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.

Randomized trial of adjuvant chemotherapy (Cx) with cisplatin plus gemcitabine (CG) versus cisplatin plus docetaxel (CD) in patients (pts) with completely resected non-small cell lung cancer (NSCLC) with quality of life (QoL) as the primary objective

7532

Background: Adjuvant Cx with vinorelbine plus cisplatin (VC) improves survival of resected NSCLC but has an immediate negative impact on QoL (Bezjak, JCO 2008). In advanced stages NSCLC, GC and DC have comparable efficacy and might be superior to VC in QoL outcomes. This trial was designed to provide with data on other adjuvant Cx regimens for pts with resected NSCLC. Methods: Pts with stage IB to III resected (R0) NSCLC, without major postoperative complication, were eligible. Surgery has to be standardized. Cx consisted of cisplatin (75 mg/m2, D1) plus gemcitabine 1,250 mg/m2 (D1,8) or docetaxel (75 mg/m2 D1) for 3 cycles. The primary endpoint was QoL (EORTC QLQC30) and the trial was designed to detect a 10 points difference in QoL scores (α=0.05; power 80%). Relapse-free survival, overall survival (OS), safety profile and costs were the secondary endpoints. Results: 136 pts (median age: 57 yrs, 74% males, pTNM: 32% IB, 34% II, 34% III; histology: 55% ADC, 23% SCC) were included. 67 and 69 pts were randomized in the GC and DC arms, respectively. Surgery was a (bi)lobectomy in 85% of cases. No imbalance was found between arms regarding major pts characteristics. Overall, a Gr3/4 hematological toxicity occurs for 33.8% and 21.7% of pts (p=0.11) and a Gr3/4 non-hematological toxicity occurs for 33.8% and 26.1% of pts (p=0.33), in the GC and DC arms. Compliance to QoL assessment was good (93%). At inclusion, global health status (GHS) scores (/100) were comparable between arms (mean score, 63.5 and 62.7, in the GC and DC arms, p=0.8). At the end of treatment (3rd month), GHS scores have slightly improve (mean score, 64.5 and 65.4, in the GC and DC arms, p=0.8). At the time of analysis, 15 pts (7 GC, 8 DC) have died. At 1 year, 100 and 96.8% of the pts were alive in the GC and DC arms; At 2 years, 92.9 and 89.8% of the pts were alive in the GC and DC arms (log-rank, p=0.88). Conclusions: Adjuvant GC and DC have comparable effect on post-operative QoL and equivalent efficacy among pts with resected NSCLC. The GC and DC efficacy, safety profiles and QoL outcomes favorably compare with the results reported for the VC regimen. Detailed analyses will be presented at the meeting.

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Improvement in anemia management with epoietin alfa (EA) in elderly and/or poor performance status (PS) patients (pts) with advanced non-small cell lung cancer (NSCLC) (GFPC 0202)

18571

Background: EA at a starting dose of 40000 UI sc once weekly (qw) has been show to be effective in the treatment of chemotherapy (CT) induced anemia in cancer pts and early intervention with EA appears important for anemia prevention and reduce CT toxicity in elderly pts. Methods: In this multicenter phase II study, chemonaive pts with stage IIIB (pleural effusion) and IV 50 pts with mild co-morbidity (Charlson score) and good performans status (PS) received docetaxel 30 mg/m2 weekly (6 wks, 2 wks off) and gemcitabine 900 mg/m2 (only on day 1, 8, 22, 29) arm A and 50 pts with higher co-morbidity and/or poor performans status (PS) received docetaxel 30 mg/m2 weekly (6 wks, 2 wks off) arm B. Anemic pts with Hb <11.5 g/dl received EA 40000 UI/qw until a target = 13 g/dl with maintenance phase during CT and 28 days after the end of CT to maintain Hb 11.5 to 12.5 g/dl. Dose could be increased to 60000 UI/qw after 4 wks depending on Hb response. Quality of life (Qol: LCSS, Spitzer score) was assessed at baseline, 8, 16 and 24 wks. This trial assessed the effect of EA on Hb level after 4 and 8 wks, tranfusion requirements and Qol. Results: From Jun 2003 to Dec 2004 100 pts were enrolled, median age was 72,7 (66–82) arm A, 76,6 (70–84) arm B, median co-morbidity 1 (0–4) arm A; 1,9 (0–5) arm B. 59 pts received EA (58% arm A; 60% arm B), mean Hb level was 11.6 at the start of CT, and 10.42 before EA. Mean Hb increase after 4 wks was 0.77 ± 1.11 (p < 0.05), and 1.63 ± 1.36 after 8 wks (p < 0.05). Only 14.1% received transfusions. There was no significant change in global Qol and fatigue (LCSS). The main grade 3/4 CT toxicity was fatigue 25% and neutropenia in arm A and fatigue 50% in arm B. Conclusions: Weekly EA increase Hb level, early EA intervention maintain Qol and decrease red blood transfusions, and mild anemia is probably associated with significant impairment in toxicity in elderly pts with advanced NSCLC.

No significant financial relationships to disclose.

Carboplatin-etoposide combination in small cell lung cancer patients older than 70 years: a phase II trial

BACKGROUND

No standard treatment is defined for elderly patients with small cell lung cancer (SCLC). Carboplatin and etoposide are highly active agents against SCLC. In this study, we evaluated the activity and toxicity of a combination of these two agents.

PATIENTS AND METHODS

Thirty-four untreated patients with limited or extensive SCLC and median age of 73.9 years entered the study. Chemotherapy consisted of carboplatin i.v. on day 1 (AUC 5 using Calvert's formula) and etoposide 100 mg/m(2) given orally on days 1-5, every 4 weeks, and thoracic irradiation was given to limited disease patients after chemotherapy.

RESULTS

The overall response rates was 59% (95% CI: 43-76). The median survival for all patients was 37 weeks (range 3-76 weeks). The toxicity was mainly haematological with grade 3-4 neutropenia in 59% of courses, febrile neutropenia in 15% of courses, and toxic death in 9% of patients.

CONCLUSION

The results of this regimen are disappointing with worse response and survival, and more haematological toxicity than expected and previously reported, despite the use of Calvert's formula. Possible explanations are the use of etoposide per os rather than i.v., the frequent comorbidities of older patients and the inclusion of patients with poor prognosis factors.