Two biomarker-directed randomized trials in European and Chinese patients with nonsmall-cell lung cancer: the BRCA1-RAP80 Expression Customization (BREC) studies

BACKGROUND

In a Spanish Lung Cancer Group (SLCG) phase II trial, the combination of BRCA1 and receptor-associated protein 80 (RAP80) expression was significantly associated with outcome in Caucasian patients with nonsmall-cell lung cancer (NSCLC). The SLCG therefore undertook an industry-independent collaborative randomized phase III trial comparing nonselected cisplatin-based chemotherapy with therapy customized according to BRCA1/RAP80 expression. An analogous randomized phase II trial was carried out in China under the auspices of the SLCG to evaluate the effect of BRCA1/RAP80 expression in Asian patients.

PATIENTS AND METHODS

Eligibility criteria included stage IIIB-IV NSCLC and sufficient tumor specimen for molecular analysis. Randomization to the control or experimental arm was 1 : 1 in the SLCG trial and 1 : 3 in the Chinese trial. In both trials, patients in the control arm received docetaxel/cisplatin; in the experimental arm, patients with low RAP80 expression received gemcitabine/cisplatin, those with intermediate/high RAP80 expression and low/intermediate BRCA1 expression received docetaxel/cisplatin, and those with intermediate/high RAP80 expression and high BRCA1 expression received docetaxel alone. The primary end point was progression-free survival (PFS).

RESULTS

Two hundred and seventy-nine patients in the SLCG trial and 124 in the Chinese trial were assessable for PFS. PFS in the control and experimental arms in the SLCG trial was 5.49 and 4.38 months, respectively [log rank P = 0.07; hazard ratio (HR) 1.28; P = 0.03]. In the Chinese trial, PFS was 4.74 and 3.78 months, respectively (log rank P = 0.82; HR 0.95; P = 0.82).

CONCLUSION

Accrual was prematurely closed on the SLCG trial due to the absence of clinical benefit in the experimental over the control arm. However, the BREC studies provide proof of concept that an international, nonindustry, biomarker-directed trial is feasible. Thanks to the groundwork laid by these studies, we expect that ongoing further research on alternative biomarkers to elucidate DNA repair mechanisms will help define novel therapeutic approaches.

TRIAL REGISTRATION

NCT00617656/GECP-BREC and ChiCTR-TRC-12001860/BREC-CHINA.

Phase II study of continuous daily sunitinib dosing in patients with previously treated advanced non-small cell lung cancer

BACKGROUND

Sunitinib malate (SUTENT) has promising single-agent activity given on Schedule 4/2 (4 weeks on treatment followed by 2 weeks off treatment) in advanced non-small cell lung cancer (NSCLC).

METHODS

We examined the activity of sunitinib on a continuous daily dosing (CDD) schedule in an open-label, multicentre phase II study in patients with previously treated, advanced NSCLC. Patients > or =18 years with stage IIIB/IV NSCLC after failure with platinum-based chemotherapy, received sunitinib 37.5 mg per day. The primary end point was objective response rate (ORR). Secondary end points included progression-free survival (PFS), overall survival (OS), 1-year survival rate, and safety.

RESULTS

Of 47 patients receiving sunitinib, one patient achieved a confirmed partial response (ORR 2.1% (95% confidence interval (CI) 0.1, 11.3)) and 11 (23.4%) had stable disease (SD) > or =8 weeks. Five patients had SD>6 months. Median PFS was 11.9 weeks (95% CI 8.6, 14.1) and median OS was 37.1 weeks (95% CI 31.1, 69.7). The 1-year survival probability was 38.4% (95% CI 24.2, 52.5). Treatment was generally well tolerated.

CONCLUSIONS

The safety profile and time-to-event analyses, albeit relatively low response rate of 2%, suggest single-agent sunitinib on a CDD schedule may be a potential therapeutic agent for patients with advanced, refractory NSCLC.

Erlotinib in patients with advanced squamous cell carcinoma of the lung

7174

Background: Erlotinib is a potent HER1/EGFR TKI that is approved for the treatment as a single agent in 2nd and 3rd line NSCLC. Several phase II studies have shown that adenocarcinoma histology together with female gender, Asian origin, and never having smoked are associated with responsiveness of NSCLC to erlotinib. The purpose of the analyisis we present here was to describe the outcome in a group of patients with squamous carcinoma of the lung treated with erlotinib. Methods: Eligilibility criteria included stage IIIB-IV chemotherapy-naive patients with confirmed NSCLC, PS 0–2, age ≥ 18 years, adequate organ functions, measurable disease and written informed consent. Patients with diagnosis of squamous cell lung cancer that received erlotinib 150 mgr/day p.o until disease progression or withdrawal were the subject of this analysis. Results: From June 2004 to March 2005, 121 patients with histological diagnosis of squamous cell lung cacer from more than 100 different Spanish hospitals were included in the TARGET study. Median age was 66 yrs. All patients in our analysis were Caucasian. 111 patients were male (92%) and 113 (93%) were current smokers or have smoke sometime in their life. 88% of them have stage IV carcinoma and 74% have received previous treatment for metastatic disease. PS 0/1/≥2 18 (15%)/68 (56%)/32 (29%). In the evaluable population for response (69 pts) 5 PR and 0 CR were observed for an overall RR of 7.25%. Clinical benefit defined as CR+PR+SD was 54%. In the ITT populations median TTP was 3.6 months [95% CI 2.7–5.3]. Median OS was 5,7 m [95% CI 4.0–6.7]. Erlotinib was well tolerated.No unexpected toxicities were observed. Conclusions: This subgroup analysis confirms that erlotinib is active and well tolerated in patients with advanced or metastatic squamous cell carcinoma of the lung. Responses were seen in both genders and in patients with or without smoking history. At this moment histology should not be used as the only selection criteria for treatment of patients with NSCLC after failure to chemotherapy.

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Multicentric descriptive study of the lung cancer treatment

20109

Background: Given the insufficient available information on the clinical characteristics and the results of the lung cancer treatment at a population level, we performed a large multicentric descriptive study in the main hospitals in our city. Methods: We analyzed the patients diagnosed and treated for lung cancer during 1999 in five University Hospitals in Barcelona (Spain). We performed a retrospective analysis of the individual data obtained from the clinical records using a specifically validated questionnaire. A descriptive analysis was performed, stratifying for type of tumor, stage, and institution. The follow-up for the complete population was 5 years. Results: We included 836 patients (94.6% male, 5.4% female) with an average age of 64 years. Karnofsky was ≥ 70% in 85% of patients. Histologic distribution was non-small cell (NSCLC) 85.5%, small-cell (SCLC) 14.5%. 42% of cases were stage IV (38% NSCLC, 67.8% SCLC). First treatment was performed in 82% of cases with therapeutic intention (52% was chemotherapy). Pulmonary resection with lobectomy and platinum-based chemotherapy were the more frequent treatments. Complete remission was obtained in 25% of cases. Survival was 42.0, 17.9 and 12.6% at 1, 3 and 5 years respectively (NSCLC: 43.8, 19.4, 13.1%; SCLC: 31.9, 9.5, 9.5%). The mean interval first visit - treatment start was 2 months. The mean of direct costs per patient was 9000 €. The cost per life-year gained was 5200 € for NSCLC and 7600 € for SCLC patients. Conclusions: The obtained results allow to describe the clinical characteristics of a wide cohort of patients diagnosed of lung cancer and their survival to 5 years. Globally, these results are similar to those who have been published in our country and others, and constitute a very thorough referent for assessing the impact of future therapeutic advances. The comparison among hospitals can also be the matter of further analysis for identifying the causes of the observed differences. Equally, specific strategies for some patients’ subgroups could be designed in order to improve the cost-effectiveness of their treatment.

No significant financial relationships to disclose.

Erlotinib as single agent in patients (p) with advanced or metastatic NSCLC: A multivariate analysis in a prospective study

7180

Background: Erlotinib is the first orally available selective EGFR tyrosine-kinase inhibitor that improves survival in 2nd and 3rd line therapy for NSCLC. This non-randomised, phase II trial evaluated the efficacy and safety of erlotinib in patients with advanced or metastatic NSCLC. Methods: Patients with previously treated advanced or metastatic NSCLC or patients that were not suitable for first line conventional chemotherapy, stage IIIB/IV, PS 0–2 were enrolled to receive erlotinib 150 mg/day until disease progression or withdrawal. The primary endpoint of the study was time to progression (TTP) in the intent to treat (ITT) population. A multivariate analysis (Cox-model) was performed. Results: 416 patients were enrolled from June 04 to March 05. Demographics: M 78%/F 22%; median age 64 y [range 28–100]; stage IV 91.6%; PS 0/1/≥2: 65 (16%)/227 (55%)/105 (25%); adeno histology 178p (43%), SCC 121p (29%), BAC 3p (0.7%), LLC 2p (20%), other 29p (7%); smoking status: yes 349 p (84%) no 62 p (15%). 1st line: 60p (14.4%); 2nd line 181p (43.5%) and ≥ 3rd line 175p (42%). 230 patients had measurable disease and were evaluable for response: 1CR, 30 PR (ORR: 13.4%), 98 SD, and 101 PD. Toxicity was predictable (mainly rash, and diarrhoea). In the ITT population the median TTP was 3.2 m [95% CI 2.8–3.6]. For evaluable population median TTP was 4.6 m in 1st line, 3.23 m in 2nd line, and 2.8 m in 3rd line. Exploratory analysis showed that ORR was associated with gender, smoking history, previous treatment and histology. The multivariate analysis for TTP showed that no smoking history (p < 0.005), adeno histology (p < 0.0001), and erlotinib as 1st line treatment (p < 0.02) correlated with better TTP. Conclusions: Erlotinib is an active and very well tolerated treatment in patients with advanced NSCLC untreated or that have previously failed to conventional chemotherapy. Our data suggest that non smoking history, adeno histology and erlotinib as 1st line treatment are associated with better TTP. The study is ongoing.

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[Malignant pleural mesothelioma: clinical characteristics, prognostic factors and treatment]

Malignant pleural mesothelioma soon leads to death no matter what type of treatment is provided. We discuss the clinical signs, prognostic factors and treatment given in 41 cases managed over the past 13 years in our oncology department. 32% had been exposed to asbestos, 61% were 60 years old or younger, 71% had a Karnofsky's index > or = 80% and 63% were stage I (Butchart). The first symptom leading to diagnosis was pain in 66% and mean time between first symptom and diagnosis was 3 months. Thirty patients never experienced full remission of disease: 15 were treated with palliative chemotherapy (CHT), 1 with palliative radiotherapy (RT), 5 with partial pleurectomy (PP) plus RT and/or CHT. Nine were given symptomatic treatment only. Only 11 (27%) patients experienced full remission after treatment: 7 had had extrapleural pneumonectomy, 2 had been given CHT and RT series and 4 had undergone PP with or without RT and/or CHT follow-up. Only 3 of these patients were still alive with no relapse more than 1 year later. Mean survival was 8 months. Univariate analysis revealed that the prognostic factors influencing survival were age and Karnofsky's index. Patients initially treated with surgery had a higher rate of survival. In conclusion, only Karnofsky's index and age were prognostic factors in our series. The better survival of patients initially treated surgically is probably related to prior screening.

Lung cancer and cigarette smoking in women: a case-control study in Barcelona (Spain)

A case-control study on lung cancer and the habit of cigarette smoking was carried out in Barcelona (Spain). Cases were 103 women newly diagnosed with primary lung cancer in 10 hospitals from the study area. Histologic confirmation was given in 101 cases, of which 53 were adenocarcinoma, 19 squamous-cell carcinoma, 9 small-cell carcinoma and 20 other types. Two controls per case were selected, matched by age, residence and hospital. Compared with the never-smokers, the odds ratios (OR), with corresponding 95% confidence intervals (CI), were 1.61 (0.4 to 6.9) for ex-smokers and 3.61 (1.6 to 8.3) for current smokers. The risk of lung cancer showed a good dose-response relationship with duration of the habit, average number of cigarettes smoked daily and cumulative cigarette consumption. The risk of lung cancer increased by 62% for each 10 pack-years. Depth of inhalation also showed a remarkable effect, independently of the intensity of the habit. Although mortality and incidence rates of lung cancer among women in Spain are lower than in other developed countries, the risk of lung cancer is that which would be expected according to the pattern of the smoking habit in Spanish women.

CHOP chemotherapy of intermediate and high-grade non-Hodgkin's lymphoma

The results of CHOP treatment in 63 patients with intermediate and high-grade non-Hodgkin's lymphoma (Working Formulation D to I), Ann Arbor stage I to IV were analyzed. The response rate was 87%, 71% complete remission and 16% partial remission with a mean duration of 22 months. The 5-year actuarial survival was 61% (95% confidence interval, 51-70%). The treatment was well tolerated and no deaths due to acute toxicity were observed. Poor prognostic factors in univariate analysis were: high-grade histology, stages III and IV, B symptoms, > or = 4 affected lymph node regions, Karnofsky index < or = 70, erythrocyte sedimentation rate (ESR) > 60 mm, haemoglobin < 100 g/l and elevated lactic dehydrogenase (LDH). Poor prognostic factors in multivariate analysis were: high-grade histology, stages III and IV, haemoglobin < 100 g/l and elevated LDH. In summary, good results were obtained with CHOP chemotherapy, without severe toxicity.

A phase II trial of carboplatin in untreated patients with extensive stage small cell lung cancer

Twenty-five untreated patients with extensive stage small cell lung cancer (ESSCLC) were treated with carboplatin (CBDCA) (500 mg/m2) given as a 24-hour infusion every 21 days. Thirteen patients responded for an overall response rate of 52% (95% confidence limits, 32% to 72%) with 3 complete responses (CR) (12%; 95% confidence limits, 0% to 25%). The median duration of response was 4.5 months. The median survival time was 8 months with three long-term survivors (12%) at 27, 33, and 43 months from the start of CBDCA treatment. Ninety-two courses of CBDCA were administered and one treatment-related death occurred. The main toxicity was myelosuppression. Grade 3 or 4 hematologic toxicity (hemoglobin level, less than 8 g/dl; granulocyte count, less than 1900/microliters; and platelet count, less than 49,000/microliters) was observed as follows: neutropenia in 7 courses (8%) and in 7 patients (28%), decreased hemoglobin level in 13 courses (15%) and in 7 patients (28%), and decreased platelet count in 10 courses (11%) all Grade 3 and in 8 patients (32%). This study demonstrates that at this dose and schedule CBDCA is a highly active drug in ESSCLC and it has tolerable toxicity.

Cisplatin and intravenous continuous infusion of bleomycin in advanced and metastatic esophageal cancer

Thirty-four patients with locally advanced or metastatic esophageal cancer were treated with cisplatin 35 mg/m2/day x 3 days in bolus, plus bleomycin 15 mg/day x 3 days, as an 18 h infusion, every 21-28 days. Twenty-nine are evaluable for response. Objective response was seen in 15 (52%, 95% confidence limits 35-69%) patients. Toxicity was mild. Twelve patients with locoregional disease were treated with this combination followed by radiotherapy and three of them are alive without disease at 18, 22 and 36 months. This combination warrants further study in the setting of combined treatment.

Long-term survival in small cell carcinoma of the lung

We analyzed the long-term survivors in a group of 255 patients with newly diagnosed small cell carcinoma of the lung (SCCL) between January 1978 and July 1983. Long-term survivors were defined as those patients free of cancer 2 years after initiation of therapy. Only 6 patients (2.5%) were free of disease at this time. Two patients relapsed at 29 and 40 months from the start of chemotherapy. Both patients were retreated with chemotherapy, and one of them achieved a complete response. Despite the increase in median survival in SCCL with chemotherapy over the past 10 years, long-term prognosis remains very poor employing standard treatments.