Medical oncology future plan of the Spanish Society of Medical Oncology: challenges and future needs of the Spanish oncologists

PURPOSE

The SEOM Future Plan is aimed at identifying the main challenges, trends and needs of the medical oncology speciality over the next years, including potential oncologist workforce shortages, and proposing recommendations to overcome them.

METHODS

The estimations of the required medical oncologists workforce are based on an updated Medical Oncologist Register in Spain, Medical Oncology Departments activity data, dedication times and projected cancer incidence. Challenges, needs and future recommendations were drawn from an opinion survey and an advisory board.

RESULTS

A shortage of 211 FTE medical oncologist specialists has been established. To maintain an optimal ratio of 158 new cases/FTE, medical oncology workforce should reach 1881 FTE by 2035.

CONCLUSIONS

Main recommendations to face the growing demand and complexity of oncology services include a yearly growth of 2.5% of medical oncologist's workforce until 2035, and development and application of more accurate quality indicators for cancer care and health outcomes measure.

A consensus statement on the gender perspective in lung cancer

Lung cancer is the most common cancer globally and has the highest mortality. Although this disease is not associated with a particular gender, its incidence is rising among women, who are diagnosed at an increasingly younger age compared with men. One of the main reasons for this rise is women taking up smoking. However, many non-smoking women also develop this disease. Other risk factors implicated in the differential development of lung cancer in women are genetic predisposition, tumour histology and molecular profile. Proportionally more women than men with lung cancer have a mutation in the EGFR gene. This consensus statement reviews the available evidence about the epidemiological, biological, diagnostic, therapeutic, social and psychological aspects of lung cancer in women.

Malignant pleural mesothelioma: new hope in the horizon with novel therapeutic strategies

Malignant pleural mesothelioma (MPM) is a rare but aggressive malignancy of the pleura, with a strong causal link to asbestos exposure. MPM incidence has been increasing in recent years and it is not expected to fall off in the next two decades. Prognosis of MPM patients is modest since the vast majority of patients are diagnosed at advanced stage and because platinum-based chemotherapy remains the cornerstone of treatment, with no standard second line treatment. Most current efforts to improve outcomes are based on a better understanding of the stromal compartment and deregulated pathways leading ultimately to the design of clinical trials based on novel therapeutic approaches such as immunotherapy or molecular-directed compounds. This review seeks to update the last clinical trials investigating novel agents in unresectable MPM.

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.

Lung cancer in women: an overview with special focus on Spanish women

Lung cancer incidence is decreasing worldwide among men but rising among women due to recent changes in smoking patterns in both sexes. In Europe, the smoking epidemic has evolved different rates and times, and policy responses to it, vary substantially between countries. Differences in smoking prevalence are much more evident among European women reflecting the heterogeneity in cancer incidence rates. Other factors rather than smoking and linked to sex may increase women's susceptibility to lung cancer, such as genetic predisposition, exposure to sex hormones and molecular features, all of them linked to epidemiologic and clinical characteristics of lung cancer in women. However, biological bases of sex-specific differences are controversial and need further evaluation. This review focuses on the epidemiology and outcome concerning non-small cell lung cancer in women, with emphasis given to the Spanish population.

Brain metastases from lung cancer responding to erlotinib: the importance of EGFR mutation

Median survival of patients with brain metastases from nonsmall cell lung cancer (NSCLC) is poor and more effective treatments are urgently needed. We have evaluated the efficacy of erlotinib in this setting and its association with activating mutations in the epidermal growth factor receptor (EGFR) gene. We retrospectively identified patients with NSCLC and brain metastases treated with erlotinib. EGFR mutations in exons 19 and 21 were analysed by direct sequencing. Efficacy and tolerability were compared according to EGFR mutational status. 69 NSCLC patients with brain metastases were identified, 17 of whom harboured EGFR mutations. Objective response rate in patients with EGFR mutations was 82.4%; no responses were observed in unselected patients (p<0.001). Median (95% CI) time to progression within the brain for patients harbouring EGFR mutations was 11.7 (7.9-15.5) months, compared to 5.8 (5.2-6.4) months for control patients whose EGFR mutational status had not been assessed (p<0.05). Overall survival was 12.9 (6.2-19.7) months and 3.1 (2.5-3.9) months (p<0.001), respectively. The toxicity of erlotinib was as expected and no differences between cohorts were observed. Erlotinib is active in brain metastases from NSCLC; this clinical benefit is related to the presence of activating mutations in exons 19 or 21 of the EGFR gene.

14–3-3 σ and checkpoint with forkhead and ring finger (CHFR) methylation in serum in erlotinib-treated non-small-cell lung cancer (NSCLC) patients (p) with EGFR mutations

7600

Background: 14–3-3 proteins have 130 potential binding partners, including Cbl. 14–3-3 expression can prevent mutant EGFR binding to Cbl, impairing ubiquitination and endocytosis. 14–3-3s is frequently methylated in NSCLC; we hypothesized that in the presence of EGFR mutations, methylated 14–3-3s could permit the formation of the EGFR-Cbl complex. CHFR is a checkpoint that delays entry into metaphase in response to mitotic stress. Methods: 73 stage IV NSCLC p with EGFR exon 19 deletion or exon 21 L858R mutation received first- or second-line erlotinib single therapy. 14–3-3s and CHFR methylation was examined in the baseline serum of these p. Results: Median age, 63 (range, 26–83); females, 48 p (65.8%); Caucasian, 72 p, Asian, 1 p; never-smokers, 45 p, ex-smokers, 21 p, smokers, 7 p; adenocarcinoma, 64 p, large cell carcinoma, 9. PS: 0, 19 p, 1, 42 p, 2–3, 12 p. 14–3-3s was methylated in 39.7% and CHFR in 42.5% of p. No differences in p characteristics were observed according to methylation status. Complete response was observed in 11.1% of p, and partial response in 75.4%. Overall response was 86.5%. There was a trend toward a higher response rate in p with unmethylated CHFR (94.4% vs 76.6%; P=ns). Overall median time to progression (TTP) and survival (MS) have not been reached either in first- or second-line. However, when split according to methylation status, there was a trend toward better TTP and MS in both first- and second-line in p with methylated 14–3-3s. TTP in second-line in p with methylated 14–3-3s has not been reached, while it was 10.8 months (m) for p with unmethylated 14–3-3s (P=ns). TTP in second-line in p with methylated CHFR was 5.2 m but was not reached for p with unmethylated CHFR (P=0.05). Conclusions: Methylated 14–3-3s can permit Cbl binding to mutant EGFR and predict longer-lasting response to erlotinib in p with EGFR mutations. The precise role of CHFR warrants further research. Complete data will be presented.

No significant financial relationships to disclose.

Skin rash as surrogate marker of efficacy in patients with non-small cell lung cancer treated with erlotinib

7602

Background: Erlotinib is an orally EGFR TKI approved for the treatment of advanced non-small-cell lung cancer. Its most frequent and specific toxicity is a rash which generally occurs in a dose-dependent manner. A relationship between rash and clinical outcome have been suggested. Methods: The TargeT trial was an open-label, non-randomized, phase II study carried out in 101 Spanish institutions. Patients (p) with confirmed NSCLC (stage IIIB-IV) were treated with 150 mg/day po until disease progression or unacceptable toxicity. Primary objective was time to progression. Here we report a retrospective analysis describing outcomes in terms of response and survival in the group of patients who developed rash and those who did not. Results: Data were available for 1,255 p. Key baseline characteristics were similar in p with and without rash. Median age 65y (range 26–95) Most p were male (75%); active/former smoker (82%) 51% adenocarcinoma histolog. ECOG PS 0/1/2 were (%) 20/53/27. The % p receiving erlotinib as 1st/2nd/3rd- line treatment were 26/39/35. 698 patients were evaluable for response. Objective response rate (ORR) 12.6% with 51% control disease rate. Skin rash of any grade was observed in 73.4% p, among these p, responses were observed in 14.3%. In p with no rash ORR was 8.1% (p=0.03). Control disease rate was significantly higher among p experiencing rash (56.6%) than those without rash (35.48%; p<0.0001). Median time to progression for p with rash were 3.8 mo (95% CI: 3.4–4.3), compared with 2.3 mo (95% CI: 2.1–2.6) in those with no rash (p<0.001). Similar trend was found in overall survival 6.5 mo (95% CI: 6.1–7.3) in p with rash versus 2.3 mo (95% CI: 2.3–2.7; p<0.001). In addition p who developed rash grade =2 had significantly longer TTP (4.2 m; 95% CI 3.6–4.8; p<0.001) and OS (7.9 mo; 95% CI 6.5–8.8). Conclusions: This retrospective analysis suggest a correlation between skin rash development and severity and treatment outcome. Skin rash seems to be a surrogate marker of efficacy. Studies to prospectively investigate the association between increased dosing of erlotinib, skin rash and optimal response are currently ongoing. However, data from our analysis indicate that skin toxicity is neither sufficient nor necessary condition for an optimal outcome.

No significant financial relationships to disclose.

Excision repair cross complementing 6 (ERCC6) single nucleotide polymorphism (SNP) and outcome to gemcitabine (gem)/cisplatin (cis) or docetaxel (doc)/cis in stage IV non-small cell lung cancer (NSCLC) patients (pts)

7605

Background: ERCC6 (alternate name CSB) is involved in both transcription coupled and base excision DNA repair, and the ERCC6 C-6530>G SNP is involved in gene regulation. Different levels of ERCC6 mRNA expression have been observed in cells according to ERCC6–6530 genotype. Methods: We investigated the ERCC6 C-6530>G SNP in 309 stage IV NSCLC pts treated with doc/cis (196 pts) and gem/cis (113 pts). DNA was extracted from peripheral lymphocytes and Taqman assay was used for SNP typing. Results: Distribution of ERCC6 genotypes was: CC 113 pts (36.6%); CG 157 pts (50.8%); GG 39 pts (12.6%). No differences in genotype were observed according to age, gender, performance status (PS), histology, chemotherapy regimen or second-line treatment. Overall time to progression (TTP) was 5.4 months (m) and median survival (MS) 9.9 m. No differences in TTP or MS were observed according to ERCC6 SNP types. However, when pts were broken down by chemotherapy regimen, TTP was 7 m for 31 CC pts treated with gem/cis and 5.4 m for 71 CC pts treated with doc/cis (P=0.04) ( Table ). MS was longer for CC pts treated with gem/cis (11 m) than for CC pts treated with doc/cis (8.9 m) (P=0.46). Differences were also observed in pts with PS 0 and in younger pts. Conclusions: ERCC6 C-6530>G SNP may confer differential sensitivity to gem or doc in combination with cis. We hypothesize that ERCC6 6350 CC is a surrogate of ERCC6 transcript, where lower ERCC6 expression levels may increase the activity of gem/cis in comparison to doc/cis.

No significant financial relationships to disclose.

[Table: see text]

Sex differences in non-small cell lung cancer (NSCLC) patients (p) participating in Spanish Lung Cancer Group (SLCG) trials

7679

Background: Previous findings about differences by sex in lung cancer have prompted us to undertake a retrospective analysis of clinicopathologic and genetic features in women (W) with advanced NSCLC participating in first-line chemotherapy (CT) SLCG trials. Methods: Data on age, histology, PS, CT schedule, XRCC3 (DNA repair capacity gene) single nucleotide polymorphisms (SNPs) assessment in DNA from peripheral blood lymphocytes and CT outcomes were obtained. Smoking history was not available. Results: 1,191 p included in 4 SLCG trials from 2001 to 2005 treated with CT based on CDDP/GEM, CDDP/DOC or DOC/GEM were analysed. 163 p (14.9%) were W. W were significantly younger than men (M) (median, 57 yrs vs 61 yrs, P<0.0001). Adenocarcinoma was the most frequent histology subtype for W but not for M (77.3% vs 46.8%, P<0.0001). There were not significant differences by sex considering PS (0/1) (P<0.85), stage (IIIB/IV)(P<0.18) or overall response rate (P<0.45). Median time to progression (TTP) was 6.8 months (m) vs 5.3 m (P<0.009) in favour of W. Median overall survival (OS) was 12.9 m for W vs 9.3 m for M (P<0.001). XRCC3 SNPs were distributed similarly between sexes. Both SNPs genotyping of XRCC3 241Met/Met and Thr/Met conditioned better survival in W vs M (P<0.05 and P<0.008). In a multivariate analysis, sex was an independent predictive marker for both OS (HR 1.5, 95% CI 1.2–1.9, P<0.0001) and TTP (HR 1.4, 95% CI 1.1- 1.7, P<0.001), others independent variables found were PS, age, type of CT (only for OS), but not XRCC3 241 genotype. Conclusions: Significant differences have been detected in advanced NSCLC by sex in this retrospective first-line SLCG trials analysis according to age, histology and survival favouring W that are in agreement with previous data. Undertaking prospective sex-specific research is crucial in order to determine the best treatment choice and it could be considered gender as a stratification factor in future phase III trials.

No significant financial relationships to disclose.

Blindness in a bladder cancer patient

Blindness is an unusual symptom in the clinical course of cancer. When it appears it is necessary to differentiate between benign and malign causes. Brain metastases in bladder cancer are extremely rare. MRI is the best diagnostic option. We present a deaf-and-dumb male with subacute blindness, 12 months after the diagnosis of a metastatic bladder cancer. Computerised tomography scan and MRI revealed a mass into the pituitary gland and sella, probably of metastatic origin.

Is a patient's self-reported health-related quality of life a prognostic factor for survival in non-small-cell lung cancer patients? A multivariate analysis of prognostic factors of EORTC study 08975

BACKGROUND

The aim of this prognostic factor analysis was to investigate if a patient's self-reported health-related quality of life (HRQOL) provided independent prognostic information for survival in non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Pretreatment HRQOL was measured in 391 advanced NSCLC patients using the EORTC QLQ-C30 and the EORTC Lung Cancer module (QLQ-LC13). The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap validation technique was used to assess the stability of the outcomes.

RESULTS

The final multivariate Cox regression model retained four parameters as independent prognostic factors for survival: male gender with a hazard ratio (HR) = 1.32 (95% CI 1.03-1.69; P = 0.03); performance status (0 to 1 versus 2) with HR = 1.63 (95% CI 1.04-2.54; P = 0.032); patient's self-reported score of pain with HR= 1.11 (95% CI 1.07-1.16; P < 0.001) and dysphagia with HR = 1.12 (95% CI 1.04-1.21; P = 0.003). A 10-point shift worse in the scale measuring pain and dysphagia translated into an 11% and 12% increased in the likelihood of death respectively. A risk group categorization was also developed.

CONCLUSION

The results suggest that patients' self-reported HRQOL provide independent prognostic information for survival. This finding supports the collection of such data in routine clinical practice.

Efficacy and pharmacogenomic correlation of the combination of oxaliplatin and paclitaxel in first line advanced non-small cell lung cancer (NSCLC). Preliminary results of the Spanish Lung Cancer Group (SLCG) 0103 phase II trial

7122

Background: Ox is an attractive platinum analogue that has not been fully explored in NSCLC. We tested the combination of ox/pac as first-line therapy in NSCLC. We also assessed single nucleotide polymorphisms (SNPs) in several DNA repair genes (XRCC1 Arg399Gln, XRCC3 Met241Thr, XPD Lys751Gln and XPD Asp312Asn) and correlated the results with outcome in these patients (p). Methods: 68 stage IIIB (pleural effusion) and IV NSCLC p received up to 6 cycles of p 200 mg/m2 on day 1 plus ox 130 mg/m2 on day 2 every 21 days. Response was assessed after the third and sixth cycles. SNPs were determined by TaqMan assay in peripheral blood extracted at baseline Results: p characteristics: median age 62; 82% male; performance status 0, 54.5%; adenocarcinoma 48%; CNS metastases (mets), 15%, liver mets, 17%. 259 cycles delivered. Grade (G) 3–4 toxicity profile: neutropenia 11%; febrile neutropenia 8%; neurosensory (G3) 5%; asthenia (G3) 8%; diarrhea (G3) 5%. Laryngodysesthesia was observed in 1 p. There were 2 deaths due to neutropenic fever. In 52 evaluable p, overall response rate was 48% (PR 46%, CR 2%, SD 6%, PD 21%). Median time to progression was 4.4 months (m) (95% CI, 2.9–5.9 m). Median survival was 7.9 m (95% CI, 5.5–10.3 m). Conclusions: The combination of ox/pac offers similar results to other platinum-based regimens with an acceptable different toxicity profile and without a significant increase in neurotoxicity. Final data on response, time to progression and survival according to SNPs will be presented.

No significant financial relationships to disclose.

Phase II study of irinotecan (cpt-11) and cisplatin (cddp) regimen (IP) with concurrent thoracic radiotherapy (TRT) in limited-stage small cell lung cancer (LS-SCLC)

7084

Background: the combination of CPT-11 and CDDP (IP) is an active regimen for SCLC. (Noda et al NEJM ’02, Hanna et al ASCO 2005). We performed a multicenter phase II study to assess the efficacy and toxicity of IP regimen with concurrent TRT in previously untreated LS-SCLC pts. Methods: Eligible pts were required to have histologically confirmed SCLC, measurable disease, no prior therapy, ECOG PS of 0–2, adequate organ functions, and to give informed consent. Treatment consisted of: CDDP 60 mg/m2 D1, I 60mg/m2 IV D1, 8 Q 21D for 4 cycles, and concurrent TRT 2.0 Gy daily to a total of 60.0 Gy, beginning with the 2nd cycle. I was adjusted to 50 mg/m2 at 2nd and 3rd cycles (during TRT). Pts were restaged after 4 cycles. Pts without progression or undue toxicity received 2 additional cycles. PCI (2.0 Gy X 10) was offered to CR pts. The primary endpoints were response rate and OS. Results: Twenty-six pts were included and 25 pts were evaluable for response (median age 62; M/F, 22/4; PS 0/1/2, 9/17; T2–4N0,T2–4N+ 6/20pts). Among 126 cycles administered, the relative dose-intensities of I and CDDP were 80% and 92% respectively. Median number of cycles/pt was 5 (1–6), and 22 pts completed the IP + TRT program. Fifteen pts achieved a CR and 6 pts a PR, for an overall RR of 84%. Median TTP was 12 months. At a median follow-up of 14 months, 19 pts are alive, and estimated median survival is 17 months. Grade 3–4 (NCI-CTC 3.0) toxicity (per cycle) during concurrent therapy included: neutropenia (25%), anemia (3%), thrombocytopenia (3%), diarrhea (10%), vomiting (5%), esophagitis (10%). There were no treatment-related deaths. Two pts required hospitalization during the concurrent therapy due to g3 diarrhea (1 pt) and febrile neutropenia (1 pt). Conclusions: The concurrent regimen of IP + TRT is highly effective in pts with LS-SCLC. The associated toxicity profile is predictable and adequate. Further study is warranted.

No significant financial relationships to disclose.

Second-line (post-study) chemotherapy received by patients treated in the phase III trial of pemetrexed plus cisplatin versus cisplatin alone in malignant pleural mesothelioma

BACKGROUND

A phase III trial in patients with malignant pleural mesothelioma demonstrated a survival advantage for pemetrexed plus cisplatin compared with single-agent cisplatin. Because post-study chemotherapy (PSC) may have influenced the outcome of the trial, we examined its use and association with survival.

PATIENTS AND METHODS

Eighty-four patients from the pemetrexed plus cisplatin arm and 105 patients from the single-agent cisplatin arm received PSC. Kaplan-Meier survival estimates were compared by treatment groups, and by PSC and non-PSC subgroups.

RESULTS

The percentage of patients receiving PSC was imbalanced between the treatment arms. Fewer pemetrexed plus cisplatin treated patients received PSC (37.2% versus 47.3%). A multiple regression analysis performed in this trial showed that PSC had a statistically significant correlation with prolonged survival (P <0.01), adjusting for baseline prognostic factors and treatment intervention. The adjusted hazard ratio for PSC over non-PSC subgroups was 0.56 (confidence interval 0.44-0.72).

CONCLUSIONS

PSC in malignant pleural mesothelioma was significantly associated with prolonged survival. It is not known whether the reduced risk of death was associated with PSC or whether patients who had prolonged survival tended to receive more PSC. The pemetrexed plus cisplatin treatment group had a statistically significant survival advantage even though fewer patients from that arm of the trial received PSC. The potentially beneficial role of PSC should be assessed in prospective trials.

Single nucleotide polymorphisms and outcome in docetaxel-cisplatin-treated advanced non-small-cell lung cancer

BACKGROUND

Platinum-based doublets are the standard chemotherapy for advanced non-small-cell lung cancer (NSCLC). Excision-repair cross-complementing 1 (ERCC1), xeroderma pigmentosum group D (XPD) and ribonucleotide reductase subunit M1 (RRM1) are essential to the repair of cisplatin DNA adducts. Multidrug resistance 1 (MDR1) has been related to antimicrotubule resistance. We assessed whether single nucleotide polymorphisms (SNPs) in ERCC1, XPD, RRM1 and MDR1, and ERCC1 mRNA expression, predicted survival in docetaxel-cisplatin-treated stage IV NSCLC patients.

PATIENTS AND METHODS

Using the TaqMan 5' nuclease assay, we examined ERCC1 118, XPD 751 and 312, RRM1 -37C/A, and MDR1 C3435T SNPs in peripheral blood lymphocytes (PBLs) obtained from 62 docetaxel-cisplatin-treated advanced NSCLC patients. ERCC1 expression was measured in RNA isolated from PBLs using real-time reverse transcriptase PCR.

RESULTS

Overall median survival was 10.26 months. Median survival was 9.67 months for 34 patients with ERCC1 118 C/T, 9.74 months for 17 patients with T/T, and not reached for 11 patients with C/C (P=0.04). Similar significant differences in time to progression were observed according to ERCC1 118 genotype (P=0.03). No other significant differences were observed.

CONCLUSIONS

Patients homozygous for the ERCC1 118 C allele demonstrated a significantly better survival. ERCC1 SNP assessment could be an important component of tailored chemotherapy trials.

Phase III randomised trial comparing paclitaxel/carboplatin with paclitaxel/cisplatin in patients with advanced non-small-cell lung cancer: a cooperative multinational trial

BACKGROUND

The combination of paclitaxel with cisplatin or carboplatin has significant activity in non-small-cell lung cancer (NSCLC). This phase III study of chemotherapy-naïve advanced NSCLC patients was designed to assess whether response rate in patients receiving a paclitaxel/carboplatin combination was similar to that in patients receiving a paclitaxel/cisplatin combination. Paclitaxel was given at a dose of 200 mg/m(2) (3-h intravenous infusion) followed by either carboplatin at an AUC of 6 or cisplatin at a dose of 80 mg/m(2), all repeated every 3 weeks. Survival, toxicity and quality of life were also compared.

PATIENTS AND METHODS

Patients were randomised to receive one of the two combinations, stratified according to centre, performance status, disease stage and histology. The primary analyses of response rate and survival were carried out on response-evaluable patients. Survival was also analysed for all randomised patients. Toxicity analyses were carried out on all treated patients.

RESULTS

A total of 618 patients were randomised. The two treatment arms were well balanced with regard to gender (83% male), age (median 58 years), performance status (83% ECOG 0-1), stage (68% IV, 32% IIIB) and histology (38% squamous cell carcinoma). In the paclitaxel/carboplatin arm, 306 patients received a total of 1311 courses (median four courses, range 1-10 courses) while in the paclitaxel/cisplatin arm, 302 patients received a total of 1321 courses (median four courses, range 1-10 courses). In only 76% of courses, carboplatin was administered as planned at an AUC of 6, while in 96% of courses, cisplatin was given at the planned dose of 80 mg/m(2). The response rate was 25% (70 of 279) in the paclitaxel/carboplatin arm and 28% (80 of 284) in the paclitaxel/cisplatin arm (P = 0.45). Responses were reviewed by an independent radiological committee. For all randomised patients, median survival was 8.5 months in the paclitaxel/carboplatin arm and 9.8 months in the paclitaxel/cisplatin arm [hazard ratio 1.20, 90% confidence interval (CI) 1.03-1.40]; the 1-year survival rates were 33% and 38%, respectively. On the same dataset, a survival update after 22 months of additional follow-up yielded a median survival of 8.2 months in the paclitaxel/carboplatin arm and 9.8 months in the paclitaxel/cisplatin arm (hazard ratio 1.22, 90% CI 1.06-1.40; P = 0.019); the 2-year survival rates were 9% and 15%, respectively. Excluding neutropenia and thrombocytopenia, which were more frequent in the paclitaxel/carboplatin arm, and nausea/vomiting and nephrotoxicity, which were more frequent in the paclitaxel/cisplatin arm, the rate of severe toxicities was generally low and comparable between the two arms. Overall quality of life (EORTC QLQ-C30 and LC-13) was also similar between the two arms.

CONCLUSIONS

This is the first trial comparing carboplatin and cisplatin in the treatment of advanced NSCLC. Although paclitaxel/carboplatin yielded a similar response rate, the significantly longer median survival obtained with paclitaxel/cisplatin indicates that cisplatin-based chemotherapy should be the first treatment option.

Primary cisplatin, methotrexate and vinblastine chemotherapy with selective bladder preservation for muscle invasive carcinoma of the bladder: long-term followup of a prospective study

PURPOSE

We evaluate the efficacy and bladder preservation rate of combined modality therapy consisting of deep transurethral resection of the primary bladder tumor followed by cisplatin, methotrexate and vinblastine chemotherapy in patients with muscle invasive transitional cell carcinoma of the bladder.

MATERIALS AND METHODS

A total of 40 consecutive patients with clinical stage T2-T4 NX M0 bladder cancer were included in the study and treated with transurethral resection followed by 3 courses of chemotherapy. Chemotherapy consisted of 100 mg./m.2 cisplatin intravenously on day 1, 30 mg./m.2 methotrexate intravenously on days 1 and 8, and 4 mg./m.2 vinblastine intravenously on days 1 and 8 administered every 21 days. Patients with disease in complete clinical remission after cycle 3 of therapy received 3 additional chemotherapy courses. Patients in whom complete clinical remission persisted after cycle 6 were closely followed with no further therapy until disease progression.

RESULTS

A complete clinical remission was achieved in 21 patients (53%) after the first 3 cycles of therapy and a partial response occurred in 10 (25%), for an overall response rate of 78% (95% confidence interval [CI] 62% to 89%). With a median followup of 78 months (range 70 to 109) the estimated 7-year progression-free and overall survival rates were 40% (95% CI 25% to 55%) and 35% (95% CI 20% to 50%), respectively. The 7-year survival rate with a functional bladder for complete clinical remission cases was 52% (95% CI 30% to 74%). Low grade, small tumor, absence of concomitant carcinoma in situ and response to therapy were all significant predictors for an increased probability of bladder preservation in univariate analysis. However, response to therapy was the only variable with independent prognostic value in the multivariate analysis (p = 0.002).

CONCLUSIONS

Transurethral resection of bladder tumor followed by cisplatin, methotrexate and vinblastine chemotherapy results in long-term bladder preservation in a significant proportion of responding patients, and may be an acceptable alternative to radical surgery in select patients with muscle invasive bladder cancer.

[Clinical pattern and therapeutic results obtained in Germ-Cell testicular cancer in Spain based on a consecutive series of 1250 patients]

BACKGROUND

Even its low incidence, germ-cell testicular cancer is very relevant due to its presentation at young ages and its potential curability over 90%. Spanish Germ Cell Cancer Group (GG) joins the efforts of 51 different Spanish centres to share their experience on the diagnosis and treatment of these special tumours.

PATIENTS AND METHOD

We describe the clinical characteristics and the results of treatment in the first 1,250 patients registered throughout 6 years by the GG.

RESULTS

11% had previous criptorchidism. The most frequent initial local simptomatology was increased testis size (90%). 20% lasted more than six months in receiving the first treatment. Inguinal orquidectomy was done in 95% of patients. 435 cases (35%) were seminoma and 815 (65%)non-seminoma. 19% of seminoma and 78% of non-seminoma produced tumour markers. 75% of seminoma but only 56% of non-seminoma were clinical stage I. Following the IGCCCG prognosis classification,20% of non-seminoma fitted in the poor-prognosis group. Stage I seminoma treatment was surveillance, chemotherapy and complementary radiotherapy in 60, 32 and 6%, respectively. Those features were 65, 35% and none in non-seminoma cases. Chemotherapy schedules used in advanced cases were EP for seminoma and BEP or BOMP-EPIin non-seminoma, according to whether the patient was in the good or bad prognosis IGCCCG group. With a median of follow-up in all serie of 30 months, we have obtained a three years overall survival of 98% (CI 95%, 96,4-9,6), whereas non-seminoma patients had a three years overall survival of 94% (CI 95%, 92-96).

CONCLUSION

The Spanish germ cell testicular cancer clinical pattern is similar to that registered in other occidental countries. Co-operative structures like GG,are able to gather an extensive experience in a short period of time that results in achieving a very high number of cured patients.

Tumor markers at the time of recurrence in patients with germ cell tumors

BACKGROUND

alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH) closely follow the course of germ cell tumors (GCTs) and are widely used for diagnosis, prognosis, and follow-up purposes. The objective of this study was to assess the concordance of tumor markers at the time of diagnosis and recurrence.

METHODS

The authors reviewed the records of 794 patients with GCTs treated in three Spanish hospitals from 1977-1996 and analyzed the concordance between AFP, HCG, and LDH levels at diagnosis and first and second recurrence. A positive marker was defined as a level of AFP > 10 ng/mL, HCG > 5 IU/L, or LDH > the upper limit of normal. One hundred twenty-five patients were identified who developed a first recurrence (123 had marker levels recorded). The median age was 27 years (range, 14-78 years). Histology was seminoma in 36 patients (29%) and nonseminomatous GCT (NSGCT) in 87 patients (71%).

RESULTS

Seventy-nine patients (64%) had elevated tumor markers at diagnosis and 76 (62%) at first recurrence. An elevated marker was present at first recurrence in 58 of 79 patients (73%) with initially positive markers and in 18 of 44 patients (41%) with initially negative markers. In 84 of 123 patients (68%), the same marker pattern (positive or negative) was present at the time of diagnosis and at first recurrence, 78% in seminomas and 64% in NSGCTs. The earliest indicator of recurrence was an elevated marker in patients with NSGCTs and a radiologic finding in patients with seminomas. Thirty patients developed a second recurrence, 27 of whom (90%) had the same marker pattern as at first recurrence.

CONCLUSIONS

Tumor marker pattern at diagnosis is not a good predictor of the pattern at recurrence, particularly in patients with NSGCTs. Marker assessment should be included in the follow-up schedule regardless of levels at the time of diagnosis. Early detection of recurrence should not rely only on marker levels, even in patients with elevated levels at presentation.

Phase II trial combining mitomycin with 5-fluorouracil, epirubicin, and cisplatin in recurrent and metastatic undifferentiated carcinoma of nasopharyngeal type

BACKGROUND

This phase-II study was conducted to investigate the potential benefit from the addition of mitomycin to a conventional anthracycline-cisplatin- and 5-fluorouracil-based chemotherapy for recurrent and metastatic undifferentiated carcinoma of nasopharyngeal type (UCNT).

PATIENTS AND METHODS

Between July 1989 and December 1991, 44 consecutive patients (M/F 36/8; median age: 45, range 20-72; performance status (PS) 0: 20 patients, PS 1: 14 patients, PS 2: 10 patients) with recurrent or metastatic UCNT were entered in this study after complete clinical, biological, and radiological pre-therapeutic work-ups. Chemotherapy (FMEP regimen) consisted of 800 mg/m2/day 5-fluorouracil in continuous infusion from day 1 to day 4 combined with 70 mg/m2 epirubicin, 10 mg/m2 mitomycin, and 100 mg/m2 cisplatin on day 1, every four weeks for six cycles. Mitomycin was delivered in cycles 1, 3, and 5 only. Eleven patients had isolated loco-regional recurrences, 12 patients had local recurrences associated with distant metastasis, and 21 patients had metastasis only. Toxicity and response were evaluated according to WHO criteria.

TOXICITY

Grade 3-4 neutropenia was observed in 122 of 212 evaluable cycles (57%) and 39 of 44 patients (89%); febrile neutropenia occurred in 16 patients (36%) and 24 cycles (11.3%). Grade 3-4 thrombocytopenia was observed in 27 patients (61%) and 45 cycles (21%), including 27 of 45 cycles (60%) with mitomycin. Grade 3 anemia was noted in 18 patients (40%) and 23 cycles (11%), including 18 of 23 cycles (78%) with mitomycin. Grade 3-4 mucositis occurred in 25 cycles (11%) and 14 patients (32%), mainly in those previously treated with radiation therapy in the head and neck area. There were four treatment-related deaths (9%); three of them neutropenia-related, and one of cardiac toxicity.

RESPONSE

Forty-four patients were evaluable for response: There were 23 of 44 objective responses (52%), including six complete responses (13%), and 17 partial responses (38%). Additional radiotherapy was given to 13 patients after documentation of response: Nasopharyngeal tumor + cervical nodes (eight patients) and/or on bone metastasis sites (five patients); mediastinal lymph nodes (one patient). At a median follow-up of 87 months (range 71-100), five patients are alive and in continuous complete remission. The median survival time was 14 months and the median time to progression nine months.

CONCLUSION

The regimen under study is active in recurrent/metastatic UCNT, but associated with excessive toxicity.

Randomized phase III study of gemcitabine-cisplatin versus etoposide-cisplatin in the treatment of locally advanced or metastatic non-small-cell lung cancer

PURPOSE

We conducted a randomized trial to compare gemcitabine-cisplatin with etoposide-cisplatin in the treatment of patients with advanced non-small-cell lung cancer (NSCLC). The primary end point of the comparison was response rate.

PATIENTS AND METHODS

A total of 135 chemotherapy-naive patients with advanced NSCLC were randomized to receive either gemcitabine 1,250 mg/m2 intravenously (IV) days 1 and 8 or etoposide 100 mg/m2 IV days 1 to 3 along with cisplatin 100 mg/m2 IV day 1. Both treatments were administered in 21-day cycles. One hundred thirty-three patients were included in the intent-to-treat analysis of response.

RESULTS

The response rate (externally validated) for patients given gemcitabine-cisplatin was superior to that for patients given etoposide-cisplatin (40.6% v 21.9%; P = .02). This superior response rate was associated with a significant delay in time to disease progression (6.9 months v 4.3 months; P = .01) without an impairment in quality of life (QOL). There was no statistically significant difference in survival time between both arms (8.7 months for gemcitabine-cisplatin v 7.2 months for etoposide-cisplatin; P = .18). The overall toxicity profile for both combinations of drugs was similar. Nausea and vomiting were reported more frequently in the gemcitabine arm than in the etoposide arm. However, the difference was not significant. Gemcitabine-cisplatin produced less grade 3 alopecia (13% v 51%) and less grade 4 neutropenia (28% v 56% ) but more grade 3 and 4 thrombocytopenia (56% v 13%) than did etoposide-cisplatin. However, there were no thrombocytopenia-related complications in the gemcitabine arm.

CONCLUSION

Compared with etoposide-cisplatin, gemcitabine-cisplatin provides a significantly higher response rate and a delay in disease progression without impairing QOL in patients with advanced NSCLC.

Detection of BRCA1 gene mutations in families with breast cancer patients and their healthy relatives

Eighty-three families with two or more cases of breast and ovarian cancer were selected to evaluate the prevalence rate of BRCA1 gene mutations, and identify healthy carriers. Blood samples from patients and healthy relatives were obtained. Haplotype study of the 17q21 region using 7 polymorphic markers was performed. Mutational analysis of the coding exons of the BRCA1 gene was performed by the PCR-SSCP method and direct sequencing. We detected germline mutations (frameshift and missense) in 6 families (9.1%). Combining haplotype analysis and PCR-SSCP screening, 18 (15%) healthy female carriers were identified. The prevalence rate of germline BRCA1 gene mutations among our families with breast cancer syndrome is low, and relatives having the same haplotype for the 17q21 region as mutation-carrying patients usually display the same genomic sequence as the patients.

Randomized study of paclitaxel-cisplatin versus cisplatin-teniposide in patients with advanced non-small-cell lung cancer. The European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group

PURPOSE

To compare two cisplatin based chemotherapy schedules in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

A total of 332 patients with advanced NSCLC were randomized to receive cisplatin 80 mg/m2 on day 1 either in combination with teniposide 100 mg/m2 on days 1, 3, and 5 (arm A) or paclitaxel 175 mg/m2 by 3-hour infusion on day 1 (arm B); cycles were repeated every 3 weeks.

RESULTS

Fifteen patients were ineligible; patient characteristics were well balanced between the two arms: 71% were male, 71% had less than 5% weight loss, 89% had a World Health Organization (WHO) performance status of 0 to 1, 51% had adenocarcinoma, and 61% had stage IV disease. Hematologic toxicity was significantly more severe in arm A (leukopenia, neutropenia, and thrombocytopenia grade 3 or 4: 66% v 19%, 83% v 55%, 36% v 2% in arms A and B, respectively), which resulted in more febrile neutropenia (27% v 3% in arms A and B, respectively), dose reductions, and treatment delays. There were a total of nine toxic deaths, six due to neutropenic sepsis: five in arm A and one in arm B. In contrast, arthralgia/myalgia (grade 2 or 3, 4% v 17%), peripheral neurotoxicity (grade 2 or 3, 6% v 29%), and hypersensitivity reactions (1% v 7%, all grades) were significantly more frequent in arm B. The frequency and severity of other toxicities were comparable between the two arms. Responses were one complete and 44 partial on arm A (28%) and two complete and 61 partial (41%) on arm B (P = .018). There was no significant difference in survival, with median and 1-year survivals 9.9 versus 9.7 months and 41% versus 43%, respectively in arm A and B. Progression-free survival was 4.9 and 5.4 months in arm A and B, respectively. Selected centers participated in a quality-of-life (QoL) assessment, which was performed by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and LC-13 administered at baseline and every 6 weeks thereafter. Arm B achieved a better score at week 6 for emotional, cognitive and social functioning, global health status, fatigue, and appetite loss, which was lost at 12 weeks. In conclusion, arm B appears superior to arm A with regard to response rate, side effects, and QoL.

CONCLUSION

Although survival was not improved, arm B offers a better palliation for advanced NSCLC patients than arm A.

Biomarker study of primary nonmetastatic versus metastatic invasive bladder cancer. National Cancer Institute Bladder Tumor Marker Network

A cohort of 109 patients with primary transitional cell carcinomas, stages T2-T3, grade 2 or higher, was identified and further divided into two groups based on lymphatic metastasis at the time of cystectomy (n = 57 cases) or absence of detectable metastatic disease over a minimum of 5 years of follow-up after cystectomy (n = 52). Blocks corresponding to the primary tumor lesions were sectioned and distributed to different laboratories to be analyzed. Immunohistochemistry on deparaffinized tissue sections was conducted for evaluation of p53 nuclear overexpression (monoclonal antibody PAb1801), assessment of proliferative index (Ki-67 antigen-monoclonal antibody MIB1), and microvascular counts (factor VIII-related antigen). DNA content/ploidy studies were performed on material obtained from thick sections. A double-blinded strategy was used for the evaluation of laboratory data versus clinical parameters. The cutoff value for p53 nuclear overexpression was > or =20% of tumor cells displaying nuclear staining. The median values for MIB1 (> or =18% of tumor nuclear cell staining) and microvascular counts (> or =40 microvessels/area screened) were used as cutoff points for these two variables. The assessment of DNA content was conducted by classifying cases as diploid, tetraploid, or aneuploid. Statistical analyses were performed using the Fisher's Exact Test (2-tailed). Results revealed that none of the markers studied had a statistically significant correlation with the end point of the study, i.e., the presence of lymph node metastatic disease, in the cohort of patients studied, although an obvious trend for p53 was noted. It is concluded that alterations of p53, Ki-67 proliferative index, microvascular counts, and ploidy are not strongly associated with lymph node status in patients affected with high-stage, high-grade bladder cancer.

A phase II study of a novel gemcitabine plus cisplatin regimen administered every three weeks for advanced non-small-cell lung cancer

BACKGROUND

The aim of this study was to determine the clinical activity and toxicity of a novel chemotherapy combination regimen of gemcitabine plus cisplatin, administered every three weeks, in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Twenty-six previously untreated stages III (14) and IV (12) patients were included. Gemcitabine was administered on days 1 and 8 at a dose of 1250 mg/m2 and cisplatin was administered at a dose of 100 mg/m2 on day 1, every 21 days.

RESULTS

Twenty-five patients were evaluable for response. One patient achieved a complete response, and 16 patients partial responses. The overall response rate was 65.3% (95% CI: 45%-82%). The main toxicity was hematological: neutropenia NCIC-CTC grade 3-4 in 54% of the patients, and thrombocytopenia grade 3-4 in 23%. The non-hematological toxicity was mild and tolerable. Only 13% of gemcitabine injections were dose-reduced or omitted due to toxicity. The actual dose-intensity of gemcitabine was 715 mg/m2/week, and 31 mg/m2/week for cisplatin. These figures represent the 86% and 93% of the theoretical dose intensity of both drugs, respectively. With a median follow-up of 10 months (range 7-13), 17 patients are still alive and nine have died. The median overall survival is 12 months.

CONCLUSION

This novel combination of gemcitabine and cisplatin administered every three weeks is well tolerated and induces a remarkably high response rate. The regimen proves more interesting than the four-week schedules, particularly regarding patients who are candidates for local therapy.

[Heart pathology of extracardiac origin. VII. Heart and neoplasms]

Cardiac alterations of neoplastic diseases can be due to direct invasion produced by primary cardiac tumors or more frequently secondary to local compression of vascular structures by extracardiac neoplasms, such as superior vena cava syndrome. One of the most important alterations is the cardiotoxicity of anticancer treatments, either chemotherapy drugs or radiotherapy techniques. These treatments cause acute and/or chronic cardiotoxicity that the oncologist and the cardiologist must be aware of. For instance, 4.5% to 7% of patients that have been treated with anthracyclines may suffer cardiac failure in their lifetime. The pathogenesis is still not clear. There is currently a lot of research on cardioprotectors, but nowadays the only one approved by the FDA is dexrazoxane, which is used on breast cancer patients treated with adriamycin.