Comparison of partial vs radical nephrectomy with regard to other-cause mortality in T1 renal cell carcinoma among patients aged ≥75 years with multiple comorbidities

OBJECTIVE

To quantify the effect of partial nephrectomy (PN) vs radical nephrectomy (RN) on other-cause mortality (OCM) in elderly patients with localized renal cell carcinoma (RCC) and/or multiple comorbidities.

METHODS

Using the Surveillance, Epidemiology, and End Results Medicare-linked database, patients with T1 RCC, aged ≥75 years, or who had ≥2 comorbidities, were identified (1988-2005). To adjust for inherent differences between treatment types, propensity-based matched analyses were performed. Competing-risks regression analyses for prediction of OCM were assessed according to treatment type. The effect of PN and RN on OCM was examined in three sub-groups: patients aged ≥75 years; patients with ≥2 comorbidities; and patients aged ≥75 years with ≥2 comorbidities.

RESULTS

After propensity-based matched analyses and adjustment for all covariates, PN was found to exert a protective effect relative to RN with respect to OCM in all patients (hazard ratio [HR]: 0.84, P = 0.048). In subanalyses, no difference was recorded between PN and RN in patients who were aged ≥75 years (HR: 0.83, P = 0.2), with ≥2 baseline comorbidities at diagnosis (HR: 0.83, P = 0.1), or in patients who were aged ≥75 years and who had ≥2 baseline comorbidities (HR: 0.77, P = 0.2).

CONCLUSIONS

Some elderly patients and/or those with multiple comorbidities at diagnosis may not benefit from PN with respect to OCM. After rigorous patient selection, alternative treatment options could be considered.

Propensity-score-matched comparison of perioperative outcomes between open and laparoscopic nephroureterectomy: a national series

BACKGROUND

Nephroureterectomy (NU) represents the primary management for patients with nonmetastatic upper tract urothelial carcinoma (UTUC). Either an open NU (ONU) or a laparoscopic NU (LNU) may be considered. Despite the presence of several reports comparing perioperative and cancer-control outcomes between the two approaches, no reports relied on a population-based cohort.

OBJECTIVES

Examine intraoperative and postoperative morbidity of ONU and LNU in a population-based cohort.

DESIGN, SETTING, AND PARTICIPANTS

We relied on the US Nationwide Inpatient Sample (NIS) to identify patients with nonmetastatic UTUC treated with ONU or LNU between 1998 and 2009. Overall, 7401 (90.8%) and 754 (9.2%) patients underwent ONU and LNU, respectively. To adjust for potential baseline differences between the two groups, propensity-score-based matching was performed. This resulted in 3016 (80%) ONU patients matched to 754 (20%) LNU patients.

INTERVENTION

All patients underwent NU.

MEASUREMENTS

The rates of intra- and postoperative complications, blood transfusions, prolonged length of stay (pLOS), and in-hospital mortality were assessed for both procedures. Multivariable logistic regression analyses were performed within the cohort after propensity-score matching.

RESULTS AND LIMITATIONS

For ONU versus LNU respectively, the following rates were recorded: blood transfusions, 15% versus 10% (p<0.001); intraoperative complications, 4.7% versus 2.1% (p=0.002); postoperative complications, 17% versus 15% (p=0.24); pLOS (≥5 d), 47% versus 28% (p<0.001); in-hospital mortality, 1.3% versus 0.7% (p=0.12). In multivariable logistic regression analyses, LNU patients were less likely to receive a blood transfusion (odds ratio [OR]: 0.6; p<0.001), to experience any intraoperative complications (OR: 0.4; p=0.002), and to have a pLOS (OR: 0.4; p<0.001). Overall, postoperative complications were equivalent. However, LNU patients had fewer respiratory complications (OR: 0.4; p=0.007). This study is limited by its retrospective nature.

CONCLUSIONS

After adjustment for potential selection biases, LNU is associated with fewer adverse intra- and perioperative outcomes than ONU.

Updated survival and outcomes for older adults with inoperable stage III non-small-cell lung cancer treated with cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel: analysis of a phase III trial from the Hoosier Oncology Group (HOG) and US Oncology

BACKGROUND

Concurrent chemoradiation with etoposide and cisplatin (EP/XRT) is standard treatment for inoperable stage III locally advanced non-small-cell lung cancer (LA-NSCLC). Consolidation docetaxel (D; Taxotere) after EP/XRT resulted in increased toxicity but no improvement in survival compared with observation (O). We report updated survival for the entire study population and include an analysis of efficacy and tolerability of EP/XRT with or without D in patients aged ≥ 70 years.

PATIENTS AND METHODS

Hoosier Oncology Group LUN 01-24 enrolled 243 patients with LA-NSCLC and randomized 166 after EP/XRT to three cycles of D versus O. the trial was terminated after an analysis of the first 203 patients demonstrated futility of D.

RESULTS

Median survival time (MST) for the overall study population was 21.5 months, and 3-, 4-, and 5-year survival rates were 30.7%, 18.0%, and 13.9%, respectively. No differences in MST or 3-year survival were noted between D and O arms. Older patients had similar MST (17.1 versus 22.8 months for younger patients, P = 0.15) but higher rates of grade 3/4 toxicity and hospitalization during induction.

CONCLUSIONS

Consolidation docetaxel after EP/XRT does not improve survival in LA-NSCLC. Fit older adults with LA-NSCLC benefit from concurrent chemoradiation similarly as younger patients but experience higher rates of hospitalization and toxicity.

A non-cancer-related survival benefit is associated with partial nephrectomy

BACKGROUND

Partial nephrectomy (PN) may better protect against other-cause mortality (OCM) when compared with radical nephrectomy (RN) in patients with localized renal cell carcinoma (RCC).

OBJECTIVE

Test the effect of treatment type on OCM.

DESIGN, SETTING, AND PARTICIPANTS

Using the Surveillance Epidemiology and End Results-Medicare-linked database, 4956 RN patients (82%) and 1068 PN patients (18%) with T1a RCC were identified (1988-2005).

MEASUREMENTS

To adjust for inherent differences between treatment types, we relied on propensity-matched analyses. One-to-one matching was performed according to age, sex, race, baseline Charlson comorbidity index (CCI), baseline diagnosis of hypercalcemia and hyperlipidemia, socioeconomic status (SES), population density, tumor size, and year of surgery. The 2- and 5-yr OCM rates were computed using cumulative incidence. Univariable and multivariable competing-risks regression analyses for prediction of OCM were performed according to treatment type. Adjustment was made for cancer-specific mortality (CSM), patient age, CCI, sex, race, SES, tumor grade, and year of surgery.

RESULTS AND LIMITATIONS

Following propensity-based matching, 1068 RN patients were matched with 1068 PN patients. The 2- and 5-yr OCM rates after nephrectomy were 5.0% and 16.0% for PN versus 6.9% and 18.1% for RN, respectively. In the postpropensity multivariable analyses, patients who underwent PN were significantly less likely to die of OCM compared with their RN-treated counterparts (hazard ratio [HR]: 0.83; 95% confidence interval, 0.69-0.98; p=0.04). Increasing age (HR: 1.08, p<0.001), higher CCI (HR: 1.14, p<0.001), female gender (HR: 0.79, p=0.02), baseline hypercalcemia (HR: 2.05, p=0.03), baseline hyperlipidemia (HR: 0.73, p=0.003), and year of surgery (HR: 0.95, p=0.003) were independent predictors of OCM.

CONCLUSIONS

Compared with PN-treated patients, RN-treated patients are more likely to die of OCM after surgery, even after adjusting for CSM, as well as baseline CCI. Consequently, PN should be offered whenever technically feasible.

Preoperative cetuximab and radiation (XRT) for patients (pts) with surgically resectable esophageal and gastroesophageal junction (GEJ) carcinomas: A pilot study from the Hoosier Oncology Group and the University of Texas Southwestern

4557

Background: Pre-operative chemoradiotherapy (CRT) followed by surgical resection is a standard treatment option for pts with resectable esophageal or GE junction (GEJ) carcinomas (CA). Cetuximab, when combined with XRT is effective treatment for locally advanced cancers of the head and neck. We conducted this study to evaluate this regimen in pts with esophageal and GEJ CA. Methods: This is a single arm, open label pilot study combining cetuximab with XRT for pts with resectable esophageal and GEJ CA. The primary objective is to determine the pathologic complete response rate (pCR) (null hypothesis: p=0.20; alternative hypothesis: p=0.35) and determine the feasibility and toxicity of this regimen when given prior to esophagectomy. Key eligibility criteria are: squamous cell (SC)or adenoCA of the esophagus or GEJ, ECOG PS 0–2, clinical stage II -IVa, and eligible for esophagectomy. Pts received a loading dose of cetuximab at 400mg/m2 2 weeks prior to XRT, then weekly at 250 mg/m2 starting one week prior to XRT until completion of 50.4 Gy XRT. After satisfactory recovery, pts had esophagectomy. Results: Patient characteristics (n=40): median age 65 years (range, 54–82); 92% male; PS 0/1 63%/32%; esophageal/GEJ 65%/35%; adenoCA/SC 78%/22%; 36 pts have completed cetuximab and radiation and 26 pts have undergone esophagectomy. Of the 26 pts that have undergone esophagectomy, 13 obtained a pCR. 5/13 SC had pCR and 8/13 adenoCA had pCR. 10 pts did not undergo surgery for various reasons including disease progression (n=7), AE unrelated to treatment (n=2), and personal decision to forgo esophagectomy (n=1). 4 patients are still completing cetuximab/XRT. The most common G3 adverse event was rash (56%). Other G3 toxicities were infrequent and included dysphagia (6%), infection (6%), and GI bleed (3%). There have been no treatment or surgery related deaths. Conclusions: Cetuximab and XRT results in pCR's in pts with esophageal and GEJ CA (rate of pCR 13/36), including patients with either SC or adenoCA histologies. G3/4 toxicities, including dysphagia were generally uncommon. Further study of this combination prior to esophagectomy is warranted.

[Table: see text]

Randomized, double blind, multicenter, phase II study of pemetrexed (PEM), carboplatin (CARBO), bevacizumab (BEV) with enzastaurin (ENZ) or placebo (PBO) in chemotherapy-naive patients with stage IIIB/IV non-small cell lung cancer (NSCLC): Hoosier Oncology Group (HOG) LUN06–116

8035^

Background: Pre-clinical data suggests that ENZ and BEV may have complementary effects in inhibiting angiogenesis. This study compared ENZ vs PBO in combination with PEM+CARBO+ BEV. Methods: Pts ≥18 years of age, non-squamous NSCLC, no prior systemic therapy, disease measurable by RECIST, and ECOG PS 0–1 were randomized. Pts received either PBO or 500 mg ENZ daily after loading dose of 375 mg orally, TID, on day 1, cycle 1. Starting on day 8, cycle 1, patients received PEM 500mg/m2, CARBO AUC 6 and BEV 15mg/kg, intravenously, every 21 days. After 4 cycles, pts continued on BEV+ENZ or BEV+PBO. Pts were stratified by ECOG status, disease stage and site with a planned sample size of 90 pts. Primary end point was progression-free survival (PFS). Secondary end points included objective response rate (ORR) and toxicity. Results: Study was terminated after a planned interim analysis for safety and efficacy. From October 2007 to July 2008, 40 pts were enrolled: 20 in each arm. Median age was 60.5 years (range: 44 to 78); M 52.5%, F 47.5%; ECOG PS 0/1 52.5% and 47.5%; stage IIIB/IV 15% and 85%. Baseline characteristics were well matched. The PEM+CARBO+BEV+ENZ arm received a median of 3 cycles of therapy and the PEM+CARBO+BEV+PBO arm 4 cycles. Median PFS was 4.3 mo and 4.2 mo for ENZ and PBO, respectively (unadjusted HR: 0.94, 95% CI [0.39, 2.33]). ORR for ENZ and PBO was 20% and 25%, respectively. Overall, grade 3/4 toxicities were similar in both arms. One patient in ENZ arm experienced a grade 3/4 hemorrhage (vs. none in the PBO arm). Two patients experienced a GI perforation (1 on each arm): 1 resulted in death on the PBO arm. Both patients had a history of diverticulosis. Conclusions: Based upon the results of this interim efficacy analysis, addition of ENZ to PEM+CARBO+BEV will not significantly prolong PFS in patients with stage IIIB/IV NSCLC. This combination does not warrant further study in NSCLC.

[Table: see text]

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Erlotinib and bevacizumab in chemotherapy-naive performance status 2 patients with advanced non-small cell lung cancer

e19082

Background: Poor performance status is a negative prognostic variable for survival and a risk for increased toxicities with standard chemotherapy. A phase 2 study combining erlotinib (E) and bevacizumab (B) demonstrated encouraging efficacy in the treatment of recurrent NSCLC with acceptable toxicity. We, therefore, tested this regimen in untreated PS 2 patients with advanced NSCLC. Methods: Single-arm phase 2 trial in treatment-naïve patients with advanced non-squamous NSCLC and either a PS of 2 or age >75. Only patients eligible for bevacizumab per label were allowed onto study. Patients received E 150 mg orally daily and B 15 mg/kg IV on day 1 every 21 days for up to 6 cycles. The primary end-point was the rate of non progressive disease at 4 months (alternative hypothesis P>60%). Other end-points included overall survival, progression free survival (PFS), toxicity evaluations and patient-reported PS (PRPS) measures. Results: 25 patients were enrolled. Patient characteristics: 56% female, median age 77 years (range: 52–90); 88% stage IV; 92% were PS 2; 20% were never or remote smokers (> 30 years) The PRPS was 1, 2, 3 in 32%, 52%, 8% respectively with data on 2 patients missing. The rate of non-progression at 4 months was 40%; overall best response: 5% PR, 40% SD, 50% PD and 5% unevaluable; median PFS 2.6 months, 95% CI (1.3–5.1); MST 5.8 months, 95% CI (3.8- 8.7). 2 patients had G3 rash. G3 diarrhea, G3 hemorrhage, G3 proteinuria, G3 duodenal ulcer and G3 pneumonitis each developed in one patient. Conclusions: E + B is an active regimen with an acceptable toxicity profile; however, this study did not meet its’ primary endpoint. Further study of this combination will not be pursued in the Hoosier Oncology Group for this patient population.

[Table: see text]

ABT-869 in non-small cell lung cancer (NSCLC): Interim results

8074

Background: ABT-869 is a novel orally active, potent and specific inhibitor of vascular endothelial growth factor and platelet derived growth factor receptor tyrosine kinases. Methods: This ongoing, open-label, randomized, multicenter phase 2 trial of ABT-869 at 0.10 mg/kg daily (Arm A) and 0.25 mg/kg daily (Arm B) until progressive disease (PD) or intolerable toxicity, was initiated to assess antitumor activity and toxicity of ABT-869 in patients (pts) with NSCLC. Eligibility criteria included locally advanced or metastatic NSCLC; ≥ 1 prior systemic treatment, and ≥1 measurable lesion by RECIST criteria. The primary endpoint was the progression free (PF) rate at 16 wks. Secondary endpoints were objective response rate (ORR), time to progression (TTP), progression free survival (PFS) and overall survival (OS). CT scans were assessed by the investigator and centrally; central assessment results are provided. Results: 138 patients (pts) were enrolled from 08/07–10/08 from 27 centers with interim data available for 94 pts (Arm A, n=43; Arm B; n=51). Median age was 64 years and 62 years in Arm A and B respectively. For the interim analysis population (Arm A, n=24; Arm B, n=24), 16 (33.3%) pts were PF at 16 wks: 7 (29.2%) in Arm A and 9 (37.5%) in Arm B. The ORR in Arm A (n=30) was 0% and 7.3% in Arm B (n=41). The median TTP and median PFS were 110 and 109 days, and 112 days and 108 days in Arm A and B, respectively. The most common adverse events (AEs) in Arm A were fatigue (35%), nausea (21%), and anorexia (21%), and in Arm B were hypertension (51%), fatigue (51%), diarrhea (43%), anorexia (41%), nausea (31%), proteinuria (31%) and vomiting (26%). The most common grade 3/4 toxicities in the Arm A were fatigue (7%), ascites (5%), dehydration (5%), pleural effusion (5%), and in the Arm B were hypertension (23%), fatigue (8%), PPE syndrome (8%), dyspnoea (6%) and stomatitis (6%). Most AE's were mild/moderate and reversible with interruptions/dose reduction/or discontinuation of ABT-869. Conclusions: ABT-869 demonstrates an acceptable safety profile and appears to be active in NSCLC patients.

[Table: see text]

Tumor regression and pharmacodynamic (PD) biomarker validation in non-small cell lung cancer (NSCLC) patients treated with the ErbB/VEGFR inhibitor BMS-690514

8098

Background: BMS-690514 is an oral selective inhibitor of EGFR, HER2, and VEGFR1–3. Previous results from the phase I portion of this phase I/II study established 200 mg/day as safe and tolerable (ASCO 2008; abstr 2564). Methods: Erlotinib-naïve and erlotinib-resistant adult patients with advanced/metastatic, measurable NSCLC received BMS-690514 200 mg/d. Eligible patients had an ECOG PS ≤1 and adequate organ function. Objectives were to assess disease control rate (DCR; CR, PR, SD ≥4 months), safety, PK and potential predictive and PD biomarkers of BMS-690514. Response was assessed every 8 weeks (modified WHO criteria). Predictive biomarkers included EGFR copy number, and EGFR and KRAS mutations. PD biomarkers included immunohistochemistry of EGFR signaling proteins in skin biopsies, circulating sVEGFR2, blood pressure, skin rash and diarrhea. Results: For 60 patients treated, DCR were 11/28 (39%) and 7/32 (22%) for erlotinib-naive and -resistant patients, respectively. DCR was significantly higher among patients harboring an EGFR mutation (6/8) than those with WT EGFR (5/18). One erlotinib-naive patient had PR (57 wks) and subsequent surgical removal of remaining tumor. Regression (48%) was seen in one erlotinib-naive patient harboring a KRAS G13D mutation. One erlotinib-resistant patient had PR (66%, 31 wks). Two erlotinib-resistant patients with EGFR T790M mutations had SD with 6% and 31% decrease in tumor burden. Most frequent treatment-related AES were diarrhea (90%), skin rash (31%), asthenia (29%), anorexia (27%), hypertension (26%), and reversible acute renal insufficiency (11%). sVEGFR2 (14% decrease from baseline, n=14) and decreased pMAPK levels from skin biopsies (14 of 18 pts) were consistent with EGFR and VEGFR2 inhibition. Conclusions: BMS-690514 200 mg/d showed evidence of anti-tumor activity and disease control in patients with NSCLC, including erlotinib-resistant and those with WT EGFR, EGFR T790M or KRAS mutations. Predictive and PD clinical biomarkers confirmed inhibition of both EGFR and VEGFR signaling pathways by BMS-690514. A randomized phase II trial versus erlotinib in NSCLC is underway.

[Table: see text]

SOS1: a new player in the Noonan-like/multiple giant cell lesion syndrome

Noonan-like/multiple giant cell lesion syndrome is a rare condition with phenotypic overlap with Noonan syndrome (NS) and cherubism. PTPN11 gene mutations were described in several individuals with this phenotype, and it is recently considered as a variant phenotype of NS. Gain-of-function mutations in the SOS1 gene were recently described as the second major cause of NS. Here, we report for the first time the involvement of SOS1 gene in a family with the Noonan-like/multiple giant cell lesion phenotype.

Multi-centre observational study of buprenorphine use in 32 Italian drug addiction centres

AIM

To examine how buprenorphine is currently being used across Italy, and to identify simultaneously best practice protocols to guide physicians in optimising the safety and efficacy of this treatment option.

DESIGN

Retrospective, observational, multi-centre study.

PARTICIPANTS

A total of 979 opioid-dependent patients were included from 32 centres involving the initiation of 1122 treatments.

FINDINGS

During the study period 33.4% of patients relapsed during the induction phase. Lower induction doses resulted in markedly higher relapse rates (51.2% of those who received 2 mg versus 20.6% of those who received 10mg of buprenorphine relapsed). Over 89% of patients who received 16 mg of buprenorphine during the induction phase successfully went on to maintenance treatment. The percentage of drug-positive urines also decreased over time on buprenorphine treatment (cocaine-positive urines decreased from 25.8% at study entrance to 0% at 24 months). Psychosocial support in addition to buprenorphine pharmacotherapy further decreased the risk of relapse and was associated with lower levels of heroin craving. Retention in treatment was increased by less-than-daily dosing of buprenorphine.

CONCLUSIONS

Higher induction doses of buprenorphine significantly decreased relapse rates and increased the percentage of patients achieving maintenance treatment. Psychosocial support and/or less-than-daily dosing also appeared to promote positive treatment outcomes.

Clinical results of cytoreduction and HIPEC for malignant peritoneal mesothelioma

Taken together, these reports provide very provocative and encouraging data that have prompted some to conclude that cytoreduction and HIPEC represents a "new standard of care" for patients with MPM [26]. Certainly, for selected patients who have good performance status (low operative risk) and in whom complete or near complete cytoreduction can be achieved, this form of therapy is associated with a very notable overall survival ranging from 67 to 92 months in 2 larger series. Patient selection remains the central criteria for successful outcome. Patients should be carefully evaluated for co-morbid illnesses that would make them an unacceptable operative risk. Subsequently, CT scan and possibly laparoscopy should be performed to assess resectability with the appreciation that patients with suboptimal resection do very poorly. Pre-operative assessment of disease resectability is difficult to ascertain but some useful information can be obtained from a careful review of the CT scan; some investigators have advocated routine laparoscopy. Technically, details of HIPEC vary from center to center to some degree with respect to type of chemotherapy, dose of chemotherapy, duration of HIPEC, degree of hyperthermia, and method of recirculating the chemotherapy using either the open or closed technique. The use of the HIPEC technique, however, is considered the optimal method of ensuring complete distribution of therapeutic agents to the peritoneal cavity. Hyperthermia is routinely used for its synergistic actions with chemotherapy and its direct tumoricidal activity in experimental models. However, the therapeutic contribution of HIPEC above the effects of successful cytoreduction cannot be determined with available data although palliation of ascites is observed with HIPEC even without cytoreduction. There are no data indicating that one intra-operative chemotherapy regimen is superior to any other. The centers that report use of prolonged induction or post-operative intraperitoneal chemotherapy do not appear to have superior outcomes to those centers that use a more simple treatment regimen. Finally, although the intensity of therapy is considerable, once recovered, the patients appear to enjoy a good HRQOL. Although not specific for patients with MPM, 2 reports have convincingly demonstrated that HRQOL is significantly improved after HIPEC.

An analysis of elderly patients (pts) treated on a phase III trial of cisplatin (P) plus etoposide (E) with concurrent radiotherapy (CRT) followed by docetaxel (D) vs observation (O) in pts with stage III non small cell lung cancer (NSCLC)

9037

Background: Concurrent CRT is standard treatment for pts with unresectable stage III NSCLC. HOG LUN01–24 is a phase III trial testing if consolidation D improves survival following EP/XRT. Few data are available on outcomes in elderly pts. We performed a subset analysis to determine the efficacy & tolerability of EP/XRT & consolidation D in elderly pts (≥70 yrs) vs younger (<70) pts. Methods: Patient (n=203), disease characteristics, survival & toxicity were compared for pts age ≥70 (n=52) vs <70 (n=151). Results: Median age for elderly was 73 vs 60 for younger pts. 34% of each group were women. Younger pts had a trend towards PS 0 (61% vs 53% elderly), FEV-1 > 2 L (48% vs 43% elderly), stage IIIB disease (61% vs 53% elderly). Younger pts were more likely to be current smokers (51% vs 15% elderly). 74% of younger pts were randomized vs 67% of elderly. During EP/XRT, elderly pts were more likely to discontinue treatment due to toxicity (12% vs 2%) & require hospitalization (40% vs 28%). Selected G3/4 toxicities during EP/XRT in elderly vs younger pts: neutropenia (42 vs 28%), anemia (9 vs 5%), febrile neutropenia (FN) (6 vs 11%), esophagitis (23 vs 15%), dehydration (15 vs 7%). Elderly pts were less likely to complete 3 cycles of consolidation D (76 vs 84%). Selected G 3/4 toxicities during consolidation D were similar between elderly (n=18) and younger pts (n=55), including FN (11.1 vs 10.9%). There was no difference in MST for older pts vs younger pts (17.2 vs 21.2 mos), p=0.3255. Conclusion: Chemoradiation is associated with higher rates of G 3/4 toxicities in elderly pts, including hospitalization rates. Elderly pts had lower rates of completing D, but similar incidence of D-related toxicity. There was no difference in MST between the age groups.

No significant financial relationships to disclose.

Multivariate analysis of prognostic variables associated with survival from a phase III study of cisplatin (P) plus etoposide (E) plus chest radiation (XRT) with or without consolidation docetaxel (D) in patients with unresectable stage III non-small cell lung cancer (NSCLC)

7668

Background: Concurrent chemoradiation is standard treatment against stage III NSCLC. HOG LUN 01–24 examines whether consolidation therapy with D improves overall survival. We present an analysis investigating the association of patient characteristics with overall survival from patients on this study. Methods: Eligible patients had untreated stage III NSCLC, FEV1 ≥ 1 liter, PS of 0–1, and weight loss < 5%. Patients received P 50 mg/m2 days 1, 8, 29, 36 with E 50 mg/m2 days 1–5, 29–33, and concurrent 5,940 cGy XRT. Patients with non-progressive disease were randomized to D 75 mg/m2 q3wk X 3 cycles vs observation. A multivariable parametric accelerated failure time model was performed to identify factors that affected survival and to estimate the treatment effect adjusting for these factors. Results: A multivariate analysis was performed on 203 patients who were the subject of a DSMB interim analysis. Median follow up was 25.6 months. Variables analyzed included age (<70 vs ≥ 70), sex, race, body mass index, PS (0 vs 1), FEV-1 (> 2 vs ≤ 2), smoking status, hemoglobin (≥12 vs <12), and stage. A multivariable parametric accelerated failure time model demonstrated the association of age <70 vs =70 years (p=0.0447), FEV1 >2 vs =2 (p=0.0153), and pre-treatment hemoglobin values (p=0.0083) as independent prognostic factors for overall survival. The median survival for hemoglobin <12 was 16.8 vs 21.5 months for hemoglobin ≥12 (p=0.0432). Similarly, the median survival with FEV >2L was 21.6 vs 18.9 months for FEV =2 L. Survival was not significantly influenced by smoking status, sex, race, PS, stage, or BMI. Conclusions: This analysis suggests that age <70, FEV-1 >2L and higher pre-treatment hemoglobin values are associated with improved overall survival in patients with stage III NSCLC.

No significant financial relationships to disclose.

Pemetrexed plus cetuximab in patients (pts) with recurrent non-small cell lung cancer (NSCLC): A phase I-IIa dose-ranging study from the Hoosier Oncology Group

7698

Background: Both pemetrexed (P) and cetuximab (C) have single agent activity in NSCLC, non-overlapping toxicities and different mechanisms of action, making the combination of P and C an attractive option to evaluate. This study evaluates the feasibility of combining these agents, and tests the activity and toxicity of this regimen in pts with recurrent NSCLC. Methods: Eligible pts had stage IIIB/IV NSCLC, previously treated ≥ 1 prior platinum containing regimen, PS 0–1. Prior use of EGFR tyrosine kinase inhibitors was permitted. The phase I portion determined the MTD (Bedano Proc ASCO et al., 2006). The primary endpoint of the phase II portion was to estimate TTP using Kaplan-Meier analysis (5% alpha, 80% beta), requiring 25 pts to demonstrate a TTP of ≥ 24 weeks vs. historical control of 12 weeks. Following a loading dose of C at 400 mg/m2 on week 1, pts received P at 750 mg/m2 iv q3wks and C at 250 mg/m2 iv weekly. Cycles were repeated every 21 days. After completing at least 4 cycles, pts with non-progressive disease (PD) were allowed to continue C alone until PD. Results: Eligible and treated phase II pts (n=23) received a median of 4 cycles (range 1–12). Pt characteristics: M:F 57%:43%; median age 64 (range 43–80), stage IIIB: IV 17%:83%; adeno:squamous cell 61%:30%; smoking status: current/former/never: 29%/62%/10%. Prior regimens, median 2 (range 1–6). G3/4/5 toxicities included: 4.3% neutropenia, 13% infection, 4.3% hemorrhage, 22% skin. There were no G3/4 episodes of anemia, TCP, febrile neutropenia, liver toxicity or diarrhea. Response data was available for 18 patients. Partial responses were seen in 2 pts (8.7 %), SD in 8 patients (34.8%). Median TTP was 25 weeks. Conclusion: It is feasible and safe to combine P at 750 mg/m2 every 21 days and C at 400 mg/m2 week 1 and 250 mg/m2 weekly thereafter. This combination resulted in longer TTP when compared with historical controls of P at 500 mg/m2 alone.

No significant financial relationships to disclose.

The impact of induction chemotherapy on the outcome of second-line therapy with pemetrexed or docetaxel in patients with advanced non-small-cell lung cancer

BACKGROUND

Using data from a large phase III study of previously treated advanced non-small-cell lung cancer (NSCLC) that showed similar efficacy for pemetrexed and docetaxel, this retrospective analysis evaluates the impact of first-line chemotherapy on the outcome of second-line chemotherapy.

PATIENTS AND METHODS

In all, 571 patients with advanced NSCLC were randomly assigned to receive pemetrexed 500 mg/m(2) or docetaxel 75 mg/m(2) on day 1 of a 21-day cycle. Comparisons were made based on type of first-line therapy [gemcitabine + platinum (GP), taxane + platinum (TP), or other therapies (OT)], response to initial therapy, time since initial therapy, and clinical characteristics. The two second-line treatment groups were pooled for this analysis due to similar efficacy and were assumed to have no interaction with the first-line therapies.

RESULTS

Baseline characteristics were generally balanced. By multivariate analysis, gender, stage at diagnosis, performance status (PS), and best response to first-line therapy significantly influenced overall survival (OS). Additional factors by univariate analysis, histology, and time elapsed from first- to second-line therapy significantly influenced OS.

CONCLUSIONS

Future trials in the second-line setting should stratify patients by gender, stage at diagnosis, PS, and best response to first-line therapy.

Phase III study of cisplatin (P) plus etoposide (E) with concurrent chest radiation (XRT) followed by docetaxel (D) vs. observation in patients (pts) with stage III non-small cell lung cancer (NSCLC): An interim toxicity analysis of consolidation therapy

7043

Background: Concurrent chemo radiotherapy is the standard treatment for pts with unresectable stage III NSCLC. A previously reported phase II study (Gandara et al J Clin Oncol 2003) suggests that consolidation D after concurrent PE/XRT may further improve survival. HOG LUN01–24, is an ongoing phase III clinical trial comparing chemo radiation. A preliminary analysis of the differences in toxicities between PE/XRT with or without consolidation D was performed. Methods: Eligible pts had previously untreated, unresectable stage III NSCLC, ECOG PS 0–1 at time of study entry (and PS 0–2 at the time of randomization), ≤ 5% weight loss in preceding 3 months, FEV-1 > 1 L. Treatment consisted of P 50 mg/m2 days 1, 8, 29, 36 with E 50 mg/m2 days 1–5 and 29–33, given concurrently with chest XRT to 5,940 cGy (180 cGy/day) beginning on day 1. Non-progressive pts were randomized (4–8 weeks after completing PE/XRT) to receive D 75 mg/m2 iv every 21 days for 3 cycles vs. observation. We report an interim toxicity analysis associated to consolidation D. Results: From 3/02 to 12/05 220 have been registered and 149 pts have been randomized to consolidation D (n=73) or observation (n=76). Median age was 63.6 years (range 33–86); male/female 34.1%/65.9%; PS 0/1 at study entry 59.1%/40.9%; stage III A/B 40.6%/59.4%; 50.2% had FEV-1 > 2 (range 1–4.2); 44.3% were current smokers. Randomized pts have PS 0/1/2 44.3%/53%/2.7. Selected grade 3/4 toxicities associated to D include: neutropenia 23.3%, febrile neutropenia 8.2%, and pulmonary toxicity 9.6%. In addition, 26.7% of pts had dose modifications or delays on D arm, 45.2% had at least one grade 3/4 toxicity and 20.5% were hospitalized due to D-related toxicity, including 4 pts (5.5%) whose death was considered therapy related. Conclusions: Concurrent PE/XRT followed by consolidation D is associated with a high rate of grade 3/4 toxicities and hospitalizations, including treatment-related deaths. Updated toxicity data will be presented at the ASCO meeting. Whether consolidation D confers a survival advantage is not yet known.

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Survival update for the phase III study of pemetrexed vs docetaxel in non-small cell lung cancer (NSCLC)

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Background: Results from a large, randomized, phase III study of pemetrexed vs docetaxel as second-line treatment for advanced NSCLC indicated that pemetrexed, a novel multitargeted antifolate, has a median survival time (8.3 months) similar to that of docetaxel (7.9 months) with a more favorable safety profile [JCO 2004;22:1589–97]. This updated analysis reflects data available 23 months after the original analysis, which was performed Jan 2003 (after 519 deaths). Methods: Pts (n = 571) were randomized from March 2001 to Feb 2002 to receive either pemetrexed (500 mg/m2 IV infusion), supplemented with vitamin B12 injections and folic acid, or docetaxel (75 mg/m2 IV infusion) on day 1 of a 21-day cycle. An unadjusted survival analysis was performed and a Cox multiple regression analysis (n = 532) was done to adjust for factors (other than treatment intervention) that affected survival including ECOG performance status (PS), disease stage, and time since last chemotherapy. Percent retention was performed using the Rothmann method. Results: The updated survival analysis (performed after 519 deaths) indicated similar median survival times for pemetrexed (8.3 months; 95% CI: 7.0–9.4) and docetaxel (8.0 months; 95% CI: 6.6–9.3), and comparable hazard ratios (HR) (original 0.99 [95% CI: .82–1.20] vs updated 0.97 [95% CI: .81–1.15]). Percent of docetaxel benefit over best supportive care retained by pemetrexed was similar in both analyses: original 102% (95% CI: 52%-157%) vs updated 106% (95% CI: 68%-163%). Cox multiple regression analysis again showed that the two drugs were similar in survival after adjusting for factors significantly associated with increased survival. Conclusions: These updated survival analyses consistently demonstrate that second-line pemetrexed has similar survival to docetaxel in pts with NSCLC. Given the continued finding of comparable therapeutic efficacy, pemetrexed may be considered a standard second line therapy.

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A phase II trial of olanzapine and palonosetron for the prevention of chemotherapy induced nausea and vomiting (CINV)

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Background: Olanzapine has been shown to be a safe and effective agent for the prevention of CINV in chemotherapy naïve cancer patients. Palonosetron has been approved for the prevention of acute CINV and for the prevention of delayed CINV in patients receiving moderately emetogenic chemotherapy (MEC). Methods: A phase II trial was performed for the prevention of CINV in chemotherapy naïve patients using the combination of olanzapine and palonosetron. The regimen was 10 mg of oral olanzapine, 0.25 mg of intravenous palonosetron, and dexamethasone (20 mg for highly emetogenic and 8 mg for moderately emetogenic chemotherapy) on the day of chemotherapy, day 1, and 10 mg/day of oral olanzapine alone on days 2–4 after chemotherapy. Forty patients (median age 60 yrs, range 38–84; 22 females; ECOG PS 0,1) consented to the protocol and all were evaluable. Results: The percentage of patients with a complete response (CR) (no emesis, no rescue) was 100% for the acute period (24 h post chemotherapy), 75% for the delayed period (days 2–5 post chemotherapy), and 75% for the overall period (0–120 h) for eight patients receiving highly emetogenic chemotherapy (HEC) (cisplatin > 70 mg/m2). CR was 97% for the acute period, 75% for the delayed period, and 72% for the overall period in 32 patients receiving MEC (doxorubicin, >50mg/m2). In the patients receiving HEC, the percentage of patients without nausea (0, scale 0–10, M. D. Anderson Symptom Inventory) was 100% in the acute period, 50% in the delayed period, and 50% in the overall period. In patients receiving MEC, the percentage without nausea was 100% in the acute period, 78% in the delayed period, and 78% in the overall period. There were no Grade 3 or 4 toxicities and no significant pain, fatigue, disturbed sleep, memory changes, dyspnea, lack of appetite, drowsiness, dry mouth, mood changes or restlessness experienced by the patients. CR and control of nausea in subsequent cycles of chemotherapy (35 patients, cycle 2; 31 patients cycle 3; 23 patients, cycle 4) were equal to or greater than cycle one. Conclusions: The combination of olanzapine and palonosetron with dexamethasone given only on the day of chemotherapy was safe and highly effective in controlling acute and delayed CINV in patients receiving HEC and MEC.

No significant financial relationships to disclose.

Gefitinib plus celecoxib in chemotherapy-naïve patients with stage IIIB/IV non-small cell lung cancer (NSCLC): A phase II study from the Hoosier Oncology Group

7066

Background: Gefitinib, an inhibitor of the epidermal growth factor receptor (EGFR) pathway, has single agent activity in NSCLC. Preclinical studies demonstrate significant interactions between the EGFR and cyclo-oxygenase 2 (COX-2) pathways and that simultaneous inhibition against NSCLC may have benefits over gefitinib alone. Methods: Eligibility required that pts were chemotherapy-naïve, had stage IIIb (with pleural effusion) or IV NSCLC and an ECOG PS 0–1. Pts received gefitinib 250mg orally daily plus celecoxib 400mg orally every 12 hours. Cycles consisted of 21 day treatment and continued until unacceptable toxicity or progression of disease. The primary objective of this single arm, two-stage, phase II study was to evaluate the overall response rate. If ≤ 10 out of 30 pts achieved a complete (CR) or partial response (PR), the study would be stopped early. If >10 out of 30 pts had a CR or PR, enrollment would continue to 50 pts. Results: From 1/04 to 11/04, 31 pts were enrolled: male/female 13/18; median age 70.8 years (range, 19–93); 67.7% had adenocarcinoma; ECOG PS 0/1 13/18; stage IIIb/IV 2/29; 5 were current smokers, 9 were remote (>30 years) or never smokers, 16 quit smoking > 3 months ago. Median number of cycles was 4 (range, 0–16). 6 pts (19.4%) discontinued therapy due to toxicity, including 3 who died due to treatment. Select grade 3/4 toxicities included: pulmonary (6.5%), hepatic (6.5%), diarrhea (6.5%), skin (3.2%). Responses included PR 5 (16.1%), stable disease 8 (25.8%), and progressive disease 18 (58.1%). Median duration of response, progression free survival, and overall survival was 5.7, 2.8, and 7.2 months, respectively. All responders were females with adenocarcinoma, 2 were remote or never smokers and 3 were former smokers. Conclusion: Gefitinib plus celecoxib in an unselected population of chemotherapy naïve patients with advanced NSCLC and a PS of 0–1 has a lower response rate and overall efficacy compared with historical controls of chemotherapy.

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Survival outcomes of resected patients who demonstrate a pathologic complete response after neoadjuvant chemoradiation therapy for locally advanced esophageal cancer

A variety of strategies, using chemotherapy, radiation therapy, and surgical resection have been employed in the treatment of locally advanced esophageal cancer. No strategy has proven superior, and poor long-term survival is anticipated. A survival benefit has been suggested for patients who achieve a pathologic complete response (pCR) following neoadjuvant chemoradiation therapy. We examined the collective results at three institutions of patients who achieved a pCR following neoadjuvant chemoradiation therapy. A retrospective, chart-based review was conducted. Kaplan-Meier calculations were used to determine overall and disease-free survival. Between 1995 and 2002, 229 patients were treated with neoadjuvant chemoradiation followed by surgery as a planned approach for locally advanced esophageal cancer. Forty-one patients (18%) demonstrated pCR and were the focus of this study. Histology was adenocarcinoma in 29, squamous in 10, and adenosquamous/undifferentiated in two patients. Forty patients were staged by endoscopic ultrasound prior to neoadjuvant therapy and all demonstrated a T-stage of 2 or higher, while 19 had evidence of nodal metastasis. Four patients died in the perioperative period. The remaining patients have been followed for an average of 46 months. Overall survival at 5 years was 56.4% and a median survival has not been reached. Esophageal cancer patients who demonstrate a pCR following neoadjuvant chemoradiation are a select subset who demonstrate excellent long-term survival. Identification of clinical variables or biomarkers predictive of pCR may therefore optimize treatment strategies of patients with locally advanced esophageal cancer.

Recombinant human angiostatin (rhAngiostatin) in combination with paclitaxel and carboplatin in patients with advanced non-small-cell lung cancer: a phase II study from Indiana University

BACKGROUND

Recombinant human angiostatin (rhAngiostatin) functions as a potent inhibitor of angiogenesis. This study combined rhAngiostatin with a standard chemotherapy regimen in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Eligible patients had chemotherapy-naïve stage IIIB (with pleural effusion) or IV NSCLC, performance status (PS) 0 or 1, no history of bleeding, brain metastasis or requirements for anti-coagulation. Patients received carboplatin (AUC 5) intravenously and paclitaxel (175 mg/m2) intravenously day 1 + subcutaneous rhAngiostatin at either 15 mg or 60 mg twice daily. Cycles were repeated every 3 weeks, for up to six cycles. Patients without progression after completing at least four cycles were continued on maintenance rhAngiostatin until disease progression.

RESULTS

Patient characteristics (n = 24) were: 16 males, median age 66 years (range 45-78), 54% PS 1, 83.3% stage IV and 62.5% adenocarcinoma. Grade 3/4 toxicities included: fatigue 47.8%, neutropenia 39.1%, dyspnea 39.1%, vascular 26.1% and infection 17.4%. The overall response rate was 39.1%, 39.1% stable disease and 21.7% progressive disease. Median time to progression was 144 days, and 1-year survival was 45.8%.

CONCLUSIONS

rhAngiostatin in combination with paclitaxel and carboplatin is feasible and results in a high disease control rate in patients with advanced NSCLC.