Lung cancer in patients ≥ 80 years of age: Analysis of the national surveillance, epidemiology and end results (SEER) database

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Background: Lung cancer is a disease of the elderly with median age at diagnosis of 70 years. In spite of this, the very elderly (patients ≥ 80 years) group has not been well studied. We analyzed the national SEER database to evaluate outcome of the disease in this subgroup. Methods: All patients with primary lung cancer in the national SEER database from 1988–1997 were included, and grouped into those <80 yrs vs. those ≥80 yrs at the time of diagnosis. We compared the 2 groups for stage distribution, 3-yr & 5-yr survival, survival based on histology, sex, race, stage and treatment. The 5-yr relative survival rate, adjusted for the normal life expectancy, was utilized except for the 3-yr survival comparison. The SEER program, Stat 6.1.4, was used for analysis and all p-values were 2-sided. Results: Of the 129,003 cases of lung cancer registered over 10 years, 14,614 (11%) occurred in patients ≥80 yrs. Overall survival at 3 and 5yrs was inferior in the octogenarian group, {11.8% vs. 20% and 8.3% vs. 16.2%, respectively (p < 0.0001)}. The inferior survival was observed in both males and females {7.1% vs. 14.3% and 9.6% vs. 18.9%, respectively (p < 0.0001)} and with non-small cell histology {9.1% vs. 18.3% (p < 0.0001)}. Stage-specific analysis revealed the same trend {24.9% vs. 46.9% - stage I, 19.1% vs. 30.4% - stage II, 3.1% vs. 9.0% - stage III and 1.1% vs. 1.8% - stage IV (p < 0.0001 for all comparisons)}. Irrespective of race, elderly patients fared worse: 6.9% vs. 12.8% in blacks, 8.4% vs. 16.7% in white and 8.4% vs. 16.3% in other racial groups (p < 0.0001 for all comparisons). Although, therapy (surgery or radiation) benefited both groups, treated elderly group performed worse than younger group {4.9% vs. 8.1% (p < 0.0001) and 45% vs. 45.7% (p < 0.02) with radiation and surgery respectively}. However, only 58% of elderly patients received surgery or radiation therapy compared to 80% of patients <80 yrs. Conclusion: In general, very elderly patients with lung cancer have a worse clinical outcome than younger patients. This is irrespective of histology, stage of disease, sex, gender or race. The worse outcome in the elderly may be due to a larger proportion of them not receiving treatment.

No significant financial relationships to disclose.

A phase II study of intravenous (IV) milataxel (M) for the treatment of non-small cell lung cancer (NSCLC) refractory to platinum-based therapy

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Background: M (TL139, MAC-321) is a novel taxane that has shown activity when administered IV or orally in both taxane-resistant and susceptible nude mouse xenograft models. The current study is an open-label study in previously treated patients (pts) with locally advanced, metastatic, or recurrent NSCLC to determine response rate. Methods: Pts with cytologically or histologically confirmed NSCLC must have received 1 or 2 prior regimens including prior platinum, and may have received prior paclitaxel or docetaxel. Good performance status (ECOG 0 or 1), and adequate hematologic, hepatic and renal function were required. Pts with clinically active brain metastases were excluded. Pts were treated with M 35 mg/m2 as a 4 hr IV infusion every 3 weeks. The primary end point was objective response rate. Results: A total of 46 pts were treated: 21 (46%) female pts and 25 (54%) male pts. Mean age was 59 (range 41–85), ECOG was PS 0 in 13 (28%) pts, PS 1 in 31 (67%) pts and unknown in 2 (4%) pts. The number of prior chemotherapy regimens was > 1 in 21 (46%) pts. Twenty-five (54%) pts had one prior taxane and 7 (15%) pts had both paclitaxel and docetaxel previously. The median number of cycles was 3 (range 1–14). Nine (20%) pts required dose reduction. Five (11%) pts discontinued treatment due to adverse events. A total of 25 (54%) pts reported drug related grade 3 or 4 adverse events. Non-hematologic grade 3 or 4 drug-related events occurring in more than 1 pt included: neuropathy 4 (9%) pts, neutropenic fever 3 (7%) pts, arthralgia 2 (4%) pts. There was no treatment related mortality. Objective responses were confirmed in 4 (9%) pts (3 PR, 1 CR). Three pts with response (including pt with CR) had received prior docetaxel. PR duration was 175, 250, and 315 days. Pt with CR received 4 cycles of M and discontinued due to the CR. Pt remained in CR at day 504. Conclusions: Milataxel 35 mg/m2 as a 4 hr IV infusion every 3 weeks provided durable responses in heavily pretreated pts including pts who had previously received taxanes.

No significant financial relationships to disclose.

Comparison of survival for non-small cell lung cancer (NSCLC) between premenopausal and postmenopausal women: An analysis of the National Surveillance, Epidemiology and End Results (SEER) Database

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Background: Estrogen signaling has been implicated in lung cancer formation and progression by pre-clinical studies. Estrogen receptor (ER) Beta is overexpressed in NSCLC. To understand the clinical impact of the estrogen pathway, we analyzed the national SEER database to compare the outcomes for NSCLC in premenopausal vs. postmenopausal women. Methods: Data from the national SEER registry between the years of 1988–2002 was analyzed. Women between the ages 40–44 were chosen as representative of the pre-menopausal group and 55–59 year-old women represented the post-menopausal group. To control the effect of age alone as a determinant of outcome, we compared the survival between 1,534 men with ages of 40–44 and 8,807 men with ages of 55–59. Survival rates were analyzed by Kaplan-Meier method and compared by Z-test through SEER*Stat software version 6.1.4. Results: A total of 7,150 women, premenopausal (1,171) and postmenopausal (5,979) were included. Adenocarcinoma (ADC) was more commonly seen in premenopausal than in postmenopausal women (58% vs 47%). Distribution by stage at diagnosis was similar between the two groups. Premenopausal women with squamous cell carcinoma (SCC) or bronchioalveolar carcinomas (BAC) had inferior overall survival than postmenopausal women. Differences in outcome between men in the two age groups were not significant. Conclusions: Premenopausal women with SCC or BAC, but not ADC have inferior survival compared to postmenopausal women. Smaller and non-significant differences were observed between males of the same aged-groups. The results suggest varying estrogen effects between the histological sub-types of NSCLC and support clinical strategies to block the ER pathway for the treatment of NSCLC.

[Table: see text]

No significant financial relationships to disclose.

Phase III randomized trial of docetaxel in combination with cisplatin or carboplatin or vinorelbine plus cisplatin in advanced non--small cell lung cancer: interim analysis

In the TAX 326 trial, 1,220 chemotherapy-naive patients with advanced or metastatic non--small cell lung cancer have been randomized to receive one of three regimens: docetaxel 75 mg/m(2) plus cisplatin 75 mg/m(2) every 3 weeks; docetaxel 75 mg/m(2) plus carboplatin to an area under the curve of 6 mg/mL x min every 3 weeks; or a control arm of vinorelbine 25 mg/m(2) weekly plus cisplatin 100 mg/m(2) monthly. The treatment and toxicity data presented are based on a planned preliminary analysis conducted after 601 patients had been enrolled. The median age of patients randomized was 60 years and 73% were male. The majority of patients had a Karnofsky score of 80 or greater, two thirds had stage IV disease and 35% had three or more sites of organ involvement. While the relative dose intensity for docetaxel was 0.97 both when combined with cisplatin and when combined with carboplatin, the corresponding figure for vinorelbine was 0.68, reflecting the frequent need for dose reduction when combined with cisplatin on the schedule used. Hematologic toxicities were tolerable and comparable across the three arms of the trial, and the rate of febrile neutropenia was below 5% in all cases. The incidence of nonhematologic toxicities also was similar, although nausea and vomiting appeared to be less frequent among patients assigned to docetaxel plus carboplatin than among patients receiving comparator regimens. Semin Oncol 28 (suppl 9):10-14.

Docetaxel (Taxotere) in combination with platinums in patients with non-small cell lung cancer: trial data and implications for clinical management

Docetaxel (Taxotere; Aventis, Antony, France) is among the most effective agents for the treatment of non-small cell lung cancer and its use in combination with cisplatin is a logical development. Docetaxel has been combined with cisplatin and is well-tolerated with promising activity in phase II studies. Extensive phase II investigations in the first-line setting recorded response rates of 32% to 52% survival (median, 8 to 12 months) with 33% to 48% of patients alive at 1 year. Neutropenia is dose-limiting. However, the incidence of severe neuropathy is low and clinically significant nephrotoxicity is uncommon. Following these encouraging findings, the combination of docetaxel with cisplatin has been studied in two randomized phase III trials that compare the new combination against reference regimens. These studies have completed accrual and data are expected shortly. The combination of docetaxel with carboplatin is also active and feasible. Neutropenia is the main adverse event and grade II or III neurotoxicity is uncommon. In phase II trials combining doses of 65 to 100 mg/m2 docetaxel with doses of carboplatin designed to maintain an area under the curve of 5 to 7.5 mg/mL/min, response rates have ranged from 30% to 67%.

Activity of docetaxel in platinum-treated non-small-cell lung cancer: results of a phase II multicenter trial

PURPOSE

Although several new chemotherapeutic agents are promising as primary therapy in non-small-cell lung cancer (NSCLC), few have demonstrated activity in platinum-refractory disease. Based on encouraging results reported in two single-institution studies of docetaxel in this setting, we performed a multicenter phase II trial evaluating this novel taxane in previously treated NSCLC patients prospectively categorized by platinum response status.

PATIENTS AND METHODS

Eighty patients with NSCLC previously treated with platinum-based chemotherapy received docetaxel at a dose of 100 mg/m(2) intravenously over 1 hour, repeated every 21 days, accompanied by dexamethasone 8 mg orally twice daily for 5 days. Forty-seven patients (59%) were defined as platinum-refractory based on response status to prior therapy.

RESULTS

The median number of cycles delivered per patient was four (range, one to 21 cycles). Partial response was observed in 13 (16%) of 80 of patients, with similar response rates in platinum-sensitive and platinum-refractory patients. The median survival time was 7 months, and the 1-year survival rate was 25%. Docetaxel was relatively well tolerated in this previously treated population. Grade IV neutropenia was common in patients (77%) but typically of brief duration. Febrile neutropenia was observed in 11 patients (14%), with no fatal infections. Severe fluid retention was rare (4% of patients).

CONCLUSIONS

This multicenter phase II trial confirms antitumor activity and encouraging survival with docetaxel therapy in platinum-treated and platinum-refractory NSCLC. To validate these results, a phase III trial randomizing platinum-treated patients to docetaxel or best supportive care is underway.

Tirapazamine with cisplatin in patients with advanced non-small-cell lung cancer: a phase II study

PURPOSE

A phase II study was conducted to evaluate the safety and efficacy of tirapazamine combined with cisplatin for the treatment of patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Forty-four patients with stage IIIB/IV NSCLC were treated with a combination of tirapazamine and cisplatin. Patients received tirapazamine 260 mg/m2 administered intravenously over 2 hours, followed 1 hour later by cisplatin 75 mg/m2 administered over an additional hour, repeated every 21 days. The duration of therapy was meant to be limited to four cycles for nonresponders and eight cycles for responders.

RESULTS

Ten of 44 patients (23%) showed a partial response. The estimated median survival for all patients was 37 weeks. Toxicities were treatable and included grade 3 nausea or vomiting (25%), fatigue (27.3%), and muscle cramps (4.5%). No dose reductions were necessary.

CONCLUSION

The results show that tirapazamine can safely be added to cisplatin. Both the median survival and response rate observed strongly suggest that tirapazamine with cisplatin is more active than cisplatin alone.

Considerations in optimizing radiation therapy for non-small cell lung cancer

Irradiation therapy for lung cancer is mostly restricted to conventional methods. To improve therapeutic ratio, we have combined a treatment planning and a gene therapy approach. Three-dimensional conformal radiotherapy is described as carried out by methods of gene therapy for radiation protection using the manganese-superoxide-dismutase transgene delivered by inhalation gene transfer. These methods may improve therapeutic outcomes in lung cancer.

Oral vinorelbine (Navelbine) in the treatment of advanced non-small cell lung cancer: a preliminary report

Vinorelbine (Navelbine; Burroughs Wellcome Co, Research Triangle Park, NC; Pierre Fabre Médicament, Paris, France) is a novel semisynthetic vinca alkaloid with antitumor activity in non-small cell lung cancer. An oral preparation of this drug is under investigation and was tested in a multicenter phase II study in patients with stage IV measurable or evaluable non-small cell lung cancer. The initial vinorelbine dose was 100 mg/m2/wk (80 mg/m2/wk for patients with prior radiotherapy). Following an initial 37% incidence of grade 3 or 4 neutropenia, the dose was reduced by 40 mg/dose. Nausea, vomiting, diarrhea, and mucositis were other frequently observed toxicities. A preliminary analysis indicated a response rate of 14%, suggesting activity of this drug when administered orally.

Phase II trial of 5 day continuous intravenous infusion of 6-thioguanine in patients with recurrent and metastatic squamous cell carcinoma of the head and neck

Fifteen patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck received a 5 day continuous I.V. infusion of 6-thioguanine repeated every five weeks. Dose limiting toxicity was primarily hematological with grade III/IV leucopenia and thrombocytopenia seen in seven patients. Nausea and vomiting was moderate and well controlled with antiemetics. No complete or partial responses were observed, with a median time to progression of 58 days and a median survival of 227+ days for the entire group. Based on these results we do not recommend I.V. 6-thioguanine for the treatment of this disease.