Phase III trial of gemcitabine plus docetaxel versus capecitabine plus docetaxel with planned crossover to the alternate single agent in metastatic breast cancer

BACKGROUND

Safety and efficacy of gemcitabine plus docetaxel (GD) and capecitabine plus docetaxel (CD) were compared in patients with metastatic breast cancer, where the alternate crossover monotherapy (GD→C or CD→G) was predetermined.

PATIENTS AND METHODS

Patients were randomly assigned to 3-week cycles of either gemcitabine 1000 mg/m(2) on days 1 and 8 plus docetaxel 75 mg/m(2) on day 1 or capecitabine 1000 mg/m(2) twice daily on days 1-14 plus docetaxel 75 mg/m(2) day 1. Upon progression, patients received crossover monotherapy. Primary end point was time to progression (TtP). Secondary end points evaluated overall response rate (ORR), overall survival (OS), and adverse events (AEs).

RESULTS

Despite over-accrual of 475 patients, the trial matured with only 324 of 385 planned TtP events due to patient discontinuations. Human epidermal growth factor receptor 2 status was not captured in this study. More CD patients (28%) discontinued due to AEs than GD patients (18.0%, P = 0.009). TtP [hazard ratio (HR) = 1.101, 95% confidence interval (CI) 0.885-1.370, P = 0.387] and OS (HR = 1.031, 95% CI 0.830-1.280, P = 0.785) were not significantly different comparing GD and CD. ORR was not statistically different (P = 0.239) comparing GD (72 of 207, 34.8%) and CD (78 of 191, 40.8%). TtP, OS, and ORR were not significantly different comparing crossover groups. GD caused greater fatigue, hepatotoxicity, neutropenia, and thrombocytopenia but not febrile neutropenia; CD caused more hand-foot syndrome, gastrointestinal toxicity, and mucositis.

CONCLUSIONS

GD and CD produced similar efficacy and toxicity profiles consistent with prior clinical experience.

A randomized, phase III multicenter trial of gemcitabine in combination with carboplatin or paclitaxel versus paclitaxel plus carboplatin in patients with advanced or metastatic non-small-cell lung cancer

BACKGROUND

Paclitaxel-carboplatin is used as the standard regimen for patients with advanced or metastatic non-small-cell lung cancer (NSCLC). This trial was designed to compare gemcitabine + carboplatin or gemcitabine + paclitaxel to the standard regimen.

PATIENTS AND METHODS

A total of 1135 chemonaive patients with stage IIIB or IV NSCLC were randomly allocated to receive gemcitabine 1000 mg/m(2) on days 1 and 8 plus carboplatin area under the concentration-time curve (AUC) 5.5 on day 1 (GC), gemcitabine 1000 mg/m(2) on days 1 and 8 plus paclitaxel 200 mg/m(2) on day 1 (GP), or paclitaxel 225 mg/m(2) plus carboplatin AUC 6.0 on day 1 (PC). Stratification was based on disease stage, baseline weight loss, and presence or absence of brain metastases. Cycles were repeated every 21 days for up to six cycles or disease progression.

RESULTS

Median survival (months) with GC was 7.9 compared with 8.5 for GP and 8.7 for PC. Response rates (RRs) were as follows: GC, 25.3%; GP, 32.1%; and PC, 29.8%. The GC arm was associated with a greater incidence of grade 3 or 4 hematologic events but a lower rate of neurotoxicity and alopecia when compared with GP and PC.

CONCLUSIONS

Non-platinum and non-paclitaxel gemcitabine-containing doublets demonstrate similar overall survival and RR compared with the standard PC regimen. However, the treatment arms had distinct toxicity profiles.

An observational study of the impact of ethnicity on patients treated for non-small cell lung cancer (NSCLC) in the second-line setting with pemetrexed: Preliminary results in African Americans

e20624

Background: African-Americans are more likely to develop and die from lung cancer than persons of any other ethnic group. Historically, African-Americans have been under-represented in oncology clinical research. This prospective, single-arm, observational study evaluates the impact of ethnicity on disease control rate (DCR) (CR + PR + SD)) in patients (pts) with non-small lung cancer (NSCLC) being treated with pemetrexed (Pem) in the second-line setting. Methods: Eligibility criteria include stage IIIB or IV NSCLC pts receiving Pem for second-line therapy with no restrictions on performance status. An accrual of 200 African-Americans, 200 Hispanics, 200 Asian-Americans, and 400 Caucasians is planned to test the hypothesis that subjects from these minority populations with advanced NSCLC will have DCRs that are not inferior to Caucasian subjects during second-line treatment with Pem in routine clinical practice. This report describes observations from an early examination of the data of the Caucasian and African-American pts enrolled. Results: 293 pts have been enrolled in this study including 243 Caucasians and 34 African-Americans. Demographics of Caucasians: M/F (136:107); median age 66 (range 37–88); histology adenocarcinoma/squamous/other/unknown (141:67:33:2). Demographics of African-Americans: M/F (21:13); median age 64 (range 43–80); histology adenocarcinoma/squamous/other/unknown (22:9:3:0). DCR in Caucasians: 38% (CI= 28–47%: 3 CR, 8 PR, and 34 SD in 120 of the 243 pts). DCR in African-Americans: 61% (CI=36–86%: 0 CR, 0 PR, and 11 SD in 18 of the 34 pts). Updated safety and efficacy data will be available. Conclusions: Preliminary results based on limited data do not indicate an inferior response for African-American pts compared to Caucasian pts being treated with Pem for NSCLC in the second-line setting. Additional data are needed to establish a definitive conclusion.

[Table: see text]

Outcomes for the elderly (≥70 years) from a three-arm phase III trial of gemcitabine in combination with carboplatin (GC) or paclitaxel (GP) versus paclitaxel plus carboplatin (PC) for advanced non-small cell lung cancer (NSCLC)

8052

Background: Approximately 50% of lung cancer patients (pts) are ≥ 70 y, however, this population has been historically underrepresented in clinical trials. Even among pts ≥ 70 y, doublet chemotherapy has been shown to be superior to single-agent therapy (Lilenbaum JCO 2005, Sederholm JCO, 2005), and the efficacy and safety of platinum-based chemotherapy doublets in NSCLC pts ≥ 70 years with good PS have been reported to be similar to those in younger pts (Fossella, ASCO 2003, #2528, Kelly, ASCO 2001, A-1313). The current analysis examined whether any differences were present by age in a three arm trial of GC or GP versus a standard regimen of PC. Methods: 1135 chemonaïve pts with stage IIIB or IV NSCLC were randomized to receive: G 1000 mg/m2 d 1,8 plus C AUC 5.5 d 1; or G 1000 mg/m2 d 1,8 plus P 200 mg/m2 d 1; or P 225 mg/m2 plus C AUC 6.0 d 1. Stratification was based on stage, baseline weight loss, and brain metastases. Cycles were repeated every 21 days up to 6 cycles or disease progression. Clinical results were retrospectively analyzed in by patient age. Results: See Table . Conclusions: In this trial of commonly used regimens for advanced NSCLC, pts 70–74 years of age had significantly longer survival than pts 75–79 years of age. Pts 80+ years of age also had lower survival than the 70–74 year age group, but this difference was not statistically significant. No pts 80+ years of age had brain metastases at study entry. There was no clear pattern with respect to the effectiveness of individual treatment regimens by age group.

[Table: see text]

[Table: see text]

Incidence and outcomes associated with brain metastases (BM) in a three-arm phase III trial of gemcitabine in combination with carboplatin (GC) or paclitaxel (GP) versus paclitaxel plus carboplatin (PC) for advanced non-small cell lung cancer (NSCLC)

8076

Background: A limited number of randomized phase III studies of advanced or metastatic NSCLC have included a mixed population of patients (pts) with and without BM at presentation. Analyses of pts with lung cancer from the 1970s and 1980s indicated that the incidence of BM at the time of diagnosis was approximately 10%. Methods: 1135 chemonaïve pts with stage IIIB or IV NSCLC were randomized to receive: G 1000 mg/m2 d 1, 8 plus C AUC 5.5 d 1; or G 1000 mg/m2 days 1 and 8 plus P 200 mg/m2 d 1; or P 225 mg/m2 plus C AUC 6.0 d 1. Stratification was based on stage, baseline weight loss, and presence or absence of BM. Cycles were repeated every 21 d up to 6 cycles or disease progression. Pts who developed BM as the only evidence of progression were able to be treated with whole brain radiation and steroids and remained on study. Results were retrospectively analyzed in by presence or absence of BM at study entry. Results: BM rates by subgroup were as follows (%): overall (17.1), nonsquamous (19.3), squamous (6.9), <70 y (21.3), ≥ 70 y (7.1), female (19.2), male (15.7), Caucasian (16.7), African American (18.8%), Hispanic (22.2), PS 0 (12.9), PS 1 (19.7), weight loss <5% (18.3), weight loss ≥ 5% (15.1), and stage IV (19.0). Among pts with (N=194) and without (N=941) BM, response rates=28.9% and 29.1%, median survival = 7.7 mos (95% CI: 6.7, 9.3) and 8.6 mos (95% CI: 7.9, 9.5), and median time to progression = 4.3 mos (95% CI: 3.4, 5.6) and 4.6 mos (95% CI: 4.2, 5.1), respectively. Rates of grade 3 or 4 adverse events were not different among pts with and without BM. Median survival among pts with BM was 7.6 mos for GC (N=66, 95% CI: 6.3, 10.1), 8.2 mos for GP (N=64, 95% CI: 4.6, 10.5), and 7.7 mos for PC (N=64, 95% CI: 6.1, 10.2). Conclusions: 1) The higher incidence of BM (17.1%) observed in this trial may be related to the increasing incidence of adenocarcinoma, or to the increasing sensitivity of imaging modalities. 2) There was no difference in response, time to progression or survival for pts with or w/o BM.

[Table: see text]

Effect of race on the safety and efficacy outcomes of gemcitabine plus paclitaxel treated patients with metastatic breast cancer (MBC): Analyses from a phase III trial

1070

Background: Population-based studies often attribute racial disparities in breast cancer outcomes to differences in access to treatment, quality of care, or other socioeconomic factors. In a controlled clinical trial setting, these systemic differences between races should be minimal. To evaluate the potential impact of race on outcomes in a controlled clinical setting, we retrospectively analyzed data from a phase III trial (B9E-MC-JHQG; NCT00006459 ) of patients (pts) with MBC. Methods: Analyses were performed on the JHQG trial database after 440 total pt deaths for both study arms. Demographics, safety, and efficacy were analyzed using safety population data from 3 racial groups: Caucasian (CA), Asian (AS), and Hispanic (HP). CA was the reference for all pair-wise comparisons. The logistic model was used to calculate odds ratios for tumor response and the Cox model was used to calculate hazard ratios for time-to-event parameters, adjusting for significant prognostic factors. Results: We report analyses of the gemcitabine (G) + paclitaxel (T) treatment arm. Demographics were balanced across the 3 groups with the exception that ER+/PR+ status was lower for AS compared to CA and HP; unknown ER/PR status was higher for AS. AS had significantly less neutropenia, fatigue, and nausea, but more anemia compared to CA and HP. Median number of treatment cycles completed was lower, but mean dose intensities for G and T were slightly higher, for AS. Response rate and progression-free survival were similar in the 3 groups. Overall survival (OS) and post-study chemotherapy (PSC) were significantly reduced for AS. Conclusions: Our analysis suggests that AS pts were better able to tolerate GT therapy compared to CA and HP pts. However, AS pts had the poorest OS outcome of the 3 racial groups, potentially due to reduced participation in PSC.

[Table: see text]

[Table: see text]

Final results of a randomized phase II trial of pemetrexed (P) + carboplatin (Cb) ± enzastaurin (E) versus docetaxel (D) + Cb as first-line treatment of patients (pts) with stage IIIB/IV non-small cell lung cancer (NSCLC)

8037

Background: E is a selective, oral serine/threonine kinase inhibitor. The combination of PCb has shown clinical activity in two phase 2 trials of advanced NSCLC. A phase 3 trial among pts with stage IIIB/IV NSCLC showed that P + cisplatin provides similar efficacy with better tolerability than gemcitabine + cisplatin (Scagliotti, JCO, 2008). The toxicity profile observed with P + platinum doublets makes these regimens attractive for the integration of novel agents with different mechanisms of action. In the TAX 326 trial, D + cisplatin was associated with a median survival of 11.3 mos vs. 10.1 mos for vinorelbine + cisplatin (P=.04). The current open-label three- arm trial was designed to assess PCb ± E versus a control arm of DCb. Methods: Between 3/06 and 5/08, pts with stage IIIB (with pleural effusion) or IV NSCLC, ECOG PS of 0 or 1, and no prior systemic therapy were enrolled. Pts were equally randomized to 3 arms: (A) P 500 mg/m2 and Cb AUC 6 every 3 wks × 6 cycles with E given orally as a loading dose of 1200 mg or 1125 mg followed by 500 mg daily until disease progression; (B) The same regimen of PCb without E; or (C) D 75 mg/m2 and Cb AUC 6 every 3 wks × 6 cycles. Pts receiving P were administered folic acid, vitamin B12 and steroid prophylaxis. Pts on D also received steroid prophylaxis. Results: See table . Conclusions: First-line treatment with PCb was associated with a significantly longer overall survival than DCb in advanced or metastatic NSCLC. E did not add to the activity of the PCb doublet. PCbE, PCb, and DCb appeared to be well tolerated. Complete results for all patients in the study will be available at the time of the meeting.

[Table: see text]

[Table: see text]

Pemetrexed (P) in relapsed small cell lung cancer (SCLC): Preliminary results of a phase II trial

7716

Background: Pts with relapsed SCLC have a poor prognosis and few effective treatment options. P is a novel multitargeted antifolate that is active and well-tolerated as a single agent in lung cancer. We undertook a trial to assess the efficacy and safety of single- agent P in both chemosensitive (S) and chemorefractory (R) relapsed SCLC pts. Methods: Eligible pts had limited or extensive- stage SCLC, PS 0 to 2, and only 1 prior chemo regimen. S pts were defined as having had a prior response with disease progression >2 mos from end of 1st-line chemo. R pts were those who progressed while on 1st-line therapy, or had any response but progression <2 mos from end of 1st-line chemo. The initial P dose tested was 500 mg/m2 q 21 d. Planned sample sizes were 36 S pts in a 2-stage sequential fashion with potential early stopping for lack of efficacy or unacceptable toxicity, and 25 R pts in a single-stage design with no stopping rule. The stopping rule was invoked when <3 of 14 qualified S pts responded. The protocol was then amended to evaluate P at 900 mg/m2 in additional cohorts of 40 S and 40 R pts. Pts were to receive folic acid and Vitamin B12 prior to treatment with P. The primary outcome measure was response rate. Results: From 7/04 to 3/06, 121 pts were enrolled, with 116 pts treated. S and R pts were analyzed separately at both dose levels. S pts (n=56): M/F, 29/27; median age 65 (range 43–82); PS 0/1/2, 25/23/8. R pts (n=65): M/F, 31/34; median age 64 (range, 35–85); PS 0/1/2, 16/37/12. *3 S pts treated with P 900 mg/m2 remain with disease control after a minimum of 11 mos of follow-up. Conclusions: Preliminary clinical benefit rates (CR+PR+SD) of 20% and 17.4% achieved respectively in S and R pts treated with P 500 mg/m2 suggest modest activity of single-agent P in relapsed SCLC. P can be given at a dose of 900 mg/m2 without a significant increase in Grades 3–4 toxicities, although this does not appear to increase efficacy.

[Table: see text] [Table: see text]

A randomized phase 3 trial of gemcitabine with or without carboplatin in performance status 2 (PS2) patients (pts) with advanced (stage IIIB with pleural effusion or stage IV) non-small cell lung cancer (NSCLC)

7533

Background: The optimal treatment of patients with advanced NSCLC and PS2 has not been resolved. A retrospective analysis of 99 pts with PS2 in CALGB 9730 (Lilenbaum, JCO 2005) demonstrated improved survival associated with combination carboplatin- paclitaxel versus paclitaxel alone (median overall survival=4.7 vs. 2.4 mos., p=.019). Gemcitabine-carboplatin (GC) is an active doublet in advanced NSCLC and is at least as active as paclitaxel-carboplatin (PC) in PS2 pts (ECOG 1599, Tester ASCO 2004). A prospective validation of the activity of GC is needed, which is addressed by comparing GC versus gemcitabine (G) alone in this setting. Methods: 161 chemonaïve pts with advanced NSCLC and PS2 were randomly assigned to G 1250 mg/m2 alone on Days 1,8 or GC (G 1000mg/m2 Days 1,8 followed by C AUC 5 on Day 1). Cycles were repeated every 21 days for 6 cycles or until disease progression or intolerable toxicity. Primary endpoint was median survival. Conclusions: GC resulted in an improved response rate among NSCLC pts with PS2 over G alone. As expected, G3–4 toxicities were greater with GC. Overall survival data will be reported at the time of the meeting.

[Table: see text] [Table: see text]

Phase I trial of escalating doses of ABI-007 (nanoparticle albumin-bound paclitaxel) and gemcitabine in patients (pts) with thoracic malignancies

18094

Background: ABI-007, nanoparticle albumin-bound paclitaxel, has a different toxicity profile than solvent-based paclitaxel including a lower rate of severe neutropenia. This trial was designed to determine the maximum tolerated dose (MTD) of ABI-007 in combination with gemcitabine (G) in patients with thoracic malignancies. Methods: Patients were required to have a performance status of 0–1, =3 cytotoxic chemotherapy regimens, and preserved renal, hepatic, and bone marrow function. Patients received G 1,000 mg/m2 on days 1, 8 in all cohorts and ABI-007 on day 1 at doses of 260, 300, 340 mg/m2 depending on the treatment cohort every 21 days (1 cycle = 21 days). Day 8 G dose modifications were: G held for ANC < 500 x 109/L or platelets (plts) < 50,000 x 109/L, and 75% of the G dose was given if the ANC 500–999 x 109/L or plts 50,000–99,000 x 109/L. Dose limiting toxicities (DLT) were assessed after the first cycle and were defined as: grade 3 non-hematologic toxicity, febrile neutropenia, grade 4 anemia or thrombocytopenia, ANC = 500 for = 7 days, 2-week delay in initiating the second cycle, or omission of the day 8 G. Doses were escalated in cohorts of 3–6 pts. Results: Thirteen patients were consented and 12 pts were treated (median age 62.5 years (range 35–75); median number of prior treatments 2.5 (range 1–4); tumor types: 6 non-small cell lung cancer (NSCLC), 5 small cell lung cancer (SCLC), and 1 esophageal. At an ABI-007 dose of 300 mg/m2, 1 of 6 pts experienced a DLT (omission of day 8 G due to ANC < 500), and at an ABI-007 dose of 340 mg/m2 2 of 3 patients experienced a DLT (1 pt grade 3 rash and pruritus; 1 pt grade 3 fatigue and anorexia). Additional grade 3 or 4 toxicities observed over all cycles were: neutropenia (n=2), sensory neuropathy (n=1), febrile neutropenia (n=1). G was given at full dose in 38 of the 39 cycles. Eight pts were evaluable for response by RECIST: 4 partial responses (SCLC, n=2; NSCLC, n=2), 4 stable disease (NSCLC, n=3; esophageal, n=1). Conclusions: The MTD of ABI-007 is 300 mg/m2 day 1 in combination with G 1,000 mg/m2 on days 1, 8 every 21 days. This combination was well tolerated and demonstrated activity in previously treated NSCLC and SCLC patients.

No significant financial relationships to disclose.

A multicenter U.S. trial of neoadjuvant pemetrexed plus cisplatin (PC) followed by extrapleural pneumonectomy (EPP) and hemithoracic radiation (RT) for stage I-III malignant pleural mesothelioma (MPM)

7561

Background: The optimal management for fit patients with early stage MPM remains controversial. One approach involves neoadjuvant chemotherapy followed by EPP and hemithoracic RT and prior trials using gemcitabine and cisplatin have been reported (Weder JCO 2004, Flores JTO 2006). We administered PC, followed by EPP and RT to further assess feasibility and survival of trimodality therapy in a larger, multicenter study. Methods: Eligibility criteria: Stage T1–3 N0–2, no prior surgical resection, adequate organ function (including predicted post-op FEV1 >35%) and PS 0–1. Pts received pemetrexed 500 mg/m2 plus cisplatin 75 mg/m2 with vitamin supplementation for 4 cycles. Pts without disease progression underwent EPP followed by RT (54 Gy). The primary endpoint was pathologic complete response (pCR) rate. Enrollment was completed in March, 2006. Results: 77 patients were enrolled and 72 are evaluable. Median age 63.5 (range 34–78), M:F = 51:21, Clinical stage I:II:III:IV = 5:31:33:1, epithelial:nonepithelial = 58:15, ECOG PS 0:1:2 = 28:42:2. 83% of patients completed all four cycles of PC. Grade 3/4 events related to chemotherapy included: neutropenia (4%), febrile neutropenia (3%), nausea (1%), vomiting (3%), pneumonia (6%), pulmonary embolism (1%), and chest pain (3%). Of 73 pts assessed for radiologic response, 3 CRs, 21 PRs, 36 SDs, 3 PDs, and 10 were unevaluable; (RR= 33% [95% CI, 0.22, 0.45]). Of 54 pts who underwent surgery, EPP completion rate was 87% (47/54); that is 47/77 (61%) by ITT. Pathologic stage I:II:III:IV:NE = 4:12:24:3:11. One pCR was confirmed. 35/39 completed RT. Preliminary TTP =13.1 mo (95% CI=9.6, 15.9; 48% censored) and median survival=16.6 mo (95% CI=13.9, 19.3; 55% censored;1-yr survival = 68%). Conclusions: This multicenter trial testing trimodality therapy in MPM showed that it is feasible with a high rate of chemotherapy delivery. One pCR was observed. Preliminary survival is below that reported by single institutions for patients undergoing EPP but with a high censorship rate at this early time point. Further analyses are necessary to identify a cohort of patients most likely to benefit. This study was sponsored by Eli Lilly & Company.

No significant financial relationships to disclose.

The impact of shortened vitamin supplementation lead-in time before pemetrexed (P) in patients with relapsed small cell lung cancer (SCLC)

7726

Background: Clinical studies of P have shown less overall toxicity and reductions in Grades 3–4 hematologic and nonhematologic toxicities when pts are pretreated with folic acid and vitamin B12. Current recommendations are to give folic acid 350 μg - 1,000 μg by mouth for at least 5 of 7 days prior to the 1st dose of P, and 1 injection of vitamin B12 1000 μg during the week preceding the 1st P dose. Treatment delay to allow this supplementation may be clinically undesirable, particularly in pts with aggressive malignancies. A trial evaluating single-agent P for the treatment of relapsed SCLC gave us opportunity to observe the effects of a shortened lead-in time for vitamin supplementation. Methods: We reviewed data from a U.S. trial designed to assess the safety and efficacy of single-agent P in chemosensitive and chemorefractory relapsed SCLC pts. Eligible pts had limited or extensive-stage SCLC, PS 0 to 2, and 1 prior chemo regimen. Pts received P doses of 500 mg/m2 or 900 mg/m2 q 21 d. The protocol required the administration of folic acid for at least 5 of 7 days prior to the 1st P dose, and vitamin B12 administration on Day 1, Cycle 1, or up to 14 days prior to the 1st P dose. Included in the analysis were pts who received at least 1 dose of folic acid prior to 1st P dose. We then analyzed preliminary toxicity results for pts receiving vitamin B12 for 0–3, 4–6 and =7 days prior to 1st P dose. Results: From 7/2004 to 3/2006, 116 pts were treated with P. At baseline M/F 57%/59%; median age 64.5 years (range 35–85); PS 0/1/2 was 39%/57%/20%. Cycle 1 vitamin administration timing data is available for 109 pts. Data for all 116 pts will be reported at time of meeting. Because toxicities observed between the 2 P doses were not significantly different, the combined toxicities for both dosing groups are reported here. Conclusions: Based on this data, Vitamin B12 given less than 7 days prior to P does not appear to be associated with increased serious toxicities.

No significant financial relationships to disclose.

[Table: see text]

Randomized phase II trial of gemcitabine plus weekly versus three-weekly paclitaxel in previously untreated advanced non-small-cell lung cancer

INTRODUCTION

Gemcitabine and paclitaxel (Taxol) each provides an efficacious non-platinum option for the treatment of advanced non-small-cell lung cancer (NSCLC), but the optimal dosage and schedule of the two agents used in combination are not well defined.

METHODS

Previously untreated patients with advanced NSCLC were randomized to receive gemcitabine-paclitaxel on a traditional three-weekly schedule (Arm A) or a novel weekly schedule (Arm B) as follows-Arm A (three-weekly): gemcitabine 1000 mg/m2 infused>30 min on days 1 and 8 and paclitaxel 200 mg/m2 infused>3 h on day 1 of a 21-day cycle or Arm B (weekly): gemcitabine 1000 mg/m2 infused>30 min and paclitaxel 100 mg/m2 infused>1 h, both administered on days 1 and 8 of a 21-day cycle.

RESULTS

One hundred patients received at least one dose of treatment. The weekly schedule, Arm B, was more efficacious and less hematologically toxic than Arm A. Confirmed complete and partial response rates were 28.2% and 26.8%, respectively. Median survival was 10.3 months on Arm B and 7.9 months on Arm A (log-rank P=0.10); 1- and 2-year survival rates also favor Arm B: 42.0% versus 34.0% and 18.0% versus 6.0%. Progression-free survival was 5.8 versus 4.8 months, again favoring Arm B (log-rank P=0.06). There was a two-fold lower frequency of grade 3/4 hematologic events with Arm B as follows: neutropenia (16% versus 30%), thrombocytopenia (4% versus 8%), and anemia (2% versus 6%). One patient (2%) in each treatment group developed febrile neutropenia.

CONCLUSION

In this trial, both schedules were efficacious and tolerable, although the weekly schedule resulted in improved survival and lower hematologic toxicity compared with a three-weekly schedule. The weekly schedule of gemcitabine-paclitaxel indicates an improved therapeutic index.

A finalized phase II report of pemetrexed (P) plus gemcitabine (G) as front-line chemotherapy for patients with peritoneal mesothelioma (PM)

2050

Background: P in combination with cisplatin is approved for the treatment of malignant pleural mesothelioma. In an expanded access program, P ± cisplatin was shown to have activity in PM. P plus G are synergistic in preclinical models, but the activity of this combination in PM is unknown. The primary objective of this study was to determine time to disease progression in pts with PM receiving P plus G. Methods: Twenty pts were accrued. Treatment consisted of G 1250 mg/m2/30 minutes on D 1 and 8, and P 500mg/m2 /10 minutes on D 8, immediately before G. Treatment was repeated every 21 days for a total of 6 cycles or until progressive disease. All received folic acid, vitamin B12 and steroid prophylaxis. Results: Median age was 67.5 years (range: 46–79). Histology was epithelial:other = 14:6, M:F = 15:5, and ECOG PS 0:1:2 = 9:6:4. A total of 93 cycles (median 6) were administered. Patient-specific Grade 3/4 hematologic toxicity included neutropenia (60.0%), febrile neutopenia (10%; including one toxic death), anemia (5%), and thrombocytopenia (0%). Grade 3/4 nonhematologic events were fatigue (20.0%), constipation (10.0%), diarrhea (5.0%), peripheral neuropathy (5.0%), and dyspnea (5.0%). Median relative dose intensity was 94.5% for P and 82.9% for G respectively. Investigator-reported response rate was 15% (95% CI: 3.2–37.9%) with 1CR, 2PR, 7SD, 7PD, and 3 Unknown. Median time to progressive disease (MTTPD) and median survival (MS) were and 16.5 months (95% C: 6.6-TBD) and 19.1 months (95% CI: 6.6-TBD) respectively. Conclusions: P plus G is well tolerated in patients with PM. The clinical benefit rate (PR + SD) of 50%, MTTP and MS suggest that this non-platinum doublet can be a reasonable alternative to a platinum doublet in this disease.

[Table: see text]

Initial results of a phase II study of biweekly pemetrexed and gemcitabine in patients with advanced NSCLC

7128

Background: Pemetrexed (P), a multi-targeted antifolate, is synergisitic with gemcitabine (G) in preclinical models. A phase I study examining a biweekly schedule established a recommended phase 2 dose of G 1500 mg/m2 followed by P 500mg/m2. Methods: Patients with Stage IIIB (with pleural effusion) or IV NSCLC, ECOG PS of 0 or 1, no prior systemic chemotherapy, immunotherapy, or biological therapy were enrolled. G was infused over 30 minutes, followed immediately by P given intravenously over 10 minutes once on day 1 every 14 days. Cycles were repeated until 12 treatments or progressive disease. All patients received folic acid, vitamin B12 and steroid prophylaxis. Results: Data on 53 patients (29 male, 24 female) are currently available. Median age: 64 (range: 35, 80), ECOG performance status 0:1 = 38%:60%, Stage IIIB:IV = 19%:81%. Three hundred twelve cycles of treatment were administered with 14 dose reductions (26.4%); median number of doses was 5 for both G and P, and median dose intensity was 98.05% for both G and P. Response data included 1 complete response (1.9%), 14 partial responses (26.4%), 24 stable diseases (45.3%), and 10 progressive diseases (18.9%), with a response rate of 28.3% (95% CI: 16.8–42.3%). Patient-based Grade 3/4 hematologic events included febrile neutropenia (9.4%), neutropenia (28.3%), and thrombocytopenia (1.9%). Grade 3/4 non-hematologic events included fatigue (22.6%), dyspnea (7.5%), dehydration (7.5%), diarrhea (5.7%), constipation (3.8%), and pneumonia (1.9%). Preliminary median survival was 7.8 months (95% CI: 6.0–10.8) with 43.4% patients censored and median TTPD was 4.6 months (95% CI: 2.8–6.1). Conclusion: Biweekly G and P appear to be well tolerated in advanced NSCLC. A clinical benefit rate (ORR + SD) of 73.6% indicates activity in patients with advanced NSCLC. The dose intensity for biweekly G and P is higher than a previously reported 6-cycle, 21-day regimen with median dose intensity of 83.2% for P and 82.2% for G (West, et al. Proc ASCO 2005; 7117).

[Table: see text]

Efficacy and safety of pemetrexed (P) in elderly cancer patients (pts)

8544

Background: P, a novel multitargeted antifolate, has demonstrated antitumor activity in a broad range of tumor types. Approximately 60% of all new cases of cancer and 70% of all cancer-related deaths occur in the elderly population. However, few studies have specifically analyzed the utility of chemotherapy in this population. The objective of this posthoc analysis was to understand the efficacy and tolerability of pemetrexed (alone or in combination) when used in the elderly cancer population. Methods: Data from three pemetrexed registration trials conducted between April 1999 and February 2003 were pooled together. Pts in these studies were diagnosed with malignant pleural mesothelioma, NSCLC, or advanced pancreatic cancer. Pts receiving P as monotherapy or in combination with another drug (gemcitabine or cisplatin) who received at least one cycle of therapy were included in this analysis (n=764). In all studies, P 500 mg/m2 was administered every 21 days. Demographics, efficacy, and safety data from pts receiving P were stratified by age ± 65 years. Kaplan-Meier method was used to estimate survival and time to PD. Cox regression model was also used to test the survival effect of pemetrexed on age after adjusting for disease stage, performance status, gender, and type of tumors, the prognostic factors considered to influence survival. Results: * P<.05 from fisher’s exact test. The adjusted hazard ratio of elderly patients over younger patients was 1.074 with p-value 0.42. Conclusions: P produced similar treatment effects in older and younger patients and appeared to be well tolerated in the elderly population. CTC grade 3/4 Lab and Non-Lab toxicity between two age groups were similar except, as expected, the elderly group had modestly higher myelosuppression. Non-hematologic toxicities were similar between the two age groups.

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Updated report of a phase III study of induction therapy with gemcitabine + carboplatin (GC) followed by either delayed vs. immediate second-line therapy with docetaxel (D) in advanced non-small cell lung cancer (NSCLC)

7032

Background: GC is an active regimen in patients with advanced NSCLC. For non-progressors after induction treatment, optimal timing of sequential therapy is unclear. Is it best to sequence immediately to an active non-cross resistant agent or delay the introduction of this agent until time of disease progression (PD)? This trial was designed to answer this question. Methods: Pts with Stage IIIB or IV NSCLC were enrolled. G 1000mg/m2 was administered on day 1,8 followed by C at AUC 5.0 on day 1. After 4 cycles, non-progressers were then randomized to immediate D (75mg/m2 administered on day 1 every 3 wks) or delayed D (pts were observed until first evidence of PD). Conclusions: This study confirms that it is possible to deliver docetaxel immediately following four cycles of GC without significantly increasing toxicity. The response rate of 42.1% and clinical benefit rate (CR+PR+SD) of 88.2% observed in the immediate D arm compares favorably with the rates of 6.1% and 60.6% of the delayed D arm. Additional toxicity and response information will be available at the time of the meeting.

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Front line therapy with gemcitabine(G) administered immediately prior to pemetrexed (P) for patients (pts) with advanced or metastatic non-small cell lung cancer (NSCLC): Final report of a phase II clinical trial

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Background: P and G have well demonstrated, single-agent activity in pts with locally advanced or metastatic NSCLC. This phase II study was designed to determine the activity of the combination of PG when G was administered immediately prior to P on day 8 of a 21-day cycle. Methods: Pts with Stage IIIB/IV NSCLC were enrolled. Treatment was G 1250 mg/m2 on D 1 and 8, with P 500 mg/m2 on D 8, immediately following G. Treatment was repeated every 21 days for 6 cycles. Pts received folic acid, vitamin B12 and steroid prophylaxis. Results: 54 pts (32 M/22 F) were enrolled in the study. Median age was 65.0 (range = 43 - 87) years, ECOG PS 0: 1 = 35.2%: 57.4%; Stage IIIB (9.3%), Stage IV (90.7%); Histology: adeno (61.1%) squamous (18.5%), and large cell (5.6%). Median dose intensity was 83.2% for P and 82.2% for G. Grade 3 toxicities were neutropenia (12.0%), thrombocytopenia (8.0%), dyspnea (16.0%), febrile neutropenia (10.0%), anemia (4.0%), fatigue (18.0%), nausea (10.0%), vomiting (8.0%), and rash (2.0%). Grade 4 toxicities were neutropenia (28%), thrombocytopenia (4%), dyspnea (6%), anemia (0%), fatigue (4%), nausea (0%), vomiting (0%), rash (0%). Five patients (10%) experienced Grade 1 alopecia. Median TTPD was 4.4 months and survival was 10.6 months. There were 0 CR, 16 PR (35.6%), 16 SD (35.6%), and 12 PD (26.7%), for an overall best response rate of 35.6%. Conclusions: In this study, PG had a disease control rate (ORR + SD) of 71.1% in the front-line treatment of NSCLC, suggesting that this is an active doublet. Administering P on D 8 rather than D 1 did not seem to negatively impact the therapeutic index.

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Phase II trial of cisplatin (C), etoposide (E) and radiation (RT) followed by gemcitabine (G) vs G and docetaxel (D) in stage III A/B unresectable non-small cell lung cancer (NSCLC)

7120

Background: SWOG 9504 demonstrated the benefit of D consolidation after E + C with radiation therapy in pts with locally advanced NSCLC. This study was developed to assess the feasibility and efficacy of consolidation with either G alone or with D after the same chemoradiation schedule as SWOG 9504. Methods: The treatment schema included concurrent C 50 mg/m2 Day 1, 8 + E 50 mg/m2 Day 1–5 for two 28-day cycles + RT 180 cGy daily for 7 weeks after which pts were randomized to consolidation treatment of either G 1000 mg/m2 Day 1, 8 (Arm A) or G 1000 mg/m2 Day 1, 8 + D 75 mg/m2 Day 1 (Arm B) every 21 days for 3 cycles. Forty-six pts have been accrued; data is currently available in 28. Conclusions: Preliminary data indicate that G or G + D following chemoradiation in locally advanced NSCLC is well tolerated. The doublet, as expected, results in more toxicity, particularly myelosuppression and fatigue. Response, survival and TTP data will be presented at the time of the meeting.

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Gemcitabine (G) plus carboplatin (C) at AUC 5 demonstrates reduced grade 4 thrombocytopenia rate compared to AUC 5.5 in first line therapy of patients with advanced stage NSCLC

7130

Background: GC is a commonly used regimen in first-line therapy of advanced stage NSCLC. Various dosing of carboplatin in the GC regimen produces different toxicity profiles. This report summarizes three recent large clinical trials, including the Coalition Trial, using GC regimens that had comparable efficacy to other modern doublets. Methods: Three trials using GC as first-line treatment for advanced NSCLC with recent best response and toxicity data were selected. Pt populations were similarly defined, including measurable or evaluable Stage IIIB (with pleural effusion) or IV disease. All utilized similar 21-d regimens of G 1000 mg/m2 d 1,8 and C AUC 5.5 or 5.0 d1. Results: Despite a grade 4-thrombocytopenia rate of 12% in Trial 1 (Coalition) there was no difference in serious bleeding events compared to the other arms (paclitaxel/carboplatin and paclitaxel/gemcitabine). Discussion: In these three trials, 1126 pts with advanced NSCLC were treated with first-line GC. This database of 743 patients assessed for safety suggests that GC AUC 5 results in a 4.7% (95% CI: 3.3–6.5%) grade 4-thrombocytopenia rate with similar anti-tumor efficacy. The regimen of G 1000 mg/m2 on d1, 8 with C AUC 5 on d1 of a 21-d cycle may be optimal for treatment of advanced NSCLC.

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Evaluation of carboplatin pharmacokinetics in the absence and presence of paclitaxel

In a clinical trial of paclitaxel (Taxol) and carboplatin in combination, the severity of thrombocytopenia was less than would be expected with an equivalent dose of carboplatin alone. To determine whether a pharmacokinetic interaction was responsible for this observation, the effect of pretreatment with Taxol on the pharmacokinetics of carboplatin was examined in 11 patients. Each patient was randomized to one of two treatment groups that determined the order of drug treatments. The treatments were carboplatin as a 30-min infusion alone or immediately following 175 mg/m2 Taxol administered as a 3-h i.v. infusion. The treatments were separated by 1 week. The carboplatin dose was chosen to produce a target area under the concentration-time curve (AUC) of 3.75 mg-min/ml according to a previously published formula (A. H. Calvert et al., J. Clin Oncol., 7: 1748-1756, 1989). The mean administered dose of carboplatin was 338 mg. Serial blood samples were collected over 24 h and analyzed for total and free platinum, and, in some patients, Taxol. The pharmacokinetics of carboplatin (i.e., total clearance and volume of distribution at steady state), was not significantly affected by pretreatment with Taxol. Total clearances of carboplatin were 67.2 +/- 28.8 ml/min and 64.6 +/- 27.9 ml/min in the absence and presence of Taxol, respectively (P = 0.56). The AUC of free carboplatin (3.45 mg-min/ml) obtained in the absence of Taxol was not significantly different from that measured in the presence of Taxol (3.27 mg-min/ml). The AUC of carboplatin in both the absence and presence of Taxol agreed with the projected target AUC of 3.75 mg-min/ml. In conclusion, the application of an individualized dosing strategy is valid for the calculation of the carboplatin dose in this combination. The pharmacokinetics of carboplatin is not altered by pretreatment with Taxol at a standard dose, and a pharmacokinetic interaction is not responsible for the altered toxicity of the combination.

Recurrent cervical cancer treated with cisplatin and methotrexate

A combination of cisplatin (80 mg/m2) and methotrexate (200 mg bolus and 400 mg as a 12-hour infusion) was given to 40 patients who developed local recurrence of cervical cancer after radiotherapy. A maximum of six courses was given at monthly intervals. Twenty-five of the forty (63%) evaluable patients responded, of which 4 (10%) responded completely. A symptomatic response, with reduction of pain, leg oedema, vaginal discharge and breathlessness was seen in 27 (68%) of patients. The median survival of all patients was 11 months. Toxicity was moderate; WHO grade 1 or greater was observed in 83% for nausea and vomiting, 67% for myelosuppression and 47% for mucositis. This combination chemotherapy is active in the treatment of recurrent cervical cancer and a modification of this regimen is currently being assessed as neo-adjuvant therapy in patients with Stage IIB-IVA cervical cancer.