Ethnic differences in the characteristics of patients with newly diagnosed lung cancer in the Te Manawa Taki region of New Zealand

BACKGROUND

Māori have three times the mortality from lung cancer compared with non-Māori. The Te Manawa Taki region has a population of 900 000, of whom 30% are Māori. We have little understanding of the factors associated with developing and diagnosing lung cancer and ethnic differences in these characteristics.

AIMS

To explore the differences in the incidence and characteristics of patients with newly diagnosed lung cancer between Māori and non-Māori.

METHODS

Patients were identified from the regional register. Incidence rates were calculated based on population data from the 2013 and 2018 censuses. The patient and tumour characteristics of Māori and non-Māori were compared. The analysis used Χ2 tests and logistic models for categorical variables and Student t tests for continuous variables.

RESULTS

A total of 4933 patients were included, with 1575 Māori and 3358 non-Māori. The age-standardised incidence of Māori (236 per 100 000) was 3.3 times higher than that of non-Māori. Māori were 1.3 times more likely to have an advanced stage of disease and 1.97 times more likely to have small cell lung cancer. Māori were more likely to have comorbidities, chronic obstructive pulmonary disease, cardiovascular disease and diabetes. They also had higher levels of social deprivation and tended to be younger, female and current smokers.

CONCLUSIONS

The findings point to the need to address barriers to early diagnosis and the need for system change including the need to introduce a lung cancer screening focussing on Māori. There is also the need for preventive programmes to address comorbidities that impact lung cancer outcomes as well as a continued emphasis on creating a smoke-free New Zealand.

Risk of cardiovascular disease in cancer survivors: A cohort study of 446,384 New Zealand primary care patients

BACKGROUND

Given advances in the management of cancer, it is increasingly important for clinicians to appropriately manage the risk of cardiovascular disease (CVD) among cancer survivors. It is unclear whether CVD risk is increased among cancer survivors overall, and there is inconsistency in evidence to date about CVD incidence and mortality by cancer type.

METHODS

Patients aged 30-74 years entered an open cohort study at the time of first CVD risk assessment, between 2004 and 2018, in primary care in New Zealand. Patients with established CVD or cancer within 2 years prior to study entry were excluded. Cancer diagnosis (1995-2016) was determined from a national cancer registry. Cause-specific hazard models were used to examine the association between history of cancer and two outcomes: (1) CVD-related hospitalization and/or death and (2) CVD death.

RESULTS

The study included 446,384 patients, of whom 14,263 (3.2%) were cancer survivors. Risk of CVD hospitalization and/or death was increased among cancer survivors compared with patients without cancer at cohort entry (multivariable-adjusted hazard ratio, mHR, 1.11, 95% CI 1.05-1.18), more so for CVD death (1.31, 1.14-1.52). Risk of CVD hospitalization and/or death was increased in patients with myeloma (2.66, 1.60-4.42), lung cancer (2.19, 1.48-3.24) and non-Hodgkin lymphoma (1.90, 1.42-2.54), but not for some cancers (e.g., colorectal, 0.87, 0.71-1.06). Risk of CVD death was increased in several cancer types including melanoma (1.73, 1.25-2.38) and breast cancer (1.56, 1.16-2.11).

CONCLUSION

CVD risk management needs to be prioritized among cancer survivors overall, and particularly in those with myeloma, lung cancer and non-Hodgkin lymphoma given consistent evidence of increased risk.

Invitation methods for Indigenous New Zealand Māori in lung cancer screening: Protocol for a pragmatic cluster randomized controlled trial

Lung cancer screening can significantly reduce mortality from lung cancer. Further evidence about how to optimize lung cancer screening for specific populations, including Aotearoa New Zealand (NZ)'s Indigenous Māori (who experience disproportionately higher rates of lung cancer), is needed to ensure it is equitable. This community-based, pragmatic cluster randomized trial aims to determine whether a lung cancer screening invitation from a patient's primary care physician, compared to from a centralized screening service, will optimize screening uptake for Māori. Participating primary care practices (clinics) in Auckland, Aotearoa NZ will be randomized to either the primary care-led or centralized service for delivery of the screening invitation. Clinic patients who meet the following criteria will be eligible: Māori; aged 55-74 years; enrolled in participating clinics in the region; ever-smokers; and have at least a 2% risk of developing lung cancer within six years (determined using the PLCOM2012 risk prediction model). Eligible patients who respond positively to the invitation will undertake shared decision-making with a nurse about undergoing a low dose CT scan (LDCT) and an assessment for Chronic Obstructive Pulmonary Disease (COPD). The primary outcomes are: 1) the proportion of eligible population who complete a risk assessment and 2) the proportion of people eligible for a CT scan who complete the CT scan. Secondary outcomes include evaluating the contextual factors needed to inform the screening process, such as including assessment for Chronic Obstructive Pulmonary Disease (COPD). We will also use the RE-AIM framework to evaluate specific implementation factors. This study is a world-first, Indigenous-led lung cancer screening trial for Māori participants. The study will provide policy-relevant information on a key policy parameter, invitation method. In addition, the trial includes a nested analysis of COPD in the screened Indigenous population, and it provides baseline (T0 screen round) data using RE-AIM implementation outcomes.

Performance of cardiovascular disease risk prediction equations in more than 14 000 survivors of cancer in New Zealand primary care: a validation study

BACKGROUND

People with cancer have an increased risk of cardiovascular disease. Risk prediction equations developed in New Zealand accurately predict 5-year cardiovascular disease risk in a general primary care population in the country. We assessed the performance of these equations for survivors of cancer in New Zealand.

METHODS

For this validation study, patients aged 30-74 years from the PREDICT open cohort study, which was used to develop the New Zealand cardiovascular disease risk prediction equations, were included in the analysis if they had a primary diagnosis of invasive cancer at least 2 years before the date of the first cardiovascular disease risk assessment. The risk prediction equations are sex-specific and include the following predictors: age, ethnicity, socioeconomic deprivation index, family history of cardiovascular disease, smoking status, history of atrial fibrillation and diabetes, systolic blood pressure, total cholesterol to HDL cholesterol ratio, and preventive pharmacotherapy (blood-pressure-lowering, lipid-lowering, and antithrombotic drugs). Calibration was assessed by comparing the mean predicted 5-year cardiovascular disease risk, estimated using the risk prediction equations, with the observed risk across deciles of risk, for men and women, and according to the three clinical 5-year cardiovascular disease risk groups in New Zealand guidelines (<5%, 5% to <15%, and ≥15%). Discrimination was assessed by Harrell's C statistic.

FINDINGS

14 263 patients were included in the study. The mean age was 61 years (SD 9) for men and 60 years (SD 8) for women, with a median follow-up of 5·8 years for men and 5·7 years for women. The observed cardiovascular disease risk was underpredicted by a maximum of 2·5% in male and 3·2% in female decile groups. When patients were grouped according to clinical risk groups, observed cardiovascular disease risk was underpredicted by less than 2% in the lower risk groups and overpredicted by 2·2% for men and 3·3% for women in the highest risk group. Harrell's C statistics were 0·67 (SE 0·01) for men and 0·73 (0·01) for women.

INTERPRETATION

The New Zealand cardiovascular disease risk prediction equations reasonably predicted the observed 5-year cardiovascular disease risk in survivors of cancer in the country, in whom risk prediction was considered clinically appropriate. Prediction could be improved by adding cancer-specific variables and considering competing risks. Our findings suggest that the equations are reasonable clinical tools for use in survivors of cancer in New Zealand.

FUNDING

Auckland Medical Research Foundation, Health Research Council of New Zealand.

ASCEND-7: Efficacy and Safety of Ceritinib Treatment in Patients with ALK-Positive Non-Small Cell Lung Cancer Metastatic to the Brain and/or Leptomeninges

PURPOSE

Central nervous system metastases are a prominent cause of morbidity and mortality in patients with ALK-positive (ALK+) non-small cell lung cancer (NSCLC). The phase II ASCEND-7 (NCT02336451) study was specifically designed to assess the efficacy and safety of the ALK inhibitor (ALKi) ceritinib in patients with ALK+ NSCLC metastatic to the brain and/or leptomeninges.

PATIENTS AND METHODS

Patients with active brain metastases were allocated to study arms 1 to 4 based on prior exposure to an ALKi and/or prior brain radiation (arm 1: prior radiotherapy/ALKi-pretreated; arm 2: no radiotherapy/ALKi-pretreated; arm 3: prior radiotherapy/ALKi-naïve; arm 4: no radiotherapy/ALKi-naïve). Arm 5 included patients with leptomeningeal carcinomatosis. Patients received ceritinib 750 mg once daily (fasted condition). Primary endpoint was investigator-assessed whole-body overall response rate (ORR) per RECIST v1.1. Secondary endpoints included disease control rate (DCR) and intracranial/extracranial responses.

RESULTS

Per investigator assessment, in arms 1 (n = 42), 2 (n = 40), 3 (n = 12), and 4 (n = 44), respectively: whole-body ORRs [95% confidence interval (CI)] were 35.7% (21.6-52.0), 30.0% (16.6-46.5), 50.0% (21.1-78.9), and 59.1% (43.2-73.7); whole-body DCR (95% CI): 66.7% (50.5-80.4), 82.5% (67.2-92.7), 66.7% (34.9-90.1), and 70.5% (54.8-83.2); intracranial ORRs (95% CI): 39.3% (21.5-59.4), 27.6% (12.7-47.2), 28.6% (3.7-71.0), and 51.5% (33.5-69.2). In arm 5 (n = 18), whole-body ORR was 16.7% (95% CI, 3.6-41.4) and DCR was 66.7% (95% CI, 41.0-86.7). Paired cerebrospinal fluid and plasma sampling revealed that ceritinib penetrated the human blood-brain barrier.

CONCLUSIONS

Ceritinib showed antitumor activity in patients with ALK+ NSCLC with active brain metastases and/or leptomeningeal disease, and could be considered in the management of intracranial disease. See related commentary by Murciano-Goroff et al., p. 2477.

Osimertinib in NSCLC: Real-World Data From New Zealand

Introduction

EGFR tyrosine kinase inhibitors (TKIs) are more effective than chemotherapy in patients with EGFR-mutant NSCLC. Disease progression on EGFR TKI therapy occurs most often owing to acquired resistance from the gain of an EGFR T790M mutation. Osimertinib, a third-generation EGFR TKI, significantly improves outcomes in patients with EGFR T790M mutation–positive NSCLC compared with platinum–pemetrexed chemotherapy. We retrospectively reviewed clinical outcomes for patients receiving osimertinib through a compassionate access program in New Zealand.

Methods

Patients with a biopsy-proven or plasma-circulating tumor-DNA–proven EGFR T790M mutation received osimertinib. Data on patient and tumor characteristics, treatments, and outcomes were collected retrospectively. Survival outcomes were calculated from the time of osimertinib commencement.

Results

A total of 39 patients were enrolled, and data from 37 patients were analyzed. EGFR T790M status was found from plasma samples in six of 37 (16%) patients. A total of 27 of 37 patients (73%) used osimertinib as a second-line treatment. At the time of data analysis, median follow-up was 18.8 months (range 1.5–29). Overall response rate was 70% (95% confidence interval [CI]: 53–84) (26 of 37). Progression-free survival (PFS) at 12 months was 62% (95% CI: 44.8–77.5), and median PFS was 14.6 months (95% CI: 12.4–16.8). Median overall survival was not reached. Osimertinib was well tolerated, with grade 1 gastrointestinal and skin toxicity as the most common adverse effects. Three patients required dose adjustments or cessation owing to toxicity.

Conclusion

Osimertinib is an effective treatment for New Zealanders with EGFR T790M mutated NSCLC who have progressed after first or subsequent lines of therapy.

Final Overall Survival and Other Efficacy and Safety Results From ASCEND-3: Phase II Study of Ceritinib in ALKi-Naive Patients With ALK-Rearranged NSCLC

INTRODUCTION

The phase II, single-arm ASCEND-3 study assessed the efficacy and safety of ceritinib in anaplastic lymphoma kinase (ALK) inhibitor (ALKi)-naive patients with ALK-rearranged NSCLC who had received at least three previous lines of chemotherapy. Here, we report the final efficacy and safety results.

METHODS

Eligible patients (including those with asymptomatic or neurologically stable brain metastases) received oral ceritinib (750 mg/day, fasted). The primary end point was investigator-assessed overall response rate (ORR). Secondary end points were Blinded Independent Review Committee-assessed ORR; investigator- and Blinded Independent Review Committee-assessed overall intracranial response rate, duration of response, time to response, disease control rate, and progression-free survival (PFS); overall survival (OS); and safety. Exploratory end points included patient-reported outcomes.

RESULTS

Of the 124 patients enrolled, 122 (98.4%) had received previous antineoplastic medications (31 patients [25.0%] received at least three regimens), and 49 (39.5%) had baseline brain metastases. The median follow-up time (data cutoff: January 22, 2018) was 52.1 (range, 48.4-60.1) months. The investigator-assessed ORR was 67.7% (95% confidence interval [CI]: 58.8-75.9), and the median PFS was 16.6 months (95% CI: 11.0-23.2). The median OS was 51.3 months (95% CI: 42.7-55.3). Most common adverse events (all grades, ≥60% of patients, all-causality) were diarrhea (85.5%), nausea (78.2%), and vomiting (71.8%). Overall, 18 patients (14.5%) had an adverse event leading to treatment discontinuation. Health-related quality of life was maintained during ceritinib treatment.

CONCLUSIONS

Ceritinib exhibited prolonged and clinically meaningful OS, PFS, and duration of response in chemotherapy-pretreated (at least three lines), ALKi-naive patients with ALK+ NSCLC. The safety profile was consistent with that reported in previous studies.

Identification of MRP2 as a targetable factor limiting oxaliplatin accumulation and response in gastrointestinal cancer

Oxaliplatin is important for the clinical treatment of colorectal cancer and other gastrointestinal malignancies, but tumour resistance is limiting. Several oxaliplatin transporters were previously identified but their relative contributions to determining oxaliplatin tumour responses and gastrointestinal tumour cell sensitivity to oxaliplatin remains unclear. We studied clinical associations between tumour expression of oxaliplatin transporter candidate genes and patient response to oxaliplatin, then experimentally verified associations found with MRP2 in models of human gastrointestinal cancer. Among 18 oxaliplatin transporter candidate genes, MRP2 was the only one to be differentially expressed in the tumours of colorectal cancer patients who did or did not respond to FOLFOX chemotherapy. Over-expression of MRP2 (endogenously in HepG2 and PANC-1 cells, or induced by stable transfection of HEK293 cells) decreased oxaliplatin accumulation and cytotoxicity but those deficits were reversed by inhibition of MRP2 with myricetin or siRNA knockdown. Mice bearing subcutaneous HepG2 tumour xenografts were sensitised to oxaliplatin antitumour activity by concurrent myricetin treatment with little or no increase in toxicity. In conclusion, MRP2 limits oxaliplatin accumulation and response in human gastrointestinal cancer. Screening tumour MRP2 expression levels, to select patients for treatment with oxaliplatin-based chemotherapy alone or in combination with a MRP2 inhibitor, could improve treatment outcomes.

EGFR Mutation Testing of Nonsquamous NSCLC in New Zealand: Trends, Selectivity and Effects on the Prevalence of EGFR Mutation

Background: Given the benefits in using epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI), clinical practice guidelines recommend EGFR mutation testing of nonsquamous non–small cell lung cancer (NSCLC). However, not all patients get tested, which may have an impact on the prevalence of EGFR mutation previously estimated. Aim: To determine the trends of EGFR mutation testing in patients with nonsquamous NSCLC in New Zealand, and to explore the possible associations between the proportions tested, selectivity and the prevalence of EGFR mutation. Methods: This population-based study involves all patients who were diagnosed with nonsquamous NSCLC in the four health regions of New Zealand between January 2010 and July 2016. We identified eligible patients from the New Zealand Cancer Registry and obtained information on EGFR testing from TestSafe, a clinical information sharing service. We then calculated the proportions of patients tested for EGFR mutation and computed selectivity indices for eleven periods. We used a log-linear model to assess the associations between the proportions tested, selectivity and the prevalence of EGFR mutation. Results: Of the 2986 patients involved in this analysis, 1280 (42.9%) were tested for EGFR mutation. The proportion tested increased from 3.7% in 2010 to 74.0% in 2016. Testing was more prevalent in younger age group, female, Asian and patients with adenocarcinoma, and when specimens for testing was available. Such selectivity, however, decreased from 2010 to 2016. The prevalence of EGFR mutation varied widely across the periods, ranging from 16.8% in January-June 2014 to 43.8% in 2010. It was negatively associated with the proportion tested ( P = 0.02), and positively associated with the selectivity of testing ( P = 0.03). The log linear models estimated that the prevalence of EGFR mutation would be at most 16.1% (95% CI: 9.5%–27.1%) if 100% of patients were tested. Conclusion: In New Zealand, the uptake of EGFR mutation testing has improved over time but there is still room for improvement. Incomplete and selective testing may result in an overestimation of the prevalence of EGFR mutation in patients with nonsquamous NSCLC.

EGFR Mutation Testing of non-squamous NSCLC: Impact and Uptake during Implementation of Testing Guidelines in a Population-Based Registry Cohort from Northern New Zealand

BACKGROUND

Since 2013, clinical practice guidelines recommend EGFR mutation testing of non-squamous NSCLC to select advanced-stage patients for first-line treatment using EGFR-TKIs.

OBJECTIVE

We aimed to determine population-based trends in the real-world uptake and impact in routine practice of these recently updated testing guidelines.

PATIENTS AND METHODS

A population-based observational study was conducted of notifications to the New Zealand Cancer Registry of patients eligible for EGFR testing diagnosed in northern New Zealand between January 2010 and April 2014. The main study variable was EGFR mutation testing. Main outcome measures (overall survival and dispensing of EGFR-TKIs) were extracted from prospectively archived electronic databases until October 2015.

RESULTS

The population-based cohort of 1857 patients had an average age of 70 years. Most had adenocarcinoma and metastatic disease at diagnosis. EGFR testing was undertaken in 500 patients (27%) with mutations detected in 109 patients (22%). EGFR testing increased during the period of study from <5% to 67% of patients (P < 0.0001). Full uptake of testing by all eligible patients was limited by a lack of availability of specimens for testing and variable testing referral practices. The proportion of patients treated with EGFR-TKIs decreased during the same time period, both among untested patients (from 12.2% to 2.8% (P < 0.0001)) and in the population as a whole (from 13.7% to 10.6% (P < 0.05)). EGFR testing was associated with prolonged overall survival (Adjusted HR = 0.76 (95% CI, 0.65-0.89) Log-rank P < 0.0001) due at least in part to the much longer overall survival achieved by mutation-positive patients, of whom 79% received EGFR-TKIs. Compared to untested EGFR-TKI-treated patients, mutation-positive EGFR-TKI-treated patients received EGFR-TKIs for longer, and survived longer both from the start of EGFR-TKI treatment and date of their diagnosis.

CONCLUSIONS

In this real world setting, high uptake of EGFR testing was achieved and associated with major changes in EGFR-TKI prescribing and improved health outcomes. Modifiable factors determined testing uptake. Study registration ACTRN12615000998549.

Multidrug Resistance-Associated Protein 2 (MRP2) Mediated Transport of Oxaliplatin-Derived Platinum in Membrane Vesicles

The platinum-based anticancer drug oxaliplatin is important clinically in cancer treatment. However, the role of multidrug resistance-associated protein 2 (MRP2) in controlling oxaliplatin membrane transport, in vivo handling, toxicity and therapeutic responses is unclear. In the current study, preparations of MRP2-expressing and control membrane vesicles, containing inside-out orientated vesicles, were used to directly characterise the membrane transport of oxaliplatin-derived platinum measured by inductively coupled plasma mass spectrometry. Oxaliplatin inhibited the ATP-dependent accumulation of the model MRP2 fluorescent probe, 5(6)-carboxy-2,'7'-dichlorofluorescein, in MRP2-expressing membrane vesicles. MRP2-expressing membrane vesicles accumulated up to 19-fold more platinum during their incubation with oxaliplatin and ATP as compared to control membrane vesicles and in the absence of ATP. The rate of ATP-dependent MRP2-mediated active transport of oxaliplatin-derived platinum increased non-linearly with increasing oxaliplatin exposure concentration, approaching a plateau value (Vmax) of 2680 pmol Pt/mg protein/10 minutes (95%CI, 2010 to 3360 pmol Pt/mg protein/10 minutes), with the half-maximal platinum accumulation rate (Km) at an oxaliplatin exposure concentration of 301 μM (95% CI, 163 to 438 μM), in accordance with Michaelis-Menten kinetics (r² = 0.954). MRP2 inhibitors (myricetin and MK571) reduced the ATP-dependent accumulation of oxaliplatin-derived platinum in MRP2-expressing membrane vesicles in a concentration-dependent manner. To identify whether oxaliplatin, or perhaps a degradation product, was the likely substrate for this active transport, HPLC studies were undertaken showing that oxaliplatin degraded slowly in membrane vesicle incubation buffer containing chloride ions and glutathione, with approximately 95% remaining intact after a 10 minute incubation time and a degradation half-life of 2.24 hours (95%CI, 2.08 to 2.43 hours). In conclusion, MRP2 mediates the ATP-dependent active membrane transport of oxaliplatin-derived platinum. Intact oxaliplatin and its anionic monochloro oxalate ring-opened intermediate appear likely candidates as substrates for MRP2-mediated transport.

Abstract 751: Mass balance, excretion and metabolism of [14C] ASA404 in cancer patients in a phase I trial

Purpose: To determine the mass balance, excretion and metabolism of the small molecule flavonoid tumor vascular disrupting agent ASA404 in patients with advanced cancer. Methods: Seven cancer patients were given a single dose of 3000 mg [14C] ASA404 by intravenous infusion over 20 minutes prior to collection of samples of plasma, urine and faeces. Pharmacokinetic samples were analysed by HPLC, liquid scintillation counting, mass spectrometry, glusulase treatment and comparison to authentic standards. Descriptive pharmacokinetic parameters were generated by non-compartmental analysis. Results: Mass balance was achieved (mean recovery of radioactivity in excreta = 86.9% of the dose) with balanced excretion between urine (mean recovery of radioactivity in urine = 53.9% of dose) and faeces (mean recovery of radioactivity in faeces = 33.3% of dose). ASA404 was eliminated as parent drug, three known metabolites (6-hydroxy-ASA404, ASA404 acyl glucuronide and 6-hydroxy-ASA404 acyl glucuronide) and as two novel metabolites (an ASA404 dimer and an ASA404 dimer glucuronide conjugate). Unchanged ASA404 was the major radioactivity component detected in plasma within the first 24 hours after dosing. At later time-points, irreversibly protein bound ASA404 and all of the metabolites that had been detected in excreta, contributed to total plasma radioactivity. Conclusion: This study defined the substantial excretion of ASA404, mainly as metabolites, in both urine (over half of the dose) and faeces (about one third of the dose) after intravenous administration. Two novel metabolites were identified that were not reported by previous studies using nonradioactive techniques.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 751. doi:1538-7445.AM2012-751

Abstract C21: A phase I trial of PR-104, a pre-prodrug of the bioreductive prodrug PR-104A, given weekly to solid tumor patients

Background: The phosphate ester PR-104 is rapidly converted in vivo to the alcohol PR-104A, a nitrogen mustard prodrug that is metabolised to hydroxylamine (PR-104H) and amine (PR-104M) DNA crosslinking agents by one-electron reductases in hypoxic cells and by aldo-keto reductase 1C3 independently of oxygen. In a previous phase I study using a q 3 week schedule of PR-104, the maximum tolerated dose (MTD) was 1100 mg/m2 and fatigue, neutropenic fever and infection were dose-limiting. The primary objective of the current study was to determine the dose-limiting toxicity (DLT) and MTD of weekly PR-104.

Methods, patients and treatment: Patients with advanced solid tumors received PR-104 as a 1-hour intravenous infusion on days 1, 8 and 15 every 28 days with assessment of pharmacokinetics on cycle 1 day 1. Twenty-six patients (pts) were enrolled (16 male/10 female; median age 58 yrs, range 30 to 70 yrs) who had received a median of two prior chemotherapy regimens (range, 0 to 3) for melanoma (8 pts), colorectal or anal cancer (3 pts), NSCLC (3 pts), sarcoma (3 pts), glioblastoma (2 pts), salivary gland tumors (2 pts) or other solid tumors (5 pts). PR-104 was administered at 135 mg/m2 (3 pts), 270 mg/m2 (6 pts), 540 mg/m2 (6 pts), 675 mg/m2 (7 pts) and 900 mg/m2 (4 pts) for a median of two treatment cycles (range, 1 to 7 cycles) and five infusions (range, 1 to 18) per patient.

Results: Dose-limiting toxicities (DLTs) during cycle one included grade four thrombocytopenia at 540 mg/m2 (1 of 6 pts) and grade four thrombocytopenia and neutropenia at 900 mg/m2 (2 of 4 pts). At an intermediate dose of 675 mg/m2, there were no DLTs among a total of seven patients given 12 treatment cycles but all experienced moderate to severe (grade 2 to 4) haematological toxicity. Thrombocytopenia was delayed in its onset and nadir, and its recovery was protracted and incomplete in many patients. There were no complete or partial tumor responses. PR-104-induced thrombocytopenia and neutropenia correlated with plasma AUC of PR-104, PR-104A and an oxidative semi-mustard metabolite (PR-104S1), but no more strongly than with PR-104 dose-level. There was no significant correlation between plasma AUC for the reduced metabolites and myelotoxicity.

Conclusions: Thrombocytopenia, and to a lesser extent neutropenia, was the DLT of weekly PR-104. The MTD was 675 mg/m2/week. PR-104 given weekly may be a suitable protocol for further clinical evaluation as a short course of treatment with fractionated radiotherapy or haematopoietic stem cell support, as its duration of dosing is restricted by delayed-onset and protracted thrombocytopenia.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C21.

Abstract B241: Extended follow-up from a phase I study of AS1409, a novel antibody-cytokine fusion protein, suggests efficacy in malignant melanoma (MM)

Introduction: AS1409 (huBC1-huIL-12) is a fusion protein comprising the humanized antibody, BC1, specific for the ED-B splice variant of fibronectin, and the human cytokine, IL-12. ED-B-fibronectin is expressed in tumor vasculature but has restricted distribution in normal tissue. IL-12 has immunostimulatory, anti-metastatic and anti-angiogenic properties. Responses to IL-12 occur in MM and RCC but with high systemic toxicity. AS1409 is designed to target IL-12 to tumor vasculature. We report extended follow-up from a phase I study to assess the tolerability, safety, pharmacokinetics and activity of AS1409 in patients with MM or renal cell carcinoma (RCC).

Methods: Patients with MM or RCC were treated in a dose-escalating trial of weekly i.v. AS1409 for 6 weeks at a starting dose of 15mcg/kg. Patients without unacceptable toxicity or disease progression could continue therapy. IFN-gamma and IP-10 were measured as markers of immune response.

Results: 13 patients (11 MM, 2 RCC) were treated (7 at 15mcg/kg, 6 at 25mcg/kg). DLTs observed at 25mcg/kg were transaminase elevation, fatigue and hemolytic anemia. Most common drug-related adverse events were Grade 1 or 2 and related to flu-like syndrome. Four patients continued to receive AS1409 beyond 6 weeks and one received 30 cycles of treatment. All patients showed elevation of IFN-gamma and IP-10 following the first dose. Tumor shrinkage was demonstrated in 5/9 evaluable MM patients - a partial response was confirmed in a patient with MM metastatic to lymph nodes and a further four patients achieved stable disease. One MM patient with previously rapidly progressive disease exhibited prolonged tumor shrinkage 12 months after discontinuing treatment. Anti-drug antibody (ADA) responses were seen in all patients. ADAs were shown not to neutralize the effect of AS1409 in vitro.

Conclusions: At 15mcg/kg, AS1409 was associated with manageable toxicity. Biomarker activation and objective radiological evidence of anticancer activity was observed at this dose in patients with MM, including one partial response and one patient with prolonged clinical benefit beyond 12 months from treatment. Further development of AS1409 in MM is warranted.

Citation Information: Mol Cancer Ther 2009;8(12 Suppl):B241.

A phase I study of AS1409, a novel antibody-cytokine fusion protein, in patients with malignant melanoma (MM) or renal cell carcinoma (RCC)

3024

Background: AS1409 (huBC1-huIL-12) is a fusion protein combining a humanized antibody specific for the ED-B splice variant of fibronectin with human IL-12. ED-B-fibronectin is expressed in tumor vasculature. IL-12 stimulates T and NK cell activity. Responses to IL12 occur in MM and RCC, but with high systemic toxicity. AS1409 is designed to target IL-12 to tumor vasculature. Methods: Patients with MM or RCC were treated in a dose-escalating trial of weekly i.v. AS1409 for 6 weeks with a starting dose of 15mcg/kg. Patients without unacceptable toxicity or disease progression could continue therapy. IFN-gamma and IP-10 were measured as biomarkers of activation of cellular immunity. Results: 13 patients (9 males; median age 53 years; 11 MM, 2 RCC) were treated (7 at 15mcg/kg, 6 at 25mcg/kg). DLTs observed at 25 mcg/kg were transaminase elevation and fatigue. Other toxicities included flu-like syndrome, fever, myalgia, and mucositis. Three patients continued to receive AS1409 beyond 6 weeks and 1 patient remained on treatment beyond 30 weeks. All patients showed elevation of IFN-gamma and IP10 following the first dose, although subsequently attenuated; prominent anti-drug antibody (ADA) responses were seen. A partial response was seen in a patient with MM metastatic to lymph nodes treated at 15mcg/kg, and a best response of stable disease was seen in 4 patients. Mean AS1409 half-life was 19.3 ±5.3h, mean distribution volume was 0.25 ± 0.098L/kg and clearance was 9.8 ± 6.5mL/hr/kg. Conclusions: At 15mcg/kg AS1409 was well tolerated. Biomarker activation and objective radiological evidence of anticancer activity was observed at this dose. Further study of AS1409 is focussed on optimizing dosing and scheduling, characterizing the ADA response, and antibody biodistribution.

[Table: see text]

Adjuvant chemotherapy for non-small cell lung cancer: a New Zealand perspective

This article reviews recent developments with the use of adjuvant chemotherapy for resected early-stage non-small cell lung cancer (NSCLC) and the implications of these developments for healthcare in New Zealand (NZ). Non-small cell lung cancer is a major cause of mortality and morbidity in NZ, and is greatly over-represented among Maori and socioeconomically deprived populations. Early-stage NSCLC is potentially curable by surgery, but long-term outcome after surgical resection is limited by disease recurrence locally or at sites distant from the primary disease. Three recent large randomised controlled phase III trials using modern platinum-based combination chemotherapy protocols have shown significant survival benefits for the use of postoperative adjuvant chemotherapy after resection of early-stage NSCLC. Cisplatin plus vinorelbine was used as the adjuvant chemotherapy regimen in two of these trials resulting in improvements in 5-year survival of 51.2% versus 42.6% (p=0.013) and 69% versus 54% (p=0.03), respectively. In NZ, adjuvant chemotherapy for NSCLC is expected to prevent up to 15 lung cancer deaths each year for relatively low drug expenditure and has the potential to benefit Maori and the economically-deprived disproportionately more than other populations. In conclusion, it is the opinion of this group of NZ lung cancer specialists that adjuvant chemotherapy with cisplatin plus vinorelbine should now be adopted as a standard of care for patients with resected stage II and III NSCLC. For this to occur, current PHARMAC policies preventing its use for these eligible patients will need to be revised.

Phase Ib/II study of DMXAA combined with carboplatin and paclitaxel in non-small cell lung cancer (NSCLC)

7102

Background: DMXAA (AS1404) is a small-molecule vascular disrupting agent, which in animal models shows additive or supra-additive effects with cytotoxics including taxanes and platinum agents. This phase Ib/II study evaluated DMXAA in combination with carboplatin (C) and paclitaxel (P) in NSCLC. Methods: Patients had histologically confirmed stage IIIb or IV NSCLC previously untreated with chemotherapy. Safety of the combination was initially assessed in 1 patient receiving C (AUC 6 mg/ml × min) + P (175 mg/m2) + 600 mg/m2 DMXAA. Seventy-seven patients were then randomised to receive up to 6 cycles of C + P with or without DMXAA (1,200 mg/m2 or 1,800 mg/m2). Safety assessments included EKG, adverse events, laboratory screens, pharmacokinetics and ophthalmic exams. Efficacy endpoints are objective response rates, time to progression, duration of response and stable disease, and median and 1-year survival. Results: 78 patients were enrolled. One received C + P + 600 mg/m2 DMXAA; no serious toxicities were observed; the patient had a partial response (PR, RECIST, investigator assessment). Randomisation was initiated: 35 patients received C + P, 36 C + P + 1200 mg/m2 DMXAA and 6 C + P + 1800 mg/m2 DMXAA. The safety profile in the control and DMXAA arms was comparable. No pharmacokinetic interactions were observed. Investigator-assessed RECIST data are available from 68 patients with at least one post-baseline CT scan. First post-baseline scans were taken after the defined stable disease interval (6 weeks), so patients without progressive disease (PD) at this point have confirmed disease control (best overall RECIST response of PR or stable disease (SD), with final disposition dependent on subsequent scans). Of 30 patients in the control arm 23 show disease control and 7 PD. Of 33 patients in the 1200 mg/m2 DMXAA arm 28 show disease control and 5 PD. Of 5 patients who received 1800 mg/m2 DMXAA, all show disease control, with 3 confirmed PRs. Conclusions: Addition of DMXAA to standard doses of C and P did not add significantly to toxicity. Initial response data suggest this combination could provide additional benefit compared with C and P alone.

No significant financial relationships to disclose.

Phase II study of docetaxel and cisplatin in advanced non-small-cell lung cancer

PURPOSE

Docetaxel (Taxotere, Rhone-Poulenc Rorer, Antony, France) and cisplatin are two of the most active single agents used in the treatment of non-small-cell lung cancer (NSCLC). A recently reported phase I study of the combination of docetaxel and cisplatin recommended a dose of 75 mg/m2 of both drugs every 3 weeks for subsequent phase II study.

PATIENTS AND METHODS

Eligible patients were aged 18 to 75 years with a World Health Organization (WHO) performance status < or = 2 and life expectancy > or = 12 weeks, with metastatic and/or locally advanced NSCLC proven histologically or cytologically. Patients were not permitted to have received prior chemotherapy, extensive radiotherapy, or any radiotherapy to the target lesion and must have had measurable disease. Concurrent treatment with colony-stimulating factors (CSFs) or prophylactic antibiotics was not permitted. Docetaxel (75 mg/m2) in 250 mL 5% dextrose was given intravenously (i.v.) over 1 hour immediately before cisplatin (75 mg/m2) in 500 mL normal saline given i.v. over 1 hour in 3-week cycles. Premedication included ondansetron, dexamethasone, promethazine, and standard hyperhydration with magnesium supplementation.

RESULTS

A total of 47 patients, two thirds of whom had metastatic disease, were entered onto this phase II study. The majority of patients were male (72%) and of good (WHO 0 to 1) performance status (85%). All 47 patients were assessable for toxicity and 36 were for response. Three patients were ineligible and eight (17%) discontinued treatment because of significant toxicity. In assessable patients, the overall objective response rate was 38.9% (95% confidence limits [CL], 23.1% to 56.5%), 36.1% had stable disease, and 25% progressive disease. On an intention-to-treat analysis, the objective response rate was 29.8%. Median survival was 9.6 months and estimated 1-year survival was 33%. Significant (grade 3/4) toxicities included nausea (26%), hypotension (15%), diarrhea (13%), and dyspnea mainly related to chest infection (13%). One patient experienced National Cancer Institute (NCI) grade 3 neurosensory toxicity after eight cycles. Grade 3/4 neutropenia was common and occurred in 87% of patients, but thrombocytopenia > or = grade 3 was rare (one patient). Significant (grade 3/4) abnormalities of magnesium levels were common (24%). Febrile neutropenia occurred in 13% of patients and neutropenic infection in 11%, contributing to two treatment-related deaths. No neutropenic enterocolitis or severe fluid retention was reported.

CONCLUSION

Compared with other active regimens used in this setting, the combination of docetaxel and cisplatin in advanced NSCLC is an active regimen with a similar toxicity profile to other combination regimens.

Carboplatin and chlorambucil combination chemotherapy as treatment for patients with ovarian cancer

Fifty-six patients with ovarian cancer (three stage IC, nine stage II, 33 stage III and II stage IV) were treated with carboplatin 350 mg m-2 i.v. day 1 and chlorambucil orally 0.15 mg kgm-1 days 1-7 inclusive, repeated every 28 days for eight courses. The regimen was well tolerated and was virtually free of nephro- and neurotoxicity. Grade III or IV hematology toxicity occurred in 18 patients but only 31 or 330 courses administered were delayed. Of 40 assessable patients eight achieved a clinical/radiologic complete response and 17 a clinical/radiologic partial response. Actuarial survival at 50 months was 65% for stage II patients, 27% for stage III patients and no stage IV patients survived beyond 20 months. Forty-two per cent of patients with residual disease less 2 cm survived 50 months, compared with 44% of patients with moderate volume (2-5 cm) residual disease and 6% of patients with bulk residual disease. This is an active, well tolerated regimen. However, only patients with small volume residual disease have a significant chance of prolonged survival.

A clinical and pharmacological study of high-dose mitozolomide given in conjunction with autologous bone marrow rescue

In conjunction with autologous bone marrow rescue, high-dose mitozolomide was given i.v. to 16 patients with refractory malignancies at doses ranging from 100 to 400 mg/m2 over 1 h. Neutropaenia occurred consistently at 300 mg/m2, and three trivial infective episodes were recorded. Thrombocytopaenia occurred consistently at 150 mg/m2, and three patients experienced episodes of minor bleeding. The death of one subject was attributable to pulmonary thromboembolism during the bone marrow reinfusion. Transient emesis and mild alopecia were the only other toxicities. Three of six evaluable patients receiving greater than or equal to 300 mg/m2 exhibited measurable reductions in tumour dimensions, although these failed to fulfil the criteria for a partial response. Mitozolomide was undetectable in plasma at 12 h after drug administration. The plasma pharmacokinetic data fitted mono- or biexponential models in all patients. Model-independent pharmacokinetic parameters were: peak plasma drug concentration, 3.4-46 mg/l; AUC, 8-82 mg h l-1; clearance, 7.6-45 l/h; steady-state volume of distribution, 11-85 l; and plasma elimination half-life, 1.4-2.8 h. Dose-dependent pharmacokinetics were not observed, and only a small percentage of the delivered dose was eliminated unchanged in the urine. The maximally tolerated dose of mitozolomide given with autologous bone marrow rescue was greater than 400 mg/m2. At this dose myelosuppression was the only major toxicity, and the plasma drug levels and AUC values were comparable to those obtained after therapeutic doses in experimental models.