Randomized phase III study of docetaxel plus bavituximab in previously treated advanced non-squamous non-small-cell lung cancer

Background

Bavituximab is a monoclonal antibody that targets phosphatidylserine in the presence of β2 glycoprotein 1 (β2GP1) to exert an antitumor immune response. This phase III trial determined the efficacy of bavituximab combined with docetaxel in patients with previously treated advanced non-small-cell lung cancer (NSCLC).

Patients and methods

Key eligibility criteria included advanced non-squamous NSCLC with disease progression after treatment with platinum-based doublet chemotherapy, evidence of disease control after at least two cycles of first-line therapy, presence of measurable disease, ECOG performance status 0 or 1, adequate bone marrow and organ function, and no recent history of clinically significant bleeding. Eligible patients were randomized 1 : 1 to receive up to six 21-day cycles of docetaxel plus either weekly bavituximab 3 mg/kg or placebo until progression or toxicity. The primary end point was overall survival (OS).

Results

A total of 597 patients were enrolled. Median OS was 10.5 months in the docetaxel + bavituximab arm and was 10.9 months in the docetaxel + placebo arm (HR 1.06; 95% CI 0.88-1.29; P = 0.533). There was no difference in progression-free survival (HR 1.00; 95% CI 0.82-1.22; P = 0.990). Toxicities were manageable and similar between arms. In subset analysis, among patients with high baseline serum β2GP1 levels ≥200 µg/ml, a nonsignificant OS trend favored the bavituximab arm (HR 0.82; 95% CI 0.63-1.06; P = 0.134). Among patients who received post-study immune checkpoint inhibitor therapy, OS favored the bavituximab arm (HR 0.46; 95% CI 0.26-0.81; P = 0.006).

Conclusions

The combination of bavituximab plus docetaxel is not superior to docetaxel in patients with previously treated advanced NSCLC. The addition of bavituximab to docetaxel does not meaningfully increase toxicity. The potential benefit of bavituximab observed in patients with high β2GP1 levels and in patients subsequently treated with immune checkpoint inhibitors requires further investigation.

Clinical trial number

NCT01999673.

ALCHEMIST: Bringing genomic discovery and targeted therapies to early-stage lung cancer

The identification of druggable molecular alterations represents one of the greatest advances in cancer treatment. Such progress is particularly evident for lung cancer, which now has numerous molecularly defined subsets such as epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements. However, understanding of the significance of these genomic alterations is largely limited to incurable, metastatic lung cancer. ALCHEMIST (Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial) is a National Cancer Institute-sponsored initiative to address these questions in earlier-stage disease.

Baseline tumour measurements predict survival in advanced non-small cell lung cancer

BACKGROUND

The association between tumour measurements and survival has been studied extensively in early-stage and locally advanced non-small cell lung cancer (NSCLC). We analysed these factors in patients with advanced NSCLC.

METHODS

Data were derived from the E4599 trial of paclitaxel-carboplatin±bevacizumab. Associations between the Response Evaluation Criteria in Solid Tumors (RECIST) baseline sum longest diameter (BSLD), response rate, progression-free survival (PFS) and overall survival (OS) were evaluated using univariate and multivariable Cox regression models.

RESULTS

A total of 759 of the 850 patients (89%) in the E4599 trial had measurable diseases and were included in this analysis. The median BSLD was 7.5 cm. BSLD predicted OS (hazard ratio (HR) 1.41; P<0.001) and had a trend towards association with PFS (HR 1.14; P=0.08). The median OS was 12.6 months for patients with BSLD <7.5 cm compared with 9.5 months for BSLD ≥ 7.5 cm. This association persisted in a multivariable model controlling multiple prognostic factors, including the presence and sites of extrathoracic disease (HR 1.24; P=0.01). There was no association between BSLD and response rate.

CONCLUSION

Tumour measurements are associated with survival in the E4599 trial. If validated in other populations, this parameter may provide important prognostic information to patients and clinicians.

Results from ARQ 197-209: A global randomized placebo-controlled phase II clinical trial of erlotinib plus ARQ 197 versus erlotinib plus placebo in previously treated EGFR inhibitor-naive patients with locally advanced or metastatic non-small cell lung cancer (NSCLC)

LBA7502

Background: Orally administered ARQ197 is a selective, non-ATP competitive inhibitor of c-MET (MET), a receptor TK implicated in cancer cell migration, invasion, and proliferation. Dual EGFR-MET inhibition is a promising strategy for overcoming MET-mediated resistance to EGFR inhibitors. A prior phase I trial demonstrated the safety of ARQ197 plus erlotinib and suggested activity in patients (pts) with advanced NSCLC.

Methods: This is a global, randomized, placebo-controlled, double-blind trial comparing erlotinib plus ARQ197 (E+A) versus erlotinib plus placebo (E+P). Archival tissue was collected for all pts for k-RAS, EGFR, and MET analyses. The primary endpoint was PFS; secondary endpoints included safety, ORR, OS, and subgroup analyses.

Results: 167 pts were randomized to E+A (84 pts) or E+P (83 pts). Mean age was 63 yrs and baseline characteristics were well balanced for sex (39%/41% F); race (93%/96% white) and smoking history (20%/22% never smoker). Imbalances were seen among treatment arms in NSCLC histology (54%/64% adeno) and predictive molecular genotypes: EGFR mutations (7%/13%) and k-RAS mutations (12%/6%). Final PFS was prolonged with E+A (median = 16.1 wks) vs E+P (9.7 wks) among ITT pts (HR 0.81 [95% CI 0.57, 1.15]; p=0.23). Planned multivariable Cox regression model adjusting for prognostic factors (including histology, genotype) yielded PFS HR 0.68 (95% CI 0.47, 0.98; p<0.05). PFS improvement was particularly prominent among pts with nonsquamous histology, EGFR wild-type status, and k-RAS mutations. Preliminary safety analysis revealed no major differences between arms with AEs (≥10% of pts; all grades) including rash (64%/52%); diarrhea (48%/53%); fatigue (33%/37%); nausea (26%/26%); and anemia (14%/13%). OS, ORR, and final safety data will be analyzed at study conclusion.

Conclusions: Combined with erlotinib in the treatment of second/third-line EGFR-inhibitor naïve NSCLC, ARQ-197 is well-tolerated and prolongs PFS. Particular benefit is observed among pts with non-squamous histology, k-RAS mutations, and EGFR wild-type status.

[Table: see text]

The association between clinical characteristics, treatment modality, and outcomes of non-small cell lung cancer

7534

Background: Non-small cell lung cancer (NSCLC) remains the leading cause of cancer death in the United States. NSCLC outcomes vary widely among patients. The degree to which these disparate outcomes reflect differences in treatment modality remains unclear. We therefore examined these associations at a medical center providing care to a diverse patient population. Methods: We performed a retrospective analysis of consecutive patients diagnosed with NSCLC stages I-III from 2000 to 2005 at the University of Texas Southwestern Medical Center. We recorded patient, disease, and treatment characteristics. The association between these characteristics and outcome was assessed using univariate analysis, multivariate logistic regression, and survival analysis. Results: A total of 482 patients met criteria for analysis. Mean age was 64 y, and 52 percent were men. For stage I/II disease, median survival was 6.7 y for patients aged < 65 y vs 4.4 y for age ≥ 65 y (P=0.01); 3.1 y for men vs >5.8 y for women (P=0.0002); 5.6 y for patients with household income below the national median ($41,995) vs 5.6 y for above-median income (P not significant). For stage III, median survival was 1.1 y for age < 65 y vs 0.7 y for age ≥ 65 y (P=0.02); 0.8 y for men vs 1.2 y for women (P=0.02); 0.7 y for below-median income vs 1.2 y for above-median income (P=0.02). Race and hospital setting (public versus private) were not associated with survival. For stage I/II, patients treated with surgery had a median survival of 5.8 y, vs 1.7 y for non-surgical treatment (P<0.0001). For stage III, patients who received surgery and/or radiation had a median survival of 1.2 y vs 0.5 y for other patients (P<0.0001). For stage I/II, treatment modality was associated with hospital setting, race, and income. For stage III, treatment modality was associated with age, gender, hospital setting, race, and income. In multivariate analysis, age (for stage I/II), gender (for stage I/II), and treatment modality (for all stages) were associated with survival. Conclusions: For stages I-III NSCLC, a number of clinical characteristics are associated with outcomes. Differences in treatment modality may account in part for these disparities. These findings warrant further study.

No significant financial relationships to disclose.

Calculated versus measured creatinine clearance for the dosing of methotrexate in patients with primary CNS lymphoma

1536

Background: High-dose methotrexate (HDMTX) (8g/m2), the cornerstone of therapy for primary central nervous system lymphoma (PCNSL), is commonly dosed using a measured 24-hour creatinine clearance (CrCl) every 2–4 weeks. Because these collections are cumbersome, costly, and at times unreliable, the use of a calculated CrCl was evaluated. Methods: A retrospective analysis was performed on data from all 25 patients (287 treatments) with PCNSL who participated in a multi-center phase II clinical trial of HDMTX conducted by the New Approaches to Brain Tumor Therapy (NABTT) CNS Consortium. Results: The 25 patients had a median age of 61 years (range 32–75 years). Seventeen patients (68%) were men. The patients received a median of 14 (range 2–21) HDMTX treatments. For 256 of 287 total treatments (89%), data were available to compare the measured and calculated (using the Cockcroft-Gault equation) CrCl. The average measured CrCl was 93±29 ml/min, and the average calculated CrCl was 107±43 ml/min. The correlation coefficient (r) was 0.66 (p<0.001) between the measured and calculated CrCl. Of the 256 HDMTX treatments evaluated, 158 (62%) had reliable 48-hour serum MTX levels documented. Forty-eight levels (30%) were in the ideal range (0.3–1 μmol/L), 98 levels (62%) were lower (<0.3 μmol/L), 12 levels (8%) were higher (>1–3 μmol/L), and no levels were in the range associated with significant toxicity (>3 μmol/L). Of these 158 treatments, the use of a calculated rather than measured CrCl would have yielded an identical MTX dose for 46 treatments (29%), a higher MTX dose for 62 treatments (39%), and a lower MTX dose for 50 treatments (32%). This distribution was not significantly different among the subsets of low, ideal, and high MTX levels (p=0.13). Conclusions: In this cohort of patients with PCNSL, there is a high correlation between the calculated and measured CrCl. For these patients, there is not a clear association between the method of determining CrCl and serum MTX levels. Therefore, the administered MTX doses using either method are likely to be similar. In this patient population, a calculated CrCl could be used to avoid the cost and inconvenience associated with measured CrCl.

No significant financial relationships to disclose.

Perceived etiology of foodborne illness among public health personnel

Few data exist about perceptions regarding the etiology of foodborne illness. Among public health staff throughout Tennessee, the three pathogens most commonly believed to cause foodborne illness in the United States actually account for only 12% of disease. Fewer than 3% of respondents correctly identified the leading cause of foodborne illness.

Teaching students about nursing and the environment: Part 2--Legislation and resources

This 2-part series is designed to assist faculty in teaching students about the impact of the environment on health. Part 1 (Gerber & McGuire, 1999/this issue) provides historical background, the role of nursing, a basic curriculum, and student learning activities. Part 2 presents national environmental health objectives, pertinent legislation, organization of environmental health services, global environmental health, and student learning activities. We designed the material to be practical, so that this critical area becomes a routine part of assessment data for nurses as they care for clients.

Teaching students about nursing and the environment: Part 1--Nursing role and basic curricula

Since the time of Nightingale, the phenomena of health, person, nursing, and environment have been considered central to nursing. However, of all the concepts, environment appears to have been the least explored, practiced, and researched. Nursing education does not adequately prepare nurses to understand the impact of the environment on health or to implement environmental interventions. This 2-part series is designed to assist faculty in teaching this content. Part 1 provides historical background, the role of nursing, a basic curriculum, and student learning activities.

Community resources for clients with mobility problems

Clients are leaving the hospital "quicker and sicker," and they frequently have acute care needs that must be met by resources outside the hospital setting. Community resources are diverse, vary widely from place to place, and have no central administration. Thus, using them can be challenging for both the nurse, client, and family. Reimbursement mechanisms underlie a person's ability to use resources and receive health care. By presenting two actual case scenarios where clients have mobility problems commonly seen by orthopaedic nurses, the authors discuss the community resources available, avenues of access to them, and their reimbursement mechanisms.

Meeting the diverse needs of clients in the community: effective use of the referral process

Because clients today generally move quickly from one care setting to another, it is essential to identify their need for follow-up care in the community. A wide array of helping resources are available to enhance continuous, comprehensive care for these clients. When nurses have an understanding of the referral process, they can help clients gain access to appropriate community resources. Establishing an effective referral system facilitates use of the referral process and identification of clients who need ongoing care.

Death in the operating room and postanesthesia care unit: helping nurses to cope

The death of patients in the OR and PACU is an unexpected event that can cause grief, burnout, and turnover among the caregivers who work there. In this era of emphasis on quality, customer satisfaction, and cost containment, prevention of these negative outcomes is important. Although there is scant literature devoted to how nurses cope with patient death in this setting, many of the principles described in the literature for other settings can be applied to assist caregivers to view death as a growth-producing experience, both personally and professionally.