristic to the active and inactive conformation, respectively. Here, we show that the clinically identified mutants influence the kinase activity in distinctive fashion by affecting the characteristic interaction networks.

Detection of tumor epidermal growth factor receptor pathway dependence by serum mass spectrometry in cancer patients

BACKGROUND

We hypothesized that a serum proteomic profile predictive of survival benefit in non-small cell lung cancer patients treated with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKI) reflects tumor EGFR dependency regardless of site of origin or class of therapeutic agent.

METHODS

Pretreatment serum or plasma from 230 patients treated with cetuximab, EGFR-TKIs, or chemotherapy for recurrent/metastatic head and neck squamous cell carcinoma (HNSCC) or colorectal cancer (CRC) were analyzed by mass spectrometry. Each sample was classified into "good" or "poor" groups using VeriStrat, and survival analyses of each cohort were done based on this classification. For the CRC cohort, this classification was correlated with the tumor EGFR ligand levels and KRAS mutation status.

RESULTS

In the EGFR inhibitor-treated cohorts, the classification predicted survival (HNSCC: gefitinib, P = 0.007 and erlotinib/bevacizumab, P = 0.02; CRC: cetuximab, P = 0.0065) whereas the chemotherapy cohort showed no survival difference. For CRC patients, tumor EGFR ligand RNA levels were significantly associated with the proteomic classification, and combined KRAS and proteomic classification provided improved survival classification.

CONCLUSIONS

Serum proteomic profiling can detect clinically significant tumor dependence on the EGFR pathway in non-small cell lung cancer, HNSCC, and CRC patients treated with either EGFR-TKIs or cetuximab. This classification is correlated with tumor EGFR ligand levels and provides a clinically practical way to identify patients with diverse cancer types most likely to benefit from EGFR inhibitors. Prospective studies are necessary to confirm these findings.

[Molecular diagnostics in lung carcinoma for therapy stratification]

Lung cancer is the most common tumor-related cause of death in western industrialized countries, despite continuous improvement in both diagnostic and therapeutic approaches. Since epidermal growth factor receptor (EGFR) is overexpressed in 80% of cases of non-small cell lung carcinoma, mediating important carcinogenic properties such as cell-cycle progression, apoptosis, angiogenesis and metastasis, it is considered a relevant target in novel specific therapies. This has lead to the development of the low-molecular EGFR tyrosine kinase inhibitors (EGFR-TKI) Gefitinib and Erlotinib. Predicting which patients will respond to an EGFR-targeted therapy is of particular clinical interest. Recent studies show a significantly better response and prolonged progression-free survival in patients with EGFR-mutated tumors, even when used as first-line therapy. Moreover, genetic mutations which correlate to primary EGFR-TKI resistance (e.g. KRAS) or produce secondary resistance to known TKI (e.g. EGFR mutation T790 M or MET amplification) have meanwhile been explained. Predictive diagnosis of these mutations using histological material is becoming increasingly important for patient stratification and will soon be indispensable not only for lung cancer.

Second-line treatments in non-small cell lung cancer. A systematic review of literature and metaanalysis of randomized clinical trials

BACKGROUND

To assess the efficacy of second-line treatments in non-small cell lung cancer (NSCLC).

METHODS

A systematic review of literature with metaanalysis of randomized clinical trials (RCTs) was independently performed by three authors. A primary analysis included all RCTs comparing any approach (chemotherapy or therapy with epidermal growth factor receptor [EGFR] inhibitors) with placebo; a secondary analysis included all RCTs comparing any treatment with docetaxel therapy every 3 weeks. The 1-year survival rate (SR) of the primary analysis was the primary outcome of the study; the 1-year SR of the secondary analysis, response rate (RR), and time to progression of primary and secondary analyses were the secondary end points.

RESULTS

Fourteen RCTs met the selection criteria. The outcomes of 2,627 and 5,952 patients were analyzed in the primary and secondary analysis, respectively. A significant heterogeneity was documented in the primary analysis for 1-year SR with odd ratio [OR] = 0.763 (p = 0.029). No heterogeneity was documented for RR in the primary analysis, with OR = 0.165 (p < 0.001). A modest heterogeneity was documented in the secondary analysis for 1-year SR and RR, with 1-year SR OR = 0.924 (p = 0.122) and RR OR = 1.069 (p = 0.643).

CONCLUSION

Second-line treatments in NSCLC seem to improve the main outcomes better than supportive care. Docetaxel administration every 3 weeks probably remains the "gold standard" because at present the data in literature are not enough to support a greater efficacy of other alternative options. Further trials are needed to identify a clinical and biological profile that could predict the response to treatments and a criterion to select the patients to be treated with chemotherapy or EGFR inhibitors.

EGFRMutations Predict Survival Benefit From Gefitinib in Patients With Advanced Lung Adenocarcinoma: A Historical Comparison of Patients Treated Before and After Gefitinib Approval in Japan

Purpose

This study evaluated whether the presence of epidermal growth factor receptor (EGFR) mutations is a predictive marker for survival benefit from gefitinib and/or a prognostic marker in patients with advanced lung adenocarcinoma.

Patients and Methods

Overall survival (OS) was compared between patients with advanced lung adenocarcinoma who began first-line systemic therapy before and after gefitinib approval in Japan (January 1999 to July 2001 and July 2002 to December 2004, respectively). Deletional mutations in exon 19 or the L858R mutation in exon 21 of EGFR were evaluated using high-resolution melting analysis.

Results

EGFR mutations were detected in 136 (41%) of the 330 patients included in this study. OS was significantly longer among the EGFR-mutant patients treated after gefitinib approval compared with the OS of patients treated before gefitinib approval (median survival time [MST], 27.2 v 13.6 months, respectively; P < .001), whereas no significant survival improvement was observed in patients without EGFR mutations (MST, 13.2 v 10.4 months, respectively; P = .13). A significant interaction between the presence of EGFR mutations and a survival improvement was seen (P = .045). Among patients treated before gefitinib approval, those with EGFR mutations lived longer than those without EGFR mutations (MST, 13.6 v 10.4 months, respectively; P = .034). The response rates to first-line cytotoxic chemotherapy were not significantly different between patients with and without EGFR mutations (31% v 28%, respectively; P = .50).

Conclusion

EGFR mutations significantly predict both a survival benefit from gefitinib and a favorable prognosis in patients with advanced lung adenocarcinoma.

Gefitinib: a consideration of cost

Cancer care is one of the most significant healthcare costs in the USA. The National Institute of Health (NIH) estimates healthcare spending at US$171.6 billion (2002), with lung cancer estimated as the diagnosis with the second highest cost. As additional lines of therapy and newer targeted agents are incorporated into the treatment of lung cancer, these costs will further increase. Gefitinib, an EGF receptor tyrosine kinase inhibitor, is well established in Asia for the treatment of advanced non-small-cell lung cancer. Although not widely available in the West, encouraging data have recently been reported from a large, global Phase III study of gefitinib in advanced non-small-cell lung cancer. This paper reviews the data supporting the use of gefitinib in the treatment of advanced non-small-cell-lung cancer and considers its potential economic impact, as well as quality-of-life outcomes, compared with cytotoxic chemotherapy.

Second-line treatment of advanced non-small cell lung cancer

After failure of first-line chemotherapy for advanced non-small cell lung cancer, many patients remain candidates to receive further antitumor treatment. To guide clinical management of these patients and to suggest priorities for clinical research, an International Panel of Experts met in Naples (Italy) in April 2007. Results and evidence-based conclusions are presented in this article. Single-agent chemotherapy with docetaxel or pemetrexed is the recommended option for unselected patients with performance status 0 to 2 who are candidates for second-line chemotherapy for advanced non-small cell lung cancer. Docetaxel has demonstrated superiority compared with best supportive care. Pemetrexed has been shown to be noninferior to docetaxel, with a more favorable toxicity profile. Erlotinib is effective in pretreated patients, and can be given second-line in patients not suitable or intolerant to chemotherapy, and in all patients as third-line treatment after failure of second-line chemotherapy. Gefitinib failed to show superiority to placebo as second- or third-line treatment, but it has been shown to be noninferior to docetaxel. In selected patients such as lifetime nonsmokers or those of East-Asian ethnicity, erlotinib, or gefitinib (where licensed) may be considered as second-line treatment even if they are fit for chemotherapy. Best supportive care in addition to active treatment remains important for all patients, but may be the exclusive option for patients unsuitable for more aggressive therapy. Further research is mandatory, to find better treatments, and to identify clinical and molecular predictive markers of efficacy, both for chemotherapy and for novel biologic agents.

Erlotinib for advanced non-small-cell lung cancer in the elderly: an analysis of the National Cancer Institute of Canada Clinical Trials Group Study BR.21

PURPOSE

National Cancer Institute of Canada Clinical Trials Group Study BR.21 established erlotinib as a standard of care in patients with non-small-cell lung cancer (NSCLC) after failure of first- or second-line chemotherapy. The current study analyzes the influence of age on outcomes in BR.21.

PATIENTS AND METHODS

BR.21 was a double-blind phase III trial that randomly assigned 731 patients to erlotinib 150 mg daily or placebo. End points included progression-free survival and overall survival (OS), response, quality of life (QOL), drug exposure, and toxicity, which are analyzed in this retrospective study by the following two age groups: >or= 70 years (elderly) or less than 70 years (young).

RESULTS

There were 163 elderly patients (112 on erlotinib, 51 on placebo) and 568 young patients (376 on erlotinib, 192 on placebo). There was no significant difference between age groups randomly assigned to erlotinib or placebo in progression-free survival (elderly: 3.0 v 2.1 months; hazard ratio [HR] = 0.63; 95% CI, 0.44 to 0.90; P = .009; young: 2.1 v 1.8 months; HR = 0.64; 95% CI, 0.53 to 0.76; P < .0001; interaction, P = .77) or OS (elderly: 7.6 v 5.0 months; HR = 0.92; 95% CI, 0.64 to 1.34; P = .67; young: 6.4 v 4.7 months; HR = 0.73; 95% CI, 0.61 to 0.89; P = .0014; interaction, P = .31). Response rates were similar between age groups. Elderly patients, compared with young patients, had significantly more overall and severe (grade 3 and 4) toxicity (35% v 18%; P < .001), were more likely to discontinue treatment as a result of treatment-related toxicity (12% v 3%; P < .0001), and had lower relative dose-intensity (64% v 82% received > 90% planned dose; P < .001).

CONCLUSION

Elderly patients treated with erlotinib gain similar survival and QOL benefits as younger patients but experience greater toxicity.

Brief report: retrospective review of efficacy of erlotinib or gefitinib compared to docetaxel as subsequent line therapy in advanced non-small cell lung cancer (NSCLC) following failure of platinum-based chemotherapy

BACKGROUND

Randomized trials of advanced non-small cell lung cancer (NSCLC) have demonstrated the activity of docetaxel in second-line and erlotinib in the third-line setting after failure of platinum-based chemotherapy. The role of epidermal growth factor receptor tyrosine kinase inhibitors (EGFRTKI) as second-line treatment prior to docetaxel is currently the subject of ongoing trials. Here we explore the outcomes of these agents' uses in clinical practice.

METHOD

A retrospective review of the NSCLC database at Princess Margaret Hospital in Toronto, Canada was undertaken. Patients who have previously received docetaxel after failure of platinum-based chemotherapy were identified and a chart review was undertaken to further identify those who also received an EGFRTKI to assess their clinical benefits. Primary outcome assessed was response rate and secondary outcomes were time to progression (TTP) and overall survival (OS).

RESULTS

Seventy-four patients received docetaxel for advanced NSCLC from 2001 to 2006, 52 (70%) as second line and 22 (30%) as third line. Twenty-two and 31 of these patients received second- and third-line EGFRTKI, respectively. In the second-line setting, the overall response rate was 10% in the EGFRTKI group and 9% in the docetaxel-treated patients. In the third-line setting, this was 20% and 5%, respectively (p-value 0.29). In both the second- and third-line setting, TTP and OS were not significantly different between the two groups.

CONCLUSION

For patients with advanced NSCLC who progressed following first-line platinum-based chemotherapy, the use of an EGFRTKI in second line appears to be equivalent to docetaxel chemotherapy, and docetaxel has activity third line, post EGFRTKI therapy.

Mutations in the epidermal growth factor receptor gene and effects of EGFR-tyrosine kinase inhibitors on lung cancers

Epidermal growth factor receptor (EGFR) gene mutations are frequent in lung cancer arising in patients of Asian ethnicity, female sex, nonsmokers, and adenocarcinoma histology. About 70% of the patients with EGFR mutations respond to EGFR tyrosine kinase inhibitors (TKIs) including gefitinib and erlotinib, whereas only 10% of those without the mutations do so. Therefore, EGFR mutation is being recognized as one of the most reliable predictive factors for treatment using EGFR-TKIs. Another important issue in clinical practice is the fatal interstitial lung disease (ILD) that can develop in patients with gefitinib treatment, especially Asian patients. A nested case-control study recently conducted in Japan identified some risk factors that cause ILD, including age > or = 55 years, a history of smoking, preexisting ILD, poor performance status, short duration since diagnosis of lung cancer, reduced extent of normal lung on computed tomography, and concurrent cardiac disease. About half of the acquired resistance to EGFR-TKIs that almost always occurs during the course of treatment is caused by a secondary mutation at codon 790 (T790M). EGFR-TKIs are not universally effective for treating lung cancers but are effective in patients with particular genotypes. Therefore, patients who would benefit from EGFR-TKIs therapy should be concentrated in clinical trials. Based on this concept, Phase III clinical trials comparing gefitinib monotherapy with standard platinum-based chemotherapy are currently ongoing for patients with EGFR mutations and lung cancer.

[NSCLC: update on second line therapy following ASCO 2007]

Since the year 2000 second line therapy for pre-treated non-small cell lung cancer patients has been established. There are currently two chemotherapeutic agents - docetaxel (Taxotere) and pemetrexed (Alimta) - which have been approved for second line treatment in Austria in addition to the tyrosinkinase-inhibitor erlotinib (Tarceva). In randomised trials these agents have shown a clear advantage over best supportive care in pre-treated patients in terms of overall survival and quality of life. However, these compounds also cause considerable drug-specific toxicities. Therefore there is an urgent need for new treatment options with higher efficacy and a lower burden of toxicity. At ASCO 2007, results of randomised trials were presented concerning new chemotherapeutic agents, such as vinflunine as well as targeting agents such as gefitinib, without affecting outcome. Another trial comparing a standard dose of pemetrexed with a higher dose also showed no improvement in outcome. A comparison of immediate application with delayed application of docetaxel after primary treatment demonstrated improved progression-free survival in selected patients in the immediate study arm but this did not translate to a survival benefit. The results of these trials may add further treatment options to the present portfolio of agents and concepts in this setting and give some optimism for the near future. At present, no changes need to be made in the options for standard second-line treatment of NSCLC in view of the results presented at ASCO 2007.

["Targeted Therapies" in NSCLC - present and future]

During the last decades considerable progress has been made in the treatment of Non Small Cell Lung Cancer (NSCLC) especially resulting from the introduction of chemotherapy. Based on the results of basic-science, a new era of medical oncology has now been entered. Targets of pivotal importance for the development and perpetuation of malignant proliferation have been identified and pharmaceutical compounds against these structures have been developed ("Targeted Therapies"). The resulting broadening of the therapeutic armamentarium has already changed some of the treatment-guidelines. At the same time, a large number of new drugs has entered the stage of clinical development and every oncologist is confronted with a large amount of new data and the resulting difficulties to keep up to date. Accordingly, the aim of this review is to provide an update on the most important recent developments in the field of "Targeted Therapy" against NSCLC.