2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting

•Nausea and vomiting are considered amongst the most troublesome adverse events for patients receiving antineoplastics. •The guideline covers emetic risk classification, prevention and management of treatment-induced nausea and vomiting. •The Consensus Committee consisted of 34 multidisciplinary, health care professionals and three patient advocates. •Recommendations are based on evidence-based data (level of evidence) and the authors’ collective expert opinion (grade). •All recommendations are for the first course of antineoplastic therapy; modifications may be needed in subsequent courses.

A randomized trial of the electronic Lung Cancer Symptom Scale for quality-of-life assessment in patients with advanced non-small-cell lung cancer

Introduction

Improving health-related quality of life (hrqol) is a key goal of systemic therapy in advanced lung cancer, although routine assessment remains challenging. We analyzed the impact of a real-time electronic hrqol tool, the electronic Lung Cancer Symptom Scale (elcss-ql), on palliative care (pc) referral rates, patterns of chemotherapy treatment, and use of other supportive interventions in patients with advanced non-small-cell lung cancer (nsclc) receiving first-line chemotherapy.

Methods

Patients with advanced nsclc starting first-line chemotherapy were randomized to their oncologist receiving or not receiving their elcss-ql data before each clinic visit. Patients completed the elcss-ql at baseline, before each chemotherapy cycle, and at subsequent follow-up visits until disease progression. Prospective data about the pc referral rate, hrqol, and use of other supportive interventions were collected.

Results

For the 95 patients with advanced nsclc who participated, oncologists received real-time elcss-ql data for 44 (elcss-ql arm) and standard clinical assessment alone for 51 (standard arm). The primary endpoint, the pc referral rate, was numerically higher, but statistically similar, for patients in the elcss-ql and standard arms. The hrqol scores over time were not significantly different between the two study arms.

Conclusions

The elcss-ql is feasible as a tool for use in routine clinical practice, although no statistically significant effect of its use was demonstrated in our study. Improving access to supportive care through the collection of patient-reported outcomes and hrqol should be an important component of care for patients with advanced lung cancer.

A phase III study evaluating the safety and efficacy of NEPA, a fixed-dose combination of netupitant and palonosetron, for prevention of chemotherapy-induced nausea and vomiting over repeated cycles of chemotherapy

BACKGROUND

Safe, effective and convenient antiemetic regimens that preserve benefit over repeated cycles are needed for optimal supportive care during cancer treatment. NEPA, an oral fixed-dose combination of netupitant, a highly selective NK1 receptor antagonist (RA), and palonosetron (PALO), a distinct 5-HT3 RA, was shown to be superior to PALO in preventing chemotherapy-induced nausea and vomiting after a single cycle of highly (HEC) or moderately (MEC) emetogenic chemotherapy in recent trials. This study was designed primarily to assess the safety but also to evaluate the efficacy of NEPA over multiple cycles of HEC and MEC.

PATIENTS AND METHODS

This multinational, double-blind, randomized phase III study (NCT01376297) in 413 chemotherapy-naïve patients evaluated a single oral dose of NEPA (NETU 300 mg + PALO 0.50 mg) given on day 1 with oral dexamethasone (DEX). An oral 3-day aprepitant (APR) regimen + PALO + DEX was included as a control (3:1 NEPA:APR randomization). In HEC, DEX was administered on days 1-4 and in MEC on day 1. Safety was assessed primarily by adverse events (AEs), including cardiac AEs; efficacy by complete response (CR: no emesis, no rescue).

RESULTS

Patients completed 1961 total chemotherapy cycles (76% MEC, 24% HEC) with 75% completing ≥4 cycles. The incidence/type of AEs was comparable for both groups. Most frequent NEPA-related AEs included constipation (3.6%) and headache (1.0%); there was no indication of increasing AEs over multiple cycles. The majority of AEs were mild/moderate and there were no cardiac safety concerns based on AEs and electrocardiograms. The overall (0-120 h) CR rates in cycle 1 were 81% and 76% for NEPA and APR + PALO, respectively, and antiemetic efficacy was maintained over repeated cycles.

CONCLUSIONS

NEPA, a convenient single oral dose antiemetic targeting dual pathways, was safe, well tolerated and highly effective over multiple cycles of HEC/MEC.

Efficacy and safety of NEPA, an oral combination of netupitant and palonosetron, for prevention of chemotherapy-induced nausea and vomiting following highly emetogenic chemotherapy: a randomized dose-ranging pivotal study

BACKGROUND

NEPA is a novel oral fixed-dose combination of netupitant (NETU), a new highly selective neurokinin-1 (NK1) receptor antagonist (RA) and palonosetron (PALO), a pharmacologically and clinically distinct 5-hydroxytryptamine type 3 (5-HT3) RA. This study was designed to determine the appropriate clinical dose of NETU to combine with PALO for evaluation in the phase 3 NEPA program.

PATIENTS AND METHODS

This randomized, double-blind, parallel group study in 694 chemotherapy naïve patients undergoing cisplatin-based chemotherapy for solid tumors compared three different oral doses of NETU (100, 200, and 300 mg) + PALO 0.50 mg with oral PALO 0.50 mg, all given on day 1. A standard 3-day aprepitant (APR) + IV ondansetron (OND) 32 mg regimen was included as an exploratory arm. All patients received oral dexamethasone on days 1-4. The primary efficacy endpoint was complete response (CR: no emesis, no rescue medication) during the overall (0-120 h) phase.

RESULTS

All NEPA doses showed superior overall CR rates compared with PALO (87.4%, 87.6%, and 89.6% for NEPA100, NEPA200, and NEPA300, respectively versus 76.5% PALO; P < 0.050) with the highest NEPA300 dose studied showing an incremental benefit over lower NEPA doses for all efficacy endpoints. NEPA300 was significantly more effective than PALO and numerically better than APR + OND for all secondary efficacy endpoints of no emesis, no significant nausea, and complete protection (CR plus no significant nausea) rates during the acute (0-24 h), delayed (25-120 h), and overall phases. Adverse events were comparable across groups with no dose response. The percent of patients developing electrocardiogram changes was also comparable.

CONCLUSIONS

Each NEPA dose provided superior prevention of chemotherapy-induced nausea and vomiting (CINV) compared with PALO following highly emetogenic chemotherapy; however, NEPA300 was the best dose studied, with an advantage over lower doses for all efficacy endpoints. The combination of NETU and PALO was well tolerated with a similar safety profile to PALO and APR + OND.

P4-14-03: Support Groups in Breast Cancer: An Evidence Based Assessment of 1606 Patients with Concerning Topics for Support Group Discussion and Presentation

Background

Cancer support groups are conducted at most cancer centers. Although there is increasing demand among patients and families for support groups, little data exist outlining which topics patients and caregivers consider as most important for support group discussion and presentation. We conducted a large web-based anonymous survey to determine preferences of patients and caregivers for cancer support groups, including 1606 individuals with breast cancer and 3723 with other malignancies.

Methods: The established patient base of NexCura®, a web-based information resource, was used to survey registered patients and caregivers in this on-line assessment. Participants ranked 26 topics on a 5-point Likert scale which evaluated the importance of each item. Demographic characteristics, clinical factors, and support group content preferences were assessed.

Results: There were 4402 respondents to the invitation to participate, and 3723 patients and caregivers elected to participate (85%). Characteristics included for all 3723 patients: 70% women, mean age 58 (range 20–89). For the 1606 patients with breast cancer, 99.8% were women, the mean age was 56 (range 27–88); 53% were free of cancer. For the whole group, the four most common cancers were breast 45%, prostate 15%, lung 6%, and colorectal 5%. 90% of participants were patients and 10% were caregivers. 80% of participants rated all 26 topics. The table below shows rankings by the top 2 categories (the percent ranking each topic as “Very Important” or “Important”) of the 10 highest rated topics (and the rank order for each item) for patients with breast cancer and for all patients.

P1-07-07: Assessing Two Methods of Meta-Analysis in Studies of Patients with Breast Cancer: Individual Patient Data-Based (IPD) Versus Literature Based Abstracted Data (AD) in 5 Meta-Analyses Including over 28,000 Patients. Are There Results Differences of Concern?

Background: Meta-analyses are widely used to provide high level evidence to resolve controversies. Differences of opinion continue concerning the two most frequently used methods (IPD and AD) and their roles in providing reliable recommendations for Evidence-Based Medicine. Some regard the IDP method as being more accurate, yet it is time-consuming, expensive, and can be troubled by getting data from all investigators. We tested whether overall conclusions would differ between the two methods when using the same studies for comparison. To overcome limitations related to simple correlation analysis, and: 1) to weigh the agreement between these 2 approaches (Bland-Altman [BA], Lancet 1986), and 2) to evaluate the eventual predictive role of the data coming from AD over IPD, an analysis with multiple methods was performed.

Methods: 5 meta-analyses in breast cancer examining 9 outcomes which had been subjected to IPD meta-analysis were selected. Literature-based AD meta-analyses were then conducted. Hazard Ratios (HR) and Risk Ratios (RRs) with 95% confidence intervals (CI) were extracted or derived from original meta-analyses. At least 90% of patients’ reports were required for the IDP analysis. Methods agreement was analyzed according to the BA method, as difference or ratios, and a comparison with the Variance-Ratio test (F-test), and the Concordance Correlation Coefficient (CCC) was done. Correlations between IPD/AD-ratios were estimated using a linear regression model with Pearson (r) and R2 coefficients (parametric) and Spearman's Rho/Kendall's Tau coefficient (non-parametric), to derive a predictive estimation on IPD when adopting AD. MedCalc® Software was used.

Results: 9 outcomes in 5 meta-analyses (28,358 patients) were analyzed, as seen in the table.

Using health-related quality of life (QL) parameters as primary endpoints in a multinational prospective NSCLC chemotherapy (chemo) trial: The Asia-Pacific QL trial

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Background: Survival and QL improvements are major goals in treating advanced NSCLC. Enhancing survival for all treated patients (pts) with advanced NSCLC beyond that achieved with 3rd generation chemo regimens is difficult in this highly symptomatic cancer; questions remain as to the impact of chemo on QL and symptoms (“PROs” or patient reported outcomes). This study was designed to: 1) evaluate the impact of chemo on QL and symptoms for all pts, 2) evaluate QL by response category (CR+PR = MR or major response, stable disease = SD, and progression); and 3) test whether barriers in QL evaluation are overcome by using a computer-assisted validated instrument (LCSS-QL). Methods: All pts received initial docetaxel-based chemo (83% with cisplatin or carboplatin) based on known response and survival results (Fossella JCO 2003) and were assessed every 3 weeks with the LCSS-QL. Results: 300 pts are entered and 243 evaluated; 91% have repeated QL measures through 3 cycles of chemo in this ongoing trial. Demographics: 77% Stage IV; 72% men; 67% adenocarcinoma; median age 58; KPS 90–100 = 66%, 70–80 = 34%. A 37% MR rate was achieved. QL feasibility: high patient and staff acceptability found (at 43 sites, 8 countries). For the whole group (using 5% as a minimally important difference), after 3 chemo cycles all 9 LCSS parameters were stable, except overall QL and cough (> 5% and 7% improvements). Evaluating PROs by chemo response: in all parameters after completion of only 2 chemo cycles, pts with MR had better symptom control than pts with progression (p<0.05 in 4 of the 6 major symptoms after cycle 3). Total LCSS-QL score was better for pts with MR (p=.007) or SD (p=.03) compared with progressive NSCLC. Conclusions: For docetaxel-based chemo: 1) MR is associated with better symptom control and total QL than SD or progression; 2) even with only a minority (37%) having a major response, QL and PRO parameters are stable or better for the whole group by key decision points of 2 and 3 chemo cycles; 3) with 91% compliance with the computer-assisted LCSS-QL, evaluation of QL in multiple centers is achievable during chemo trials. This study demonstrates that QL and PRO evaluation is feasible and should influence chemotherapy treatment decisions.

[Table: see text]

Determining issues of importance for patients with breast cancer: Results of a web-based study in 1,072 patients to enhance the content validity for the development of a new health-related quality of life (QL) instrument, the Breast Cancer Symptom Scale (BCSS)

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Background: Identifying key issues for patients with malignancy is central to assessing QL and patient reported outcomes during all points of the illness trajectory. The involvement of patients in establishing content validity is crucial for instrument development. The conceptual model for the BCSS focuses on areas of importance for patients (Hollen, Supp Care Ca 1994). Methods: We used the established patient base of the web-based NexCura information resource to survey registered patients with breast cancer. Demographic stratifications included disease stage, age, menopausal status, time since diagnosis, prior/current treatment with surgery, RT, chemotherapy, hormonal, targeted, and CAM approaches. 1072 patients (median age 53, 65% stage I, 43% > 2 years since diagnosis) completed the anonymous web-conducted survey. Patients ranked 21 issues on a 5-point scale, assessing the importance of each item. Issues included general, physical, functional, psychosocial and summative items. Results: The 9 highest ranked items are seen below. Results are described by the percent of patients choosing the top category (very important) and the top 2 importance categories. The five lowest ranked items dealt with appetite, breast-specific issues, hot flashes and sexuality. Ratings by breast cancer subsets (newly diagnosed, on treatment, NED, hormonal or non-hormonal treatment, metastatic disease, survivors) showed some differences compared with the whole group. Conclusions: These results represent one of the largest surveys of concerns expressed by patients with breast cancer and support using computer-assisted technology to assess such information for rapid input of large patient samples. This study gives strong support for content validity for the BCSS and provides data on which to base separate QL instruments for specific breast cancer settings.

[Table: see text]

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The impact of randomized trial results and altered regulatory policies on ESA use, transfusions, and thrombosis: A longitudinal analysis over a 3-year period of resource utilization data from a large comprehensive oncology program

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Background: Recent randomized trials and meta-analyses demonstrated unexpected findings with ESA use with chemotherapy. Results revealed an overall increase in thrombosis rates with the use of ESAs as well as decrements in survival in some malignancies, particularly with breast and head and neck cancers (Bohlius, JNCI, 2006; Raftopoulos, Proc ASCO, 2008; Bennett, JAMA 2008). Benefits with ESA use have resulted in an average 1–1.5g/dl rise in hemoglobin. The impact on quality of life and fatigue remains controversial. Toxicity issues have led to restricted labeling by the FDA and reimbursement decisions by the Centers for Medicare and Medicaid Services (CMS). Despite these risks associated with the use of ESAs, concerns regarding increased use of transfusions remain prominent. A longitudinal study to assess the impact of these ESA policies was conducted to assess the demand on transfusion services and ESA use over time. Methods: Our center comprises a large comprehensive combined hematology and oncology program and has a non- restrictive transfusion policy, allowing physician discretion and the capacity to accommodate all out-patient transfusions. We analyzed ESA use over the 3 year period, 2006–2008. 2006 functioned as our baseline; 2007 was the year of initial FDA and CMS changes; 2008 allowed us to see if practice changes would persist. Results: We present in the table below, our data on ESA use and transfusion resource utilization. Conclusions: With over 60,000 patient visits during 3 years, longitudinal assessment reveals a continued, marked decrease in ESA use. Despite liberal transfusion policies, there has been little effect on transfusion rates. Increases in transfusions are commensurate with a rise in patient visit volume. We are now evaluating whether this marked decrease in ESA use translates into decreased thrombosis rates over this 3-year period at our cancer center.

[Table: see text]

No significant financial relationships to disclose.

Determining issues of importance for patients with prostate cancer: Results of a web-based study in 2,128 patients with prostate cancer for the development of a quality of life (QL) instrument, the prostate cancer symptom scale (PCSS)

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Background: Identifying key issues for patients with malignancy is central to assessing QL and patient reported outcomes. This aids in evaluating the effectiveness of treatment programs for those with the disease. The immediate aim of this study was to determine content validity using a large patient panel for the PCSS, a QL measure for patients with prostate cancer. The PCSS also uses an inexpensive hand-held pocket PC to enhance feasibility. The PCSS concept is based on the LCSS (a validated lung cancer instrument). Methods: We used the established patient base of the web-based NexCura patient information resource to survey registered patients with prostate cancer. Demographic stratifications included stage of disease, prior radical prostatectomy, and current treatment (none, hormonal, non-hormonal). 2,128 patients completed the anonymous web-conducted survey, performed over a 3-day period. Patients were asked to rank 18 issues on a 5-point scale assessing the importance of each item. Issues included general, prostate-specific, psychosocial and summative items. Results: The 10 highest (and 2 lowest) ranked items are seen in the table ; results are described by the percent of patients choosing the top category (very important) and the top 2 rating categories of importance. Ratings by disease subsets (such as NED or metastatic disease; hormonal or non-hormonal treatment) were quite similar to results found for the whole group, as listed in the table . Conclusions: These results represent the largest survey of patient concerns in prostate cancer and support using computer-assisted survey technology to assess such information in all malignancies to obtain patient input rapidly from large patient samples. Strong support for content validity for the PCSS was obtained.

[Table: see text]

No significant financial relationships to disclose.

Comparing two methods of meta-analysis in clinical research - individual patient data-based (IPD) and literature-based abstracted data (AD) methods: Analyzing five oncology issues involving more than 10,000 patients in randomized clinical trials (RCTs)

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Background: Meta-analyses are one of the highest recommendations levels in Evidence-Based Medicine (EBM). Recently, meta-analyses have increased using either IPD or AD methods. Controversy exists regarding reliability, applicability and feasibility of the different methods to draw conclusions from conflicting RCTs and to estimate magnitude of benefit of different treatments. Methods: As seen in the table , we selected 5 major issues in 3 malignancies subjected to IPD meta-analysis, and then conducted AD meta-analyses from publications of the individual studies, using published methods (Bria, Cancer Treat Rev 2006). We required that >90% of patient numbers for both IPD and AD analyses be available. Event-based relative risk ratios (RRs) with 95% confidence intervals (CI) were derived. Fixed- and random-effect models, and absolute benefits (AB) were calculated. Correlations between IPD Hazard Ratios (HRs) and AD-RRs were estimated using a linear regression model according to Pearson (r) and R2 coefficients (parametric) and Spearman (Rho) coefficient (non- parametric). Results: Results are below. A strong linear correlation exists between IPD-HRs and AD-RRs (r=0.994, R2=0.989; p<0.001; Rho=1.00). Conclusions: The strong correlation supports using high quality meta-analyses with either method to resolve major issues. Differences exist between the methods: IDP is well-suited for sensitivity analyses and for hypothesis generation involving issues not originally anticipated; AD is a practical method allowing EBM to be applied rapidly to major issues in oncology in a timely fashion.

No significant financial relationships to disclose.

[Table: see text]

Is symptom improvement in patients with small cell lung cancer (SCLC) associated with clinical response? An analysis using the Patient Symptom Assessment Lung Cancer (PSALC) scale in a randomized trial comparing oral topotecan (OT) with best supportive care (BSC)

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Background: SCLC is a highly symptomatic disease with poor survival in prior treated patients. To evaluate the role of chemotherapy, a recent multicenter trial randomized 141 patients with prior treatment to receive either OT + BSC or BSC only. This was the first trial to use a BSC control group in SCLC while evaluating survival, response and symptoms. Survival data were reported (O'Brien et al JCO 2006; median survival of 25.9 weeks on OT + BSC vs 13.9 weeks on BSC, p = 0.01). 51% on OT had “disease control” (partial response [PR] + stable disease [SD]); no patient on BSC was reported to have a major response, although response was not an endpoint for this group. Trials have shown that those with progressive disease have the most symptom worsening, as occurred in this trial. The objective of this analysis is to determine if patients with PR report greater symptom relief than those with SD, in that SD can reflect a more indolent course in some patients while PR is due to treatment effect only. Methods: We used the investigators evaluation of response (PR or SD) and analyzed these groups by the patients’ scoring of their symptoms using the PSALC instrument which evaluates 9 SCLC symptoms, in the 71 patients on the OT + BSC arm. Results: Patients with lower ECOG PS at baseline reported more severe symptoms (higher PSALC score). Mean changes in PSALC score from baseline are shown in the Table and demonstrate an association between tumor response and decrease in symptoms. Conclusions: Patients who achieved a major response on OT treatment reported significantly better symptom control than those whose best response was SD. This indicates that in addition to a survival benefit, treatment with this chemotherapy can aid in symptom control. While the small number of patients limits the strength of the conclusions, this trial represents the largest BSC controlled study in SCLC.

No significant financial relationships to disclose.

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Is it cost-effective to add erlotinib to gemcitabine in advanced pancreatic cancer?

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Background: Single agent gemcitabine has been considered the standard of care in advanced pancreatic cancer since 1996. A recent 569 patient randomized trial comparing gemcitabine alone with gemcitabine + erlotinib as first line therapy found a small but statistically significant difference in survival (6.0 vs 6.4 months, respectively, p = .028). The impact on survival may be small, but with nearly 33,000 new cases of pancreatic cancer per year, the impact on health care costs with the use of the combined regimen may be large. Using the known survival data and costs, we analyzed the incremental cost-effectiveness of adding erlotinib. Methods: Costs for a six month course of gemcitabine were developed using Medicare reimbursement from the January, 2006 CMS Drug Payment Table and Physician Fee Schedule assuming no change in infusion reimbursement. Since erlotinib is not approved as a Medicare Part B drug, costs were developed from wholesale and retail sources. Drug dosing and schedules were based on the clinical trial protocol leading to approval. Incremental cost effectiveness of adding erlotinib was calculated. Results: Six month course of gemcitabine alone costs $23,493. The addition of erlotinib increases cost by $12,156 wholesale or $16,613 retail. Given an increase of 0.4 months in median survival over gemcitabine alone, the addition of erlotinib costs $364,680 per year of life gained (YLG) wholesale and $498,379/YLG retail. Sensitivity analyses were conducted assuming shorter therapy of 4 and 5 months. In order to be cost effective even at the $100,000/YLG level, six months of erlotinib would have to be reduced to 20% of the current retail cost (lowered to $18.52 per tablet.) Conclusions: Adding erlotinib to gemcitabine does not approach cost effectiveness at even the highest year per life gained parameters. Such impacts on health care costs, especially for very small gains, become more pressing as all health care costs continue to increase.

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A prospective evaluation of the attitudes of patients, physicians and nurses using a computer-assisted quality of life instrument (LCSS-QL) in a multicenter clinical trial in non-small cell lung cancer (NSCLC)

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Background: The LCSS has been computerized (LCSS-QL) for inexpensive hand-held devices (pocket-pc) to enhance feasibility, provide immediate results, and automatically record data. Correlation coefficient between paper form and electronic version is excellent (r=0.93). This analysis determines the acceptability and value of LCSS-QL assessed by patients and health care professionals. Methods: NSCLC patients utilized LCSS-QL in a clinical trial and also completed a form evaluating their experiences after their first and third treatment cycles. All received docetaxel and platinum. Eleven physicians and nurses administered LCSS-QL and completed an evaluation form. The evaluation included: time required, satisfaction with the process, value of assessment, impact on communication, resource utilization. Results: The evaluation form was completed by 126 patients (cycle 1) and 94 (75%) completing cycle 3. Baseline characteristics: Stage III/IV 29/71%; median KPS 80%; 56% male; median age 69 yrs. Results are in the table : All physicians considered their time per patient was not lengthened and 80% felt that QL evaluation could save time. 67% of nurses felt the instrument could save time, while 83% felt that their time with patients was lengthened. Utilization: 67% of professionals reported QL evaluation would identify earlier patients not benefiting from chemo; 91% were more aware of pain issues. Conclusions: Patients and health-care professionals found using a validated QL instrument in a computerized form via a hand-held device was easy, added value and satisfaction while enhancing communication and awareness of PRO issues. This electronic format added no physician time. These results indicate that this QL evaluation method should be used more frequently in clinical trials and patient management. Supported in part by a grant from Sanofi-Aventis Canada, Laval, QC.

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Examining the cost and cost-effectiveness of adding bevacizumab to carboplatin and paclitaxel in advanced non-small cell lung cancer

6057

Background: Two-drug platinum-containing regimens are considered the standard of care in advanced non-small cell lung cancer. A recent randomized trial (ECOG 4599) compared carboplatin + paclitaxel (PC) with PC + bevacizumab (PCB). PCB was found to result in a modest improvement in survival (12.5 months vs 10.2 months with PC, p = .007). This finding was exceptional in showing a survival benefit with the addition of a molecularly targeted agent to chemotherapy in a largely unselected population, and doing so in this most common cause of malignant death in the US. Additionally, new therapies can have a major impact on health care costs. Using the known survival data and costs, we analyzed the cost-effectiveness of the addition of bevacizumab to this chemotherapy regimen. Methods: Medicare reimbursement (cost) of the two regimens was developed using the CMS Drug Payment Table and Physician Fee Schedule for January, 2005. Incremental cost effectiveness was calculated. Results: Carboplatin and paclitaxel regimen costs $14,073 for 6 cycles (the number of cycles planned in the clinical trial.) The addition of bevacizumab increases cost by $66,270 to $80,343. Given an increase of 2.3 months in median overall survival over chemotherapy alone, the addition of bevacizumab to chemotherapy costs $345,762 per year of life gained. Conclusions: Adding bevacizumab to chemotherapy is not cost effective even at the $100,000 per Year of Life Gained (YLG) threshold. To be cost effective at the $100,000/YLG level, bevacizumab reimbursement would have to be reduced to $14.70/10 mg. ($1,764/cycle) or 26% of 2005 Medicare reimbursement of $57.08/10 mg. ($6,849/cycle). Prior analyses have examined the impact of chemotherapy on survival and cost-effectiveness. Several factors beneficially influence survival in NSCLC, as shown in meta-analyses, including: chemotherapy vs supportive care, two-agents vs one, and the choice of which platinum agent to use. While all of these may increase costs, some are cost-effective, while others are not. The addition of bevacizumab is the most costly and least cost-effective of any of these interventions.

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Combined data from two phase III trials of the NK1 antagonist aprepitant plus a 5HT 3 antagonist and a corticosteroid for prevention of chemotherapy-induced nausea and vomiting: effect of gender on treatment response

GOALS OF WORK

Prevention of chemotherapy-induced nausea and vomiting (CINV) with standard antiemetics has been more difficult to achieve in female patients. Data from two phase III trials of the NK1 antagonist aprepitant were assessed for potential effect of gender on treatment response.

PATIENTS AND METHODS

1,044 patients receiving cisplatin (> or = 70 mg/m2) were randomly assigned to control regimen [ondansetron (O) 32 mg i.v. and dexamethasone (D) 20 mg p.o. on day 1; D 8 mg twice daily on days 2-4] or aprepitant (A) regimen (A 125 mg p.o. plus O 32 mg and D 12 mg on day 1; A 80 mg and D 8 mg once daily on days 2-3; and D 8 mg on day 4). The primary endpoint was overall complete response (no emesis and no rescue therapy over days 1-5). Data were analyzed by a modified intent-to-treat approach. Between-treatment comparisons for each gender were made using logistic regression.

MAIN RESULTS

Women comprised 42 and 43% of the aprepitant and control groups, respectively. In the control group, 41% of women had overall complete response compared with 53% of men. In the aprepitant group, 66% of women had overall complete response compared with 69% of men.

CONCLUSION

The addition of aprepitant may negate the adverse prognostic effect of female gender on the prevention of CINV in patients receiving highly emetogenic chemotherapy.

A comparison of visual analogue and numerical rating scale formats for the Lung Cancer Symptom Scale (LCSS): does format affect patient ratings of symptoms and quality of life?

PROBLEM AND PURPOSE

The Lung Cancer Symptom Scale (LCSS), a site-specific health-related quality of life measure for patients with lung cancer, was originally developed using a Visual Analogue Scale (VAS) format. However, the VAS format is not readily compatible with data management and software programs using scanning. The primary aim of this study was to evaluate the convergence of ratings obtained with a Numerical Rating Scale (NRS), with an 11-pt response category format, to those obtained with a VAS format. The intent was to determine the degree of agreement between two formats to generalize the existing psychometric properties for the original measure to the new presentation.

DESIGN/SETTING

This methodological study evaluated the feasibility, reliability, and validity of a NRS format for the LCSS. The study was conducted at two cancer centers in New York City. PATIENTS/PROCEDURES: Sixty-eight patients with non-small cell lung cancer (NSCLC) completed both versions of the LCSS along with demographic and feasibility questions on a single occasion. The VAS form was administered first, followed by the NRS form to prevent bias. The intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), and Bland-Altman plots were used to evaluate agreement and to characterize bias.

RESULTS

Cronbach's alpha for the NRS format total score was 0.89 for the 68 patients with NSCLC. Agreement was excellent, with both the ICC and CCC > or = 0.90 for the two summary scores (total score and average symptom burden index) for the LCSS. Only five of the nine individual items showed this level of strict agreement. An agreement criterion of > or = 0.80 (representing excellent) was observed for seven of the nine individual items (all but appetite loss and hemoptysis). Mean differences tended to be slightly lower for the VAS format compared to the NRS format (more so for the appetite and hemoptysis items), with evidence of scale shift for the same two items. The summary measures showed good concordance as measured by the ICC and CCC, but did display mean differences (VAS - NRS) of -2.7 and -3.1, respectively.

CONCLUSIONS

Overall, the NRS format for the LCSS suitable for scanning has good feasibility, reliability (internal consistency), and convergent validity. The complete set of concordance evaluation measures supports the reproducibility of VAS scores by NRS scores, particularly for the two summary scores.

Multi-Institutional Phase I/II Trial of Oral Bexarotene in Combination With Cisplatin and Vinorelbine in Previously Untreated Patients With Advanced Non–Small-Cell Lung Cancer

PURPOSE: Bexarotene (Targretin; Ligand Pharmaceuticals, Inc, San Diego, CA) is a retinoid-X-receptor (RXR)-selective retinoid with preclinical antitumor activity in squamous cell cancers. In this phase I/II trial, we combined bexarotene with cisplatin and vinorelbine in the treatment of patients with non–small-cell lung cancer (NSCLC).

PATIENTS AND METHODS: Forty-three patients who had stage IIIB NSCLC with pleural effusion or stage IV NSCLC and had received no prior therapy received bexarotene in combination with cisplatin (100 mg/m2) and vinorelbine (alternating doses of 30 mg/m2 and 15 mg/m2). In the phase I portion, the daily dose of bexarotene was escalated in cohorts of three patients from 150 mg/m2 to 600 mg/m2, beginning 1 week before the start of the cisplatin-vinorelbine regimen. Once the maximum-tolerated dose (MTD) of bexarotene was determined, the study entered the phase II portion. Response rate was the primary end point; median survival time and 1-year survival rate were secondary end points.

RESULTS: In the phase I portion, the daily MTD of bexarotene was determined to be 400 mg/m2. Eight of 43 patients exhibited major responses. Seven (25%) of the 28 patients in the phase II portion responded to treatment. The median survival time in the phase II portion was 14 months; nine (32%) of the 28 patients were still alive at a minimum follow-up of 2 years. One-year and projected 3-year survival rates were 61% and 30%, respectively. The most common grade 3 and 4 adverse events were hyperlipemia, leukopenia, nausea, vomiting, pneumonia, dyspnea, anemia, and asthenia. Grade 3 and 4 laboratory abnormalities with incidences greater than 5% were decreased hemoglobin levels and WBC, absolute neutrophil, and absolute lymphocyte counts and increased prothrombin time and creatinine and amylase levels. Of the two cases of pancreatitis, one required hospitalization and both were associated with increased triglyceride levels. There was one death secondary to renal insufficiency unrelated to bexarotene treatment.

CONCLUSION: In patients with advanced NSCLC, bexarotene with cisplatin and vinorelbine yielded acceptable phase II response rates (25%) and was associated with better-than-expected survival (14-month median survival time; 61% 1-year, 32% 2-year, and 30% projected 3-year survival rates). The regimen should be studied in larger clinical trials.

Efficacy of intravenous granisetron to control nausea and vomiting during multiple cycles of cisplatin-based chemotherapy

The safety and efficacy of granisetron (10 micrograms/kg and 40 micrograms/kg) were evaluated during a second (n = 393) and third (n = 200) cycle of chemotherapy in this multicenter, double-blind, randomized, parallel-group study. Granisetron was administered as a single intravenous dose before the start of cisplatin chemotherapy (> or = 60 mg/m2). Total control (no vomiting, no retching, no nausea, and no use of antiemetic rescue medication) after the first 24 hr following chemotherapy was achieved in 40% and 49% of patients in Cycles 2 and 3, respectively, for the 10 micrograms/kg group, and in 42% and 38% of patients in Cycles 2 and 3, respectively, for the 40 micrograms/kg group. Both dose levels of granisetron were well tolerated. The results demonstrate comparable efficacy between the 10 micrograms/kg and 40 micrograms/kg doses of granisetron in preventing nausea and vomiting during repeat cycles of high-dose cisplatin-based chemotherapy. The results of this study show that granisetron 10 micrograms/kg is safe and well tolerated, and remains effective with repeat cycle use.