In situ protein expression of RRM1, ERCC1, and BRCA1 in metastatic breast cancer patients treated with gemcitabine-based chemotherapy

Ribonucleotide reductase 1 (RRM1) is a determinant of gemcitabine efficacy in non-small-cell lung cancer and pancreatic cancer. We investigated the protein levels of RRM1 and two other DNA repair enzymes, ERCC1 and BRCA1, in 55 metastatic breast cancer (MBC) patients undergoing gemcitabine-based chemotherapy. With automated in situ protein quantification (AQUA v1.6), the average scores for RRM1, ERCC1, and BRCA1 ranged from 245.6-2774.1, 74.0-410.3, and 54.4-1833.1, respectively. They were significantly associated with each other (Spearman's rho > or = .36; p < or = .007). Given their pattern of distribution, RRM1 and BRCA1 are potentially suitable markers for clinical decision making in MBC.

Neoadjuvant chemotherapy for non-small cell lung cancer

Even with aggressive surgical treatment, relapse rates remain high for patients with resectable non-small cell lung cancer (NSCLC). In an effort to improve survival in these patients, numerous clinical trials have evaluated neoadjuvant and adjuvant chemotherapy. Three large, randomized clinical trials and two meta-analyses have demonstrated a survival benefit for adjuvant cisplatin-based chemotherapy compared to surgery alone. Adjuvant chemotherapy has become the standard of care for patients with resected NSCLC. A neoadjuvant approach offers several potential advantages over adjuvant therapy, including earlier treatment of micrometastatic disease, improved compliance and pathologic confirmation of efficacy. Randomized trials have shown neoadjuvant therapy to be feasible and safe and some studies have yielded promising efficacy. The applicability of these results has been limited due to patient heterogeneity, imprecise staging and lack of standardization with respect to inclusion of radiation therapy. With novel agents, improved staging, better supportive care and relevant molecular markers, a neoadjuvant strategy is promising for future clinical trials in NSCLC.

What can interest tell us about uptake of genetic testing? Intention and behavior amongst smokers related to patients with lung cancer

BACKGROUND

Much of the research examining psychosocial aspects of genetic testing has used hypothetical scenarios, based on the largely untested assumption that hypothetical genetic testing intentions are good proxies for behavior. We tested whether hypothetical interest predicts uptake of genetic testing and whether factors that predict interest also predict uptake.

METHODS

Participants (n = 116) were smokers and related to patients with lung cancer, who completed a telephone survey. Interest in genetic testing for lung cancer risk was indicated by responding 'definitely would' to a Likert-style question. Internet-delivered genetic testing for lung cancer risk was then offered. Uptake was indicated by requesting the test and receiving the result.

RESULTS

63% of participants said they 'definitely would' take the genetic test; uptake was 38%. Participants who said they 'definitely would' take the test were more likely than others to take the offered test (45% vs. 26%, p = 0.035). Interest was associated with attitudes towards genetic testing and motivation to quit smoking. Uptake was associated with motivation, prior awareness of genetic testing, and daily Internet use.

CONCLUSION

Hypothetical interest only modestly predicts uptake of genetic testing. Interest in genetic testing likely reflects generally positive attitudes that are not good predictors of the choices individuals subsequently make.

National survey of physicians practice patterns: Fertility preservation and cancer patients

CRA9508

Background: Addressing the impact of cancer treatment on fertility is a high priority in providing quality cancer care to patients of childbearing age. Evidence suggests less than 50% of patients receive adequate fertility information prior to cancer treatment. This study assessed the practice patterns of physicians and identified perceptions of barriers to communication about fertility. Methods: A 37 item survey was developed by a review of the literature and previous qualitative interviews. A random sample of physicians from the American Medical Association Masterfile was stratified by board specialty related to oncology. Three waves of surveys were distributed across the United States. The domains of the survey included demographics, knowledge, attitudes and practice behaviors related to FP with patients of childbearing age. Results: Of 1,979 physicians identified, a total of 613 physicians completed the survey, yielding a 33% response rate among oncologists. Oncologists with favorable attitudes towards FP were 4.9 times more likely to discuss the impact of cancer treatment on future fertility than those who have unfavorable attitudes. GYN or Medical/Hematological oncologists were 2.1 times more likely than other specialists to report feeling comfortable discussing FP with their patients. The majority of oncologists reported discussing FP with patients and indicated the primary barrier to discussion was a patient too ill to delay treatment. However, less than 25% of oncologists report referring patients for FP and only 38% report knowledge of the ASCO guidelines suggesting oncologists should discuss FP and refer all patients of childbearing age. Less than 25% of physicians surveyed reported distributing educational materials regarding FP. Conclusions: The majority of physicians in this survey report discussing FP; however they are not consulting specialists or providing educational materials to their patients. Future research will include the development of physician and nurse training curricula and interventions to facilitate discussion of FP between physicians and cancer patients.

No significant financial relationships to disclose.

National survey of physicians practice patterns: Fertility preservation and cancer patients

CRA9508

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.

Chemoprevention with enzastaurin: First-year results

1520

Background: Chemoprevention is crucial for reducing lung cancer mortality. The implementation and conduct of such trials is complex. We evaluated accrual in an ongoing trial. Methods: We are conducting a study evaluating if enzastaurin, a protein kinase C beta inhibitor, decreases the Ki-67 labeling index in bronchial epithelium after 6 months of therapy compared to placebo. Eligibility includes age 45 or younger, smoking 30 or fewer packs per year, quit for less than one 1 year, and bronchial meta/dysplasia. Results: Two-thousand eight hundred and nine potential subjects were selected from our database. Between December 2007 and November 2009, 1,242 were invited to participate by an introductory letter and at least 3 attempted telephone contacts. Phone contact was established with 621 (50%) subjects. 245 (39%) declined, 238 (38%) were ineligible, and 138 (22%) were interested in trial participation. At the first face-to-face visit, 57 out of 138 (38%) were eligible, 71 (51%) had not quit smoking for less than 1 year, one (1%) was ineligible for other reasons, and nine (7%) visits are pending. All 57 eligible subjects had an induced sputum exam: 36 had atypia, 19 were normal, and two were inadequate. Bronchoscopies with white light and laser-induced fluorescence and three or fewer biopsies have been done on 22 subjects (4 pending, 4 withdrew, 6 ineligible for bronch). Three had normal histology at all sites, 16 had metaplasia, and two had dysplasia in at least one site (84% abnormal bronchial histology rate, 1 pending). No occult cancers were identified. Conclusions: Of 1,242 preselected potential participants, 11% presented for a first face-to-face visit, 4.6% were eligible after a sputum exam, and 2.4% were fully eligible for randomization. Thus, to reach the accrual goal of 186 patients, we estimate that we will need to contact 7,700 subjects. During our 12-month period, we accessed 1,242 patients with 2.0 FTE for study coordinators (not including the pathologist, bronchoscopist, and laboratory personnel). Our expectation had been to accomplish accrual over a period of 42 months from a pool of 2,809 existing putative patients. Unless our eligibility rate of 2.4% increases, further sources of patients must be identified to accomplish our accrual goal.

No significant financial relationships to disclose.

In situ protein expression of RRM1, ERCC1, and BRCA1 in metastatic breast cancer patients treated with gemcitabine-including chemotherapy

1129

Background: Ribonucleotide reductase 1 (RRM1) is a determinant of gemcitabine efficacy in non-small cell lung cancer (NSCLC) and pancreatic cancer. We investigated the tumoral levels of RRM1 in a population of metastatic breast cancer (MBC) patients treated with gemcitabine-based regimens. The protein levels of the excision repair cross-complementation group 1 (ERCC1) and breast and ovarian cancer susceptibility gene 1 (BRCA1) were also measured. Methods: Fifty-five patients were treated and followed prospectively from September 2004 to December 2007. Treatment consisted of gemcitabine plus a taxane in 46 patients and gemcitabine plus pegylated liposomal doxorubicin in 9 patients. RRM1, ERCC1, and BRCA1 were determined by automated in situ protein quantification (AQUA v1.6) on a tissue microarray containing triplicate tumor specimens. Results: The average scores for RRM1, ERCC1, and BRCA1 ranged from 245.6–2, 774.1, 74.0–410.3, and 54.4–1, 833.1, respectively. A statistically significant correlation between the levels of expression of all three markers (Spearman's rho > .36; P < 0.007) was observed. There was no significant association between RRM1, ERCC1, or BRCA1 levels and disease response, progression free survival, or overall survival. Conclusions: In tumor specimens from patients with MBC, RRM1, and BRCA1 had a range of expression and pattern of distribution that makes these markers potentially suitable for clinical decision making. In contrast, the relatively narrow range of ERCC1 expression might signify that ERCC1 protein levels are not useful predictors of platinum efficacy in MBC. Consistent with what has been shown in NSCLC, RRM1, ERCC1, and BRCA1 levels were significantly correlated, suggesting that the coexpression of such DNA repair proteins may be universal to epithelial malignancies. The lack of correlation between marker levels and clinical outcome may be explained by the specific chemotherapy combinations used.

No significant financial relationships to disclose.

Survival predictors after surgical resection of synchronous bilateral non-small cell lung cancers (NSCLC)

7517

Background: Non-small cell lung cancer (NSCLC) that presents with bilateral lung lesions, but without extra-thoracic metastasis, is uncommon. Prognosis is typically poor: No long-term survivor is expected with systemic chemotherapy. However, small reports have suggested the feasibility of bilateral resections. To date, the predictors of survival following this treatment approach remain unknown. Methods: Our institutional tumor registry was searched for patients who underwent bilateral resections of NSCLC during 1998–2006. Patients with metachronous presentations (second lesion found ≥ 2 years afterward) were excluded. Kaplan-Meier survival estimate and Cox proportional hazards model were used to identify survival predictors. Results: Of the 2582 patients operated for NSCLC, 50 patients were included in this analysis. Median age was 69.2 years. Median tumor sizes were 2.0 cms; Adenocarcinomas were the most common (51%). Of 103 thoracotomies, pneumonectomy was performed in 3 patients. Overall peri-operative mortality was 1.9%. Median progression-free survival was 46.0 months (95% CI, 33.1–66.6); overall survival was 77.5 months (95% CI, 43.1–111.1). Performance status, presence of comorbidity, and pathological vascular invasion were important prognostic factors (Table). Risk score based on the sum of these factors (present =1; absent =0) was a strong predictor of survival. Patients with score ≥ 2 (N=11) had a median survival of 17.2 months, compared with 83.5 months among those with score ≤ 1 (HR 5.52, 95% CI 2.27–13.46; p=0.0002). Conclusions: In this largest series of surgery for synchronous bilateral NSCLC to date, the overall survival rate at 5 years is approximately 50%. Performance status, comorbidity, and vascular invasion are strong predictors of survival. Patients with vascular invasion are at an increased risk of progression or death and adjuvant therapy should be considered.

[Table: see text]

No significant financial relationships to disclose.

Correlation of RRM1 expression in muscle invasive locally advanced urothelial cancer with age

e16021

Background: RRM1, the regulatory subunit of ribonucleotide reductase, plays a role in DNA repair after chemotherapy damage and in gemcitabine metabolism. Prior studies demonstrated a survival benefit to high expression in resected early stage lung cancer and a trend toward longer time to progression with low expression in advanced bladder cancers treated with gemcitabine and cisplatin. We hypothesized that patients with resected locally advanced (T2–4NxM0) urothelial transitional cell carcinoma (TCC) whose tumors had higher RRM1 expression would have longer overall survival (OS). Methods: 84 radical cystectomy specimens with muscle invasive TCC were identified from existing tissue microarrays (TMAs) containing 343 specimens. The medical records of these patients were retrospectively reviewed to confirm pathology and stage. Presence of muscle invasion was required. Specimens were analyzed for RRM1 expression using AQUA. The median value of RRM1 was established a priori as the cutoff for high and low expression. Results: Median age of the patients was 69.3 years. There was near equal distribution of stages: 30%, 38%, and 32% for stage II, III, and IV respectively. The majority were high grade (99%) with no nodal involvement (69%). Median OS was 2.0 years (0–13.1). Median RRM1 expression was 1493.3. Degree of RRM1 expression did not correlate with OS, but when adjusted for age, adding an interaction term, high RRM1 expression in younger patients correlated with increased OS (p = 0.0278). Median OS for high expressors age <69.3 years was 6 years compared to 2.3 years for low expressors. 35% of patients less than 70 years were high expressors. Conclusions: Our results suggest that high RRM1 expression may be a prognostic factor for improved survival in locally advanced TCC patients less than 70 years old. These results deserve further study in a larger prospective analysis with disease-specific survival assessment and correlation with other possible prognostic genes such as ERCC1.

[Table: see text]

The impact of PET-based staging on survival of patients with stage I lung cancer

7570

Background: Patients with completely resected stage I lung cancer have the best survival. Stage I, as defined by Mountain in 1997, includes tumors of any size located within one lobe of the lung without involvement of the parietal pleura, a distance of 2 cm or more from the carina, and no evidence for metastatic disease in any pulmonary, hilar, or mediastinal lymph node or distant site. The 5-year survival for such patients is 57–67% (Mountain, 1997). We hypothesized that the introduction of FDG-positron emission tomography (PET) scanning would lead to upstaging of stage I patients with a consequential increase in survival. Methods: To test this hypothesis, we compiled a database of all patients with stage I lung cancer that underwent a complete surgical resection at the Moffitt Cancer Center from 1996 to 2006. Results: During this 11-year period, 1230 patients fulfilled these criteria. Surgery was performed by two thoracic surgeons (LR and ES). Description of pts: 638 women, 592 men; 11 African-American, 1215 Caucasian; 18 Hispanic, 1202 Non-Hispanic; age range 28.1–94.0 y, mean 68.9 y, median 69.9 y; 26 pneumonectomies, 243 segmentectomies or wedge resections; 699 adeno-, 15 adenosquamous, 325 squamous, 25 large cell, 57 neuroendocrine carcinomas; maximum tumor diameter range 0.1–25 cm, mean 2.9 cm, median 2.3 cm; 477 dead (survival 0.0–138.8 months), 753 alive (survival 0.1–144.4 months). The median OS by year of resection was: 88.0 m (1996, N=49), 61.2 m (1997, N=52), 72.1 m (1998, N=73), 58.0 m (1999, N=87), 83.6 m (2000, N=100), 75.0 m (2001, N=114), 70.7 m (2002, N=133), >55.7 m (2003, N=140), >41.5 m (2004, N=158), >33.1 m (2005, N=164), and >17.9 m (2006, N=160). These differences were not statistically significant (log-rank p=0.72). PET scanning was initiated at the beginning of the year 2000. The median OS for the 261 patients treated between 1996 and 1999 was 70.7 m (95% CI: 53.9–84.0), and the median OS for the 969 patients treated between 2000 and 2006 was 75.1 m (95% CI: 66.4–83.7). This difference was not statistically significant (log-rank p=0.34). Conclusions: We conclude that the introduction of PET scanning has not impacted on the survival of patients with stage I lung cancer at our institution.

No significant financial relationships to disclose.

A message of hope: creation of the Faces of Lung Cancer project for increasing awareness of clinical trials

In 2002, the Thoracic Oncology Advocacy Program at H. Lee Moffitt Cancer Center and Research Institute was created with a mission to contribute to the prevention and cure of lung cancer by embracing the patient perspective. In an effort to increase awareness of clinical trials (CTs) and to humanize the CT process, members of the advocacy programme were involved in the creation of the Faces of Lung Cancer project. Twelve lung cancer patients who participated in a CT, four caregivers of patients who had been on a trial and four thoracic health care professionals were interviewed and photographed by a professional photographer with prior experience in photo-documentary work. Preliminary results indicate just the process of participating in the Faces of Lung Cancer project and creating the photo essay has had a positive impact on the lives of cancer patients and their caregivers. Formal evaluation of the Faces of Lung Cancer project is underway; however, preliminary results indicate that the project is viewed as successful in terms of conveying a message of hope and increasing awareness. By including visual displays, in conjunction with patient interviews, the photo essay is able to generate and blend powerful information and images that provide a richer, more complete portrayal of the context of a patient's experience.

Pilot phase II study of preoperative gefitinib in early stage non-small cell lung cancer with assessment of intratumor gefitinib levels and tumor target modulation

7603

Background: Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI) can provide clinical benefit in advanced non-small cell lung cancer patients. Here we examined the effect of single agent gefitinib in patients with early stage NSCLC with additional assessment of plasma and tumor concentrations of gefitinib. Previous studies have suggested considerably higher tumor concentrations of gefitinib compared to levels identified in blood, yet the results in human lung cancers is unknown. Methods: We conducted a pilot phase II study of a 28 day preoperative course of gefitinib 250 mg PO daily followed by surgical resection for patients with stage IA to selected IIIA non-small cell lung cancer. Response was assessed by RECIST using CT and changes in FDG metabolism were assessed using PET. Tumor penetration of gefitinib was assessed in surgically resected tumor samples along with plasma assessment on day 28. Results: Sixteen patients (7 men, 9 women) completed therapy on protocol and all who started on gefitinib were able to undergo a complete surgical resection. There were 0/16 objective responses (CR/PR), 14/16 SD, and 2/16 PD. Three of the 6 patients had more than 20% reductions in FDG SUVmax assessed by PET scanning. Day 28 plasma concentrations of gefitinib averaged 531 ± 344 nM (range 65 to 1,211 nM) while tumor concentrations of gefitinib averaged 33,108 ± 44,312 nM (range 474 to 134,669 nM). Conclusions: Our results demonstrate that NSCLC tumor penetration of gefitinib is much higher than concentrations found in plasma. Assessment of pharmacodynamic markers including tumor EGFR and downstream signaling pathways is ongoing. PET scanning may be an early marker of clinical benefit of EGFR TKI.

No significant financial relationships to disclose.

Molecular analysis-directed individualized therapy (MADeIT) in advanced non-small cell lung cancer (NSCLC)

7502

Background: RRM1 (R1) is a crucial gene for nucleotide metabolism, and it is the dominant molecular determinant of gemcitabine efficacy. ERCC1 (E1), a component of the nucleotide excision repair complex, is important for platinum-induced DNA adduct repair. We hypothesized that selection of dual agent chemotherapy based on tumoral R1 and E1 expression would be feasible and beneficial for patients with advanced NSCLC. Methods: A prospective phase II clinical trial in patients with advanced NSCLC was conducted. Patients were required to have a dedicated tumor biopsy for determination of R1 and E1 gene expression by real-time quantitative RT-PCR. The primers and probes had been validated by sequencing of cDNA amplicons. Dual agent chemotherapy consisting of carboplatin (C), gemcitabine (G), docetaxel (D), and vinorelbine (V) was selected based on gene expression as follows: GC for low R1/low E1; GD for low R1/high E1; DC for high R1/low E1; and DV for high R1/high E1. Eligibility included pathologically confirmed advanced NSCLC (stage IV and wet IIIB); PS 0–1; no prior systemic therapy for NSCLC; age ≥18; adequate hematologic, hepatic, and renal function; and measurable or evaluable disease by RECIST. Disease response and patient survival were measured. Results: Sixty eligible patients were enrolled from 2/04 to 12/05. Tumor specimens were collected in all with one minor and clinically insignificant complication. Expression analysis was successful in 55 patients. R1 expression ranged from 0–1,637; E1 expression ranged from 1–8,103; and their expression was correlated (Spearman's rho=0.46, p<0.01). The partial response rate was 44% (95% CI 31–59%). OS and PFS and were 59% and 14% at 12 months with medians of 13.3 and 6.6 months respectively. Conclusion: Therapeutic decision making based on RRM1 and ERCC1 gene expression for patients with advanced NSCLC is feasible and promising for improvement in patient outcome.

No significant financial relationships to disclose.

A phase II study of enzastaurin as second- or third-line treatment of non-small cell lung cancer (NSCLC)

7543

Background: Enzastaurin, an oral serine/threonine kinase inhibitor, suppresses signaling through PKC and the PI3K/AKT pathway, induces tumor cell apoptosis, reduces proliferation, and suppresses tumor-induced angiogenesis. Over-expression and activity of PKC and PI3K/AKT are associated with poor prognosis and treatment resistance in NSCLC. This multicenter phase II trial of enzastaurin as second- and third-line treatment of NSCLC determined the rate of progression-free survival (PFS) at 6 months (mos). Secondary objectives included safety and the rate of overall survival (OS) at 12 mos. Methods: Eligibility included metastatic (stage IV and wet IIIB) NSCLC and prior platinum-based chemotherapy. Patients (pts) received 500 mg of oral enzastaurin, once daily, until disease progression or unacceptable toxicity occurred. All pts were eligible for 2nd or 3rd line treatment. Results: In the 54 pts enrolled [54% M, 46% F; median age: 63 (range: 43–82); 22.2% stage III, 77.8% stage IV, ECOG PS=2], adenocarcinoma was the most frequent diagnosis (67%). Prior therapies included radiotherapy (74%) and EGFR inhibitors (28%). At the final analysis, the median PFS was 1.9 mos (95% CI: 1.7–1.9), and the PFS rate at 6 mos was 14% (95% CI: 4.4%–23.6%). The median OS was 9.9 mos (95% CI: 6.5–14.6). The OS rate at 12 mos was 46.3% (95% CI: 32.1%–60.5%). Nineteen pts (35%) had stable disease (SD); none had a complete or partial response. Ten (19%) pts were on-study for =6 cycles, 3 of whom continued for >10 months. The most common toxicity, fatigue (grade =2, n=15), occurred within 1 week of enrollment and was not reported in pts with SD. Grade =3 toxicities observed were ataxia (n=1), fatigue (n=2), thrombo-embolism (n=1), and anemia (n=1). Two pts discontinued due to fatigue and dizziness. Five pts died on-study and 4 within 30 days of discontinuation due to PD. Post-study chemotherapy (n=28) included bevacizumab, erlotinib, pemetrexed, gemcitabine, cisplatinum and paclitaxel. Conclusion: Although no objective tumor responses occurred, 14% of the pts were progression-free at 6 months. Based on encouraging survival and tolerability data, further evaluation of enzastaurin as a single agent or in combination, is warranted in NSCLC.

No significant financial relationships to disclose.

Phase II trial of docetaxel (D) plus gefitinib (G) in elderly (≥70 years) patients with advanced stage non-small cell lung cancer (ANSCLC)

7690

Background: Adding G to first-line doublet chemotherapy did not improve survival in comparison to doublet chemotherapy alone in phase III trials (INTACT 1 and INTACT2). We hypothesized that therapy with D and G will yield similar efficacy to doublet chemotherapy but with improved toxicity profile that would be especially meaningful for elderly patients. We report here the results of a completed phase II trial. Methods: Previously untreated elderly patients with ANSCLC with ECOG performance status (PS) of 0 or 1, were eligible. D was given at 75 mg/m2 IV on day1, Q 21 days. G given orally daily; starting day 1, at a dose of 250mg. D-G was given for 2 cycles beyond maximal response. G was continued until progression. Tumors were assessed every two cycles while on D-G and every two months while on G. The RECIST criteria were used to measure responses. Results: Forty-four eligible patients were enrolled from 07/2003 to 11/2005. Demographic characteristics were M/F = 25/19; Median age 75 years (range; 70 to 84 years); ECOG PS 0/1= 27/16; Stage IV/IIIB = 38/6; Never-smoker/smoker 8/36; Adenocarcinoma/non-adeno-NSCLC 30/14; Median number of D-G cycles administered is 4 (range; 1 to 6). Median duration on maintenance D was 5 months (range; 1 to 36) Overall response rate was 29% (CR- 2%; PR- 27%) with 48% stable disease. Median progression free survival (PFS) was 8 months (95% CI: 6.2–10.6), PFS at 12 months was 34%, and 24 months was 19%. Median Overall Survival (OS) was 12 months (95% CI: 5.6–17.5). OS at 12 months was 52% and 24 months was 20%. The most common hematologic and non- hematologic adverse events were lymphopenia/anemia, and fatigue/hyperglycemia (steroid-induced)/dyspnea, respectively. Three patients had febrile neutropenia (6.8%). Detailed toxicity analyses will be reported at the meeting. Conclusion: The combination of D and G demonstrates comparable efficacy to conventionally used doublet chemotherapy regimens. The relatively favorable toxicity profile warrants further development of this approach, especially in clinical situations or special populations where toxicities are an impediment to treatment.

No significant financial relationships to disclose.

Quality-of-life (QoL) outcome of standard chemotherapy for advanced non-small cell lung cancer (NSCLC): A comparison between cisplatin- and non-cisplatin-based regimens

18067

Background: Among standard chemotherapy regimens for NSCLC, cisplatin-based regimen is known to be associated with significant nausea and vomiting. QoL during treatment with cisplatin-based chemotherapy, when compared with others is unclear. Methods: We performed a MEDLINE search for all phase III randomized controlled trials of NSCLC that reported QoL outcomes and used standard chemotherapy regimens containing cisplatin in one arm and non-cisplatin in the other. Two reviewers independently extracted data and assess quality. QoL reporting criteria were priori hypothesis stated, rationale for instrument reported, psychometric properties reported, cultural validity verified, adequacy of domains covered, instrument administration reported, baseline compliance reported, timing of assessment documented, missing data documented, clinical significance addressed, and presentation of results (Efficace et al, JCO 2003). Results: Out of 893 potential titles, 9 studies were identified. Two did not meet the minimum QoL reporting criteria and were excluded. Of the 7 included studies (N=3439), only one measured QoL as a primary endpoint; only two satisfied all 11 quality criteria for QoL reporting. Due to the heterogeneity of the reporting formats, we were unable to pool data on QoL. Two of seven studies indicated that a cisplatin-containing regimen was associated with a significantly worse QoL when compared with a non-cisplatin regimen (Table). Among these selected studies, treatment-related death was higher with cisplatin-based regimens [reported from 8 studies, N=3290, RR=0.66;95%CI (0.46–0.95), p=0.03]. Grade 3 and 4 neutropenia and neutropenic fever were also more common in the cisplatin-based arms. Conclusion: We found a suboptimal quality of QoL reporting and a lack of standardization of QoL analysis method in these trials. This limits a comparison between studies and the usefulness of QoL endpoint for clinical decision-making.

[Table: see text]

No significant financial relationships to disclose.

A global genome damage score predictive of lung cancer patients outcome

Genome damage is a hallmark of human cancer. Efforts at assessing the impact of genome damage on tumor phenotype and patients outcome have focused on measurements of the relative DNA content in tumor cells compared to normal cells and the assessment of allelic loss at single or multiple selected loci that are thought to harbor genes important in cancer biology. We adapted a global, high-resolution genotyping method for determination of global and unbiased allelic loss. We generated a score, termed global genome damage score (GGDS), that is a continuous variable from zero to one and a measure of the extent of damaged DNA in individual tumors. In 71 patients with completely resected non-small-cell lung cancer, the GGDS ranged from 0.0006 to 0.5530 with a median value of 0.0401 indicating that between 0.06 and 55.3% of the genome has allelic loss. Patients with high scores (>0.04) had a significantly worse outcome than those with low scores (median overall survival time 35.5 vs >120.0 months, P=0.006 log-rank test; median disease-free survival 28.3 vs >120.0 months, P=0.003 log-rank test). This suggests that the clinical behavior of lung tumors with low GGDS is relatively benign whereas tumors with high GGDS are aggressive resulting in early death of patients.

Dose-dense pemetrexed (P) and gemcitabine (G) as neoadjuvant therapy in resectable non-small cell lung cancer (NSCLC)

7129

Background: Adjuvant chemotherapy is standard of care for NSCLC stage IB-III after complete resection. Neoadjuvant therapy has potential advantages. P and G are efficacious in NSCLC with low toxicity. In combination, they can be given dose-dense, which may result in better efficacy, lower toxicity, and higher patient acceptability than traditional platinum-based therapy. Methods: Patients with resectable IB-IIIA and selected IIIB, PS 0–1, w/o prior therapy were eligible. CT, PET, brain MRI, and mediastinoscopy were used for staging. P (500 mg/m2) and G (1,500 mg/m2) were given on d1, 15, 29, and 43. Imaging studies were repeated 7–14 days after treatment and response determined by RECIST. Patients had surgery 3–4 weeks after the last treatment. F/U was every 3 months for 2 years with imaging studies. The primary clinical endpoint is radiographic disease response rate. The secondary endpoints are overall and disease-free survival, pathologic response rate, treatment-related toxicity, and surgical respectability and outcome Results: From 4/04 to 12/05, 45 eligible patients were enrolled. The disease stages were IB in 17, IIA in 3, IIB in 10, IIIA in 12, and IIIB in 3 patient. 8 had adeno, 15 squamous, and 22 large cell or unspecified NSCLC on initial diagnosis. 27 had a PS of 0 and 18 PS 1. 3/45 had weight loss. 22 were women. The median age was 67 (range 42–83 years). 2 were never-smokers, 24 had quit, and 19 were active smokers. Disease response rates to PG were 3% CR, 34% PR, 55% SD, and 8% PD. An R0 resection was performed in 75% of patients, 15% had an incomplete resection, and 10% did not have a thoracotomy. There have been no deaths or unexpected morbidities related to surgery or chemotherapy. Conclusions: Dose-dense PG is well tolerated with acceptable side effects. It appears to be equally as efficacious as platinum-containing chemotherapy doublets in terms of radiographic response rates. Survival rates and the median survival time are forthcoming to allow for a better comparison of this regimen with platinum-containing doublets.

No significant financial relationships to disclose.

Evaluation of publicly-sponsored lung cancer trials in US: Are experimental treatments better than the control ones?

7157

Background: Lung cancer is one of the leading causes of cancer deaths in the US. A considerable number of these patients are treated in randomized clinical trials (RCTs). However, how often experimental lung treatments are superior to control treatments is not known. To accurately assess this, three factors have to be taken into consideration: publication rate, methodological quality of trials and the choice of the comparator intervention. Methods: All phase 3 RCTs that were completed to date by 3 National Cancer Institute cooperative groups (ECOG, NCCTG and RTOG) were eligible for the analysis. We identified 50 RCTs enrolling 11,631 lung cancer patients. The methodological quality of the trials was assessed for possible effects of bias and random error on the outcomes of the trials. The possible impact of the choice of a comparator intervention was also assessed. To evaluate the outcomes, we extracted data on survival (OS), disease free survival (DFS), response rate (RR) and treatment-related mortality (TRM). In addition, the final investigators’ preference about experimental or control interventions was used to assess whether experimental treatments were better than controls. Results: In terms of OS, DFS and RR experimental treatments were as likely as control treatments to be successful—Hazard ratio [HR]= 0.96 (99%CI 0.92–1.01)], [HR = 0.98 (99%CI 0.98–1.17)] and [RR = 1.11 (99%CI 0.84–1.46)], respectively. TRM was worse with experimental treatments [HR = 1.61 (99% CI 1.10–2.36)]. Investigators’ preferences for experimental vs. control treatments were 30% and 70%, respectively (p < 0.001). The quality of trials was high. We did not find any evidence that the methodological quality of trials/choice of comparator influenced the results. Conclusions: We found that there is no clear pattern that predicts which treatment will be better. In aggregate, there is about an equal chance for experimental and standard treatments to result in successful outcomes or that the outcomes may not differ between two types of the treatments, although TRM is slightly higher with experimental arms. This is a welcome finding because if one intervention (experimental or control) was consistently better, maintaining randomization will be difficult.

No significant financial relationships to disclose.

Prospective evaluation of RRM1 as a predictor of response to gemcitabine/carboplatin (GC) in non-small cell lung cancer (NSCLC)

7054

Background: RRM1 is the regulatory subunit of ribonucleotide reductase. It is a molecular target of G. RRM1 increases upon continuous exposure of cell lines to G. Preliminary data suggest improved survival for patients with low as opposed to high tumoral expression of RRM1 when treated with G-based chemotherapy. Methods: We determined the efficacy of G and C as induction therapy in patients with locally advanced NSCLC. Trial eligibility included measurable disease, no prior chemotherapy or RT, PS 0–1, and no weight loss. Patients were staged with CT, PET, and brain MRI. GC consisted of two 28-day cycles of G, 1,000 mg/m2 d1&8 and C, AUC 5 d 1. Unidimensional tumor measurements were obtained before and after GC. The study required tumor collection prior to therapy by core needle biopsy. Specimens were frozen in LN. Tumor cells were collected by LCM. Real-time quantitative RT-PCR gene analysis was performed in triplicate per sample for RRM1 and 18SrRNA. Results: Between 11/03 and 7/05, 30 eligible patients were enrolled, and the required tumor biopsies were obtained in all. In one patient, a pneumothorax developed that required chest tube placement. Disease response ranged from a 9% increase to a 100% decrease. 14/26 had SD, 11/26 PR, and 1/26 CR. The patients’ age was 47- 87 years; 12 were women; 13 had IIIA and 13 IIIB; 10 had sq, 7 ad, and 9 LC or NOS NSCLC. RRM1 expression ranged from 0.18 to 129.3. There was a significant (p = 0.014) inverse correlation (r = −0.474) between RRM1 expression and disease response. When grouping patients into those with response (CR/PR) and without response (SD), RRM1 expression was significantly (p = 0.027) associated with response. No significant association was found between RRM1 expression and other parameters. Conclusions: In a prospective clinical trial intratumoral RRM1 expression was significantly and inversely correlated with disease response to gemcitabine and carboplatin. These results strongly suggest that tumoral RRM1 expression is a major predictor of disease response to gemcitabine-based chemotherapy.

No significant financial relationships to disclose.

The benefits of a restaging PET scan after two cycles of neoadjuvant chemotherapy for resectable non-small cell lung cancer

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Background: Neoadjuvant chemotherapy can potentially improve the outlook of resectable non-small cell lung cancer (NSCLC). Whole-body 2-deoxy-2-[18F] fluoro-D-glucose (FDG)-PET is often used as an initial test to determine tumor resectability, but its role as a restaging test after neoadjuvant chemotherapy is unclear. Restaging PET after neoadjuvant chemoradiation helps identify unexpected distant metastasis and avoid unnecessary thoracotomy. We explored its benefits after neoadjuvant chemotherapy. Methods: Patients with stage IB-IIIA and selected IIIB resectable NSCLC received induction gemcitabine (1,000 mg/m2) and vinorelbine (25 mg/m2) on days 1, 8, 22, and 29. PET and CT scan were performed before enrollment and between day 43–50. Response from CT scan was defined by RECIST criteria; from PET, defined as >20% reduction in the SUVmax (a decrease of > 2 SD of spontaneous change in FDG uptake, previously validated). This abstract explores patients participated in a published prospective trial with available both pre- and post-treatment PET scans. Results: There were 19 patients: stage IB-7, stage IIB-2, and stage III-10. Median age was 67 years. Mean interval between staging and restaging PET scan was 59 days. By PET, 10 patients responded. By RECIST criteria, complete response occurred in 0, partial response in 6, and stable disease in 13 patients. Most successfully underwent a complete resection, but positive margins were present in 3; multi-station lymph node involvement was found intraoperatively in 1 patient. Overall median survival was 20.5 months. We found that restaging PET did not help identify any distant metastasis. Moreover, no survival difference was observed between PET responders and non-responders, though PET responders had more advanced stage than their counterparts: median survival 16 months vs. not reached (p = 0.08 adjusted for stage). PET response was correlated with RECIST response (p = 0.05) as well as the response as obtained by SUV max divided by the activity of contralateral lung or aorta ratio. Conclusion: Based on this small group of patients, a restaging PET scan obtained after two cycles of neoadjuvant chemotherapy among patients with resectable NSCLC did not appear to impact the decision on a planned thoracotomy.

No significant financial relationships to disclose.