Phase II study of docetaxel for recurrent or metastatic non-small-cell lung cancer

A phase II study of docetaxel and vinorelbine combination chemotherapy in patients with advanced non-small cell lung cancer

A phase II study was conducted to determine the efficacy and the safety of docetaxel combined with vinorelbine as first-line chemotherapy in patients with metastatic or unresectable non-small cell lung cancer (NSCLC). 39 patients, median age 54 years (range: 35-69), with stage IIIB (5 patients; 13%) or IV (34 patients; 87%) NSCLC were treated with 75 mg/m(2) docetaxel given intravenously (i. v.) over 1 h on day 1 and with 20 mg/m(2) vinorelbine given i.v. over 15 to 30 min on days 1 and 5. Cycles were repeated every 3 weeks. 9 of the 39 patients had a partial response (overall response rate 23.1%, 95% confidence interval (CI): 11.1-39.3%) with a median duration of response of 20 weeks (95% CI; 17-30). The median survival was 40 weeks (95% CI: 21-49 weeks) with a 1-year survival rate of 31% in the intent-to-treat population. Neutropenia grade IV occurred in 33 patients (92%). 16 patients (41%) experienced febrile neutropenia with a concomitant stomatitis in 9 patients (23%). One patient died due to febrile neutropenia associated with a grade 4 stomatitis and 1 patient due to a septicaemia concomitant with a grade 4 neutropenia. Although the combination of docetaxel and vinorelbine is feasible, the efficacy does not seem to be improved compared with single-agent docetaxel or vinorelbine and the rate of febrile neutropenia is unacceptable in this population with incurable disease. Therefore, different doses and/or schedules are to be explored.

A Phase I Trial of Outpatient Weekly Docetaxel and Concurrent Radiation Therapy for Stage III Unresectable Non–Small-Cell Lung Cancer: A Vanderbuilt Cancer Center Affiliate Network (VCCAN) Trial

Docetaxel has demonstrated activity as a radiosensitizer in numerous preclinical studies, probably due to its role as a cell cycle synchronizer for the G2/M radiosensitive phase of the cell cycle. We conducted a phase I trial to determine the maximum-tolerated dose (MTD) and dose-limiting toxicities (DLT) of docetaxel with concurrent thoracic radiation therapy (TRT) to patients with unresectable stage III non small-cell lung cancer (NSCLC). Fifteen patients were entered into this study. Docetaxel was administered as a 1-hour intravenous (I.V.) infusion, repeated every week for 6 weeks with starting dose of 20 mg/m2. Doses were escalated in 10 mg/m2 increments in successive cohorts of three new patients, if tolerated. Unacceptable toxicity was defined as grade = 3 nonhematologic or hematologic toxicity according to Eastern Cooperative Oncology Group (ECOG) toxicity criteria. TRT was administered to the primary tumor and regional lymph nodes (40 Gy) followed by a boost to the tumor (20 Gy). At the first dose level (20 mg/m2/week), one patient developed grade 4 hyperglycemia and accrual was expanded to five patients. At the second level (30 mg/m2/week), two out of six patients developed grade 3 esophagitis. At the third level (40 mg/m2/week), two out of four patients developed grade 3 esophagitis and one patient developed grade 3 pulmonary toxicity. The weekly docetaxel MTD with concurrent radiation therapy (RT) was found to be 30 mg/m2. The DLT was esophagitis and pulmonary toxicity. Other toxicities encountered included skin reaction, nausea and vomiting, as well as diarrhea. Additionally, there were no treatment-related mortalities or late-occurring toxicities. Esophagitis was the principal DLT of concurrent weekly docetaxel and thoracic radiation in the outpatient setting. The MTD of concurrent weekly docetaxel with TRT is 30 mg/m2 weekly for 6 weeks. This study is still open to accrual with weekly docetaxel and TRT in locally advanced NSCLC patients.

Docetaxel in Combination with Platinum Compounds for Non–Small-Cell Lung Cancer

Assessing the combination of docetaxel with cisplatin or carboplatin was based on their activity as single agents, their nonoverlapping toxicity profiles, and their lack of cross-resistance. Phase I studies of docetaxel in combination with cisplatin established that 75 mg/m2 of each agent could be administered with reasonable safety and appeared to be active in non small-cell lung cancer (NSCLC). We evaluated the docetaxel/cisplatin combination in patients with advanced NSCLC. The response rate was 32%, and the median survival was 11.5 months. Efficacy was comparable to that observed in the Australian and French trials with the same combination. This is now being evaluated further in two large randomized trials for patients with advanced NSCLC and has been incorporated into the combined modality programs for early-stage disease. Carboplatin, devoid of the nephrotoxicity and neurotoxicity associated with the parent cis-platin, was then combined with docetaxel. The recommended dose of docetaxel for further evaluation in combination with carboplatin (AUC=6 mg/mL.min) was 90 mg/m2 with filgrastim support and 80 mg/m2 without filgrastim support. Our phase II trial of the combination of docetaxel and carboplatin in advanced NSCLC demonstrated an overall response rate of 36%; median survival was 13.9 months, and 1-year survival was 52%. Comparable activity has been seen by other investigators, and the regimen is being evaluated in two randomized trials. The combination of docetaxel with either of the two platinum agents has reasonable activity in NSCLC, though the carboplatin/docetaxel doublet appears to have a better therapeutic index.

Single-Agent Docetaxel (Taxotere®) in the Treatment of Advanced Non–Small-Cell Lung Cancer: Clinical Concepts and Commentary

Chemotherapy in recurrent or metastatic non small-cell lung cancer (NSCLC) has been shown to im-prove quality of life, and to provide a modest prolongation of survival. Docetaxel is a semisynthetic taxane that is an active agent for the treatment of NSCLC, both in previously untreated patients as well as those who have relapsed or progressed following cisplatin-based chemotherapy. After encouraging results in phase II studies, randomized trials have shown that treatment with single-agent docetaxel is superior to best supportive care for advanced NSCLC in both untreated and previously treated patients. This article will review the published data on the use of single-agent docetaxel in the treatment of advanced NSCLC.

Docetaxel in combination with carboplatin for the treatment of advanced non-small cell lung carcinoma: a multicentre phase I study

Docetaxel and carboplatin have shown in vitro and in vivo activity against non-small cell lung cancer (NSCLC). A phase I study was conducted in order to determine the dose-limiting toxicities (DLTs) and the maximum tolerated doses (MTDs) of their combination. Chemotherapy-naïve patients with stage IIIB and IV NSCLC, age<75 years old, performance status (WHO) 0-2, with adequate bone marrow, renal, liver and cardiac function, were treated with docetaxel and carboplatin. Docetaxel was given at escalated doses starting from 70 mg/m(2) with increments of 10 mg/m(2) followed by carboplatin also administered at escalated doses starting from AUC 5 to 7 AUC (mg/ml. min); the regimen was administered every 3 weeks. No colony-stimulating factor or intrapatient escalation was allowed. The toxicity of the regimen was assessed during the first chemotherapy cycle. 35 enrolled patients received a total of 114 chemotherapy cycles (median 3 cycles/patient; range: 1-8). All patients were assessable for toxicity. Neutropenia was the main dose-limiting toxicity of the regimen; overall, grade 3/4 neutropenia occurred in 16 (14%) cycles; six (5%) neutropenic episodes were complicated with fever but there was no septic death. Grade 3/4 thrombocytopenia was uncommon (two cycles; 2%). Grade 3/4 diarrhoea occurred in 5 (14%) patients whilst neurotoxicity, fatigue and mucositis were extremely uncommon. Two MTDs were defined: the MTD(1) was docetaxel 80 mg/m(2) and carboplatin AUC 7 mg/ml x min whilst MTD(2) was docetaxel 100 mg/m(2) and carboplatin AUC 6 mg/ml x min. The combination of docetaxel and carboplatin is a feasible and well-tolerated outpatient regimen for the treatment of patients with locally advanced and metastatic NSCLC. This regimen merits further investigation in phase II trials.

Paclitaxel and docetaxel combinations in non-small cell lung cancer

Paclitaxel, the first of the taxanes, has exhibited unique and encouraging single-agent activity in the treatment of non-small cell lung cancer (NSCLC). Yet, with single-agent response rates approaching 25%, it was logical to examine the impact of paclitaxel in combination chemotherapy regimens. In trials evaluating the activity of paclitaxel in combination with one of the platinum compounds, cisplatin or carboplatin, response rates have ranged from 35 to > 50% and were significantly better than response rates observed with etoposide/cisplatin, the previous standard regimen for treatment of NSCLC. Docetaxel is a newer taxane that also has exhibited notable single-agent activity and response rates ranging from 20 to 50% when combined with cisplatin. Future research will look to refine the use of taxane combinations in NSCLC and to examine the potential of these unique and promising drugs when combined with newer agents that are active against this disease.

Advanced non-small cell lung carcinoma: the emerging role of docetaxel

The treatment of advanced non-small cell lung carcinoma (NSCLC) has improved greatly over the past decade. With the advent of new agents, in particular taxanes, gemcitabine, vinorelbine, and topoisomerase I inhibitors, response rates have improved from 15-20% to 25-35%, with commensurate improvement in median and one year survival rates to 8-10 months and 35-45%, respectively. These improvements have proven statistically significant in multiple studies [1-4]. Docetaxel, either alone or in combination with platinols, has shown particular promise; and, in some arenas, it has become a standard component of our therapeutic armamentarium. We will review the preclinical data and single agent activity of docetaxel in treatment-naive and previously treated NSCLC patients, its activity in combination with cisplatin and carboplatin, as well as other new agents, and finally focus on ongoing studies evaluating its role in locally advanced disease.

The role of new agents in advanced non-small-cell lung carcinoma

Over the past 5 to 7 years, new and promising systemic agents have entered the therapeutic armamentarium in the treatment of advanced non-small-cell lung cancer. In particular, the taxanes, irinotecan, vinorelbine, and gemcitabine, have each been shown to perturb the natural history of this disease. In combination with cisplatin, these agents have yielded improvements in response rates and in survival, compared with either cisplatin alone or with older platinum combinations, with consistent 1-year survival rates of 30% to 40% or more and response rates exceeding 25%. Other factors may also be responsible for improved survival rates, including patient selection, improved supportive care, and more extensive screening procedures, such as CT and positron emission tomography, which have resulted in stage migration. Future directions will focus on the role of nonplatinum combinations, particularly in the elderly and in patients with compromised performance status; salvage therapy in patients with intact performance status; quality of life and quality adjusted survival; and the role of new biologic agents, which alter the tumor milieu and may be readily integrated into standard cytotoxic regimens. Except for unfit or unwilling patients, there is no room for therapeutic nihilism.

Second-line treatment with gemcitabine and vinorelbine in non-small-cell lung cancer (NSCLC) cisplatin failures: a pilot study

PURPOSE

This pilot study was designed to evaluate the efficacy and toxicity of the gemcitabine/vinorelbine combination in non-small-cell lung cancer (NSCLC) patients who had failed cisplatin-based first-line chemotherapy.

PATIENTS AND METHODS

Eligible patients had refractory or resistant NSCLC, WHO performance status 0-2, adequate hematologic parameters and normal hepatic, renal and cardiac function. Gemcitabine (1200 mg/m2) was administered on days 1, 8 and 15; vinorelbine (25 mg/m2) was administered on days 1 and 8, every 4 weeks until patients experienced disease progression.

RESULTS

From September 1997 to March 1998, 16 patients were enrolled (six: stage IIIB: ten: stage IV). All 16 patients were assessable for toxicity and evaluated for response. One complete (6.25%) response and no partial responses were observed. Median survival was 25 weeks (95% CI 19-30). A median of 3.31 courses per patient was administered, and the median interval between courses was 28 days. The median delivered dose was 664.85 mg/m2 per week of gemcitabine and 10.71 mg/m2 per week of vinorelbine, corresponding to a relative dose intensity of 0.73 and 0.85, respectively. Grade 2/3 thrombocytopenia occurred in 13 (24.52%) of 53 courses administered. Neutropenia Grade 2/3 occurred in 14 courses (26.41%). There were seven (13.20%) episodes of fever related to the drug administration. Mild asthenia was observed in six (37.5%) patients. Other toxicities were mild to moderate.

CONCLUSION

These results suggest that this gemcitabine/vinorelbine combination is not an active salvage regimen in patients with refractory NSCLC. The combination merits further evaluation with modified regimens.

Docetaxel (Taxotere) in the neo-adjuvant setting in non-small-cell lung cancer

BACKGROUND

There is a potential for neo-adjuvant chemotherapy to provide significant benefit in outcome for patients with locally advanced non-small-cell lung cancer (NSCLC). Patients with N2/T3 NSCLC have a poor prognosis when treated by surgery alone since micrometastases result in relapse in the majority of cases. The same is true of patients with N3/T4 disease treated only with radiotherapy. Systemic therapy is therefore required, and cisplatin-based induction chemotherapy prior to surgery or radiotherapy has been shown to improve survival when compared with surgery or radiotherapy alone. Docetaxel has been shown to have significant activity in stage IV NSCLC and ongoing phase III trials are comparing single agent docetaxel or doceatxel in combination with cisplatin or VP16 before local treatment to local treatment alone.

DESIGN

Patients with locally-advanced (stage IIIa or IIIb) NSCLC receive three cycles of docetaxel (100 mg/m2) followed by appropriate local therapy, or local therapy alone. Local therapy for stage IIIa patients is surgery (with or without radiotherapy depending on completeness of resection) and for stage IIIb patients curative intent radiotherapy. In another on-going study in stage IIIa NSCLC, docetaxel (75 mg/m2) is given in combination with cisplatin (40 mg/m2) followed by surgery. Patients must have histologically or cytologically confirmed NSCLC, have received no prior treatment for the disease and are suitable to undergo surgery or radical radiotherapy, as appropriate.

RESULTS

Initial results from the phase III comparative study show that single agent docetaxel in the neo-adjuvant setting is effective and associated with acceptable toxicity. Two hundred of the planned two hundred ninety-two patients have been accrued to the single-agent docetaxel neo-adjuvant study. In the first 49 evaluable patients in the docetaxel arm, 1 CR and 18 PR have been achieved (response rate 39%) and no patients receiving docetaxel neo-adjuvant therapy have progressed. All patients were able to receive the full doses of docetaxel.

CONCLUSION

The details of time-to-progression and survival in this study will eventually confirm the results from recent small trials of neo-adjuvant chemotherapy in locally-advanced NSCLC.

Docetaxel (Taxotere) in combination chemotherapy and in association with thoracic radiotherapy for the treatment of non-small-cell lung cancer. Thoracic Oncology Program

Docetaxel is one of the most active single agents for the treatment of non-small-cell lung cancer. Given the preclinical indications for synergy and the lack of cross-resistance with other active agents in this disease, clinical trials of docetaxel combinations have been undertaken. Phase I and II clinical trials of docetaxel in combination with cisplatin, carboplatin, gemcitabine, vinorelbine, or thoracic radiation for patients with non-small-cell lung cancer were reviewed. The endpoint for phase I trials was to define the phase II doses for the docetaxel combinations where overall response rates, median and one year survival were the endpoints. Five phase I-II studies of docetaxel and cisplatin have reported response rates ranging from 21% to 48%. Median survival times ranged from 8 to 13 months, and one-year survivals from 32% to 58%. Combining docetaxel with vinorelbine resulted in a 37% response rate and a median survival of 9.4 months. Docetaxel in combination with gemcitabine produced a response rate of 53%. The adverse events of these combinations were manageable. Responses have also been reported in studies of docetaxel administered with carboplatin or thoracic radiation therapy. Combinations of docetaxel with platinum, vinorelbine, gemcitabine, and radiation were active in non-small-cell lung cancer with acceptable adverse effects. Phase III trials are currently in progress to further define the role of docetaxel combinations in the first-line treatment of this disease.

Combination chemotherapy with carboplatin, docetaxel, and gemcitabine in advanced non-small-cell lung cancer: a phase II study

PURPOSE

To evaluate the efficacy and toxicity of the combination of carboplatin, docetaxel, and gemcitabine in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Forty-five chemotherapy-naive patients with NSCLC were treated on an out-patient basis with carboplatin area under the curve 5 intravenous (IV) and gemcitabine 800 mg/m(2) IV on day 1 and docetaxel 75 mg/m(2) IV and gemcitabine 800 mg/m(2) IV on day 8. Granulocyte colony-stimulating factor (150 ug/m(2) subcutaneously) was given prophylactically from day 3 to day 6 and day 10 to day 16. Chemotherapy was repeated every 4 weeks. Patients were evaluated for response every two cycles of treatment.

RESULTS

The median age of the patients was 58 years (range, 24 to 75 years). The performance status was 0 for 16 patients, 1 for 17 patients, and 2 for 12 patients. Nine patients (20%) had stage IIIB disease, and 36 (80%) had stage IV; histology was mainly squamous cell carcinoma (51.2% of patients) that was poorly differentiated (37.8%). All 45 patients were assessable for toxicity, and 41 were assessable for response. On an intent-to-treat analysis, the objective response rate was 46. 5% (21 out of 45 patients; 95% confidence interval [CI], 31.7% to 62. 5%). Of the 45 patients, four (8.8%) achieved a complete response (95% CI, 2.5% to 21.2%); 17 (37.7%) achieved a partial response (95% CI, 23.8% to 53.5%); seven (15.5%) had stable disease; and 14 (31. 1%) had progressive disease. The median survival time was 13.5 months, and the actuarial 1-year survival rate was 51.11%. The median duration of response was 7.6 months, and the time to tumor progression was 8.1 months. Grade 3/4 anemia and thrombocytopenia occurred in 17.7% and 28.8% of patients, respectively. Twenty-one patients (46.6%) developed grade 3/4 neutropenia, and six patients (13.3%) were complicated with fever. Alopecia was universal. Grade 3 diarrhea occurred in four patients (8.8%); grade 3/4 neurotoxicity occurred in 10 patients (22.2%); and grade 2/3 allergic reaction occurred in three patients (16.6%). There were no treatment-related deaths. Six patients (13.3%) required a dose reduction, two of which required two reductions.

CONCLUSIONS

The combination of carboplatin, docetaxel, and gemcitabine is an effective regimen for the treatment of chemotherapy-naive patients with advanced NSCLC, causing only moderate toxicity.

Phase I study of cisplatin and docetaxel plus mitomycin C in patients with metastatic non-small cell lung cancer

BACKGROUND

Docetaxel, cisplatin and mitomycin C are some of the active drugs used in the treatment of patients with metastatic non-small cell lung cancer (NSCLC). The purpose of this study was to determine the maximum tolerated dose (MTD) and recommended dose of the three drugs in combination for such patients.

METHODS

Chemotherapy-native patients with metastatic NSCLC were enrolled in this study. The doses of docetaxel and cisplatin were fixed at 60 and 80 mg/m2, respectively. It was planned to increase the dose of mitomycin C from 4 to 6 and 8 mg/m2. All drugs were administered on day 1 and repeated every 3-4 weeks.

RESULTS

All six patients received 60 mg/m2 of docetaxel and 80 mg/m2 of cisplatin, three of them with 4 mg/m2 of mitomycin C (level 1) and the other three with 6 mg/m2 of mitomycin C (level 2). Two of the three level 2 patients experienced dose-limiting toxicities (DLTs) in first cycle: febrile neutropenia and grade 3 hyponatremia. Based on these data, the MTD was concluded to be 60 mg/m2 for docetaxel, 80 mg/m2 for cisplatin and 6 mg/m2 for mitomycin C. Evaluation of the data from all of the cycles, however, showed that four of the six patients experienced DLTs.

CONCLUSIONS

The addition of mitomycin C to docetaxel and cisplatin resulted in relatively high toxicities. It was impossible to use a high enough dose of mitomycin C to improve the survival of NSCLC patients. We therefore concluded that further evaluation of this combination is unwarranted.

Docetaxel in combination with epirubicin in metastatic breast cancer: pharmacokinetic interactions

Epirubicin (75 mg/m2) and docetaxel (75 mg/m2) were administered to 16 patients affected by metastatic breast cancer following two different schedules: (1) docetaxel as infusion administered 1 h after epirubicin administration (schedule A); and (2) docetaxel as infusion immediately (10 min) after the end of epirubicin i.v. bolus administration (schedule B). Experimental non-compartmental analyses such as AUC and Css, were affected very little by the drug combination, irrespective of whether the administration of docetaxel was immediately after the epirubicin bolus (10 min) or delayed (1 h). However, serum levels showed evidence of transient drug interaction: in schedule A, docetaxel infusion was associated with a transient increase of plasma epirubicin in correspondence with Cssmax of docetaxel. Bi-compartmental analysis showed a significant difference in epirubicin clearance between protocols A and B. It is suggested that polysorbate 80, used in minimal amounts to formulate docetaxel, may interfere with epirubicin plasma level.

Chemotherapy-induced anemia in adults: incidence and treatment

Anemia is a common complication of myelosuppressive chemotherapy that results in a decreased functional capacity and quality of life (QOL) for cancer patients. Severe anemia is treated with red blood cell transfusions, but mild-to-moderate anemia in patients receiving chemotherapy has traditionally been managed conservatively on the basis of the perception that it was clinically unimportant. This practice has been reflected in the relative inattention to standardized and complete reporting of all degrees of chemotherapy-induced anemia. We undertook a comprehensive review of published chemotherapy trials of the most common single agents and combination chemotherapy regimens, including the new generation of chemotherapeutic agents, used in the treatment of the major nonmyeloid malignancies in adults to characterize and to document the incidence and severity of chemotherapy-induced anemia. Despite identified limitations in the grading and reporting of treatment-related anemia, the results confirm a relatively high incidence of mild-to-moderate anemia. Recent advances in assessing the relationships of anemia, fatigue, and QOL in cancer patients are providing new insights into these closely related factors. Clinical data are emerging that suggest that mild-to-moderate chemotherapy-induced anemia results in a perceptible reduction in a patient's energy level and QOL. Future research may lead to new classifications of chemotherapy-induced anemia that can guide therapeutic interventions on the basis of outcomes and hemoglobin levels. Perceptions by oncologists and patients that lesser degrees of anemia must be endured without treatment may be overcome as greater emphasis is placed on the QOL of the oncology patient and as research provides further insights into the relationships between hemoglobin levels, patient well-being, and symptoms.

Concurrent conventionally factionated radiotherapy and weekly docetaxel in the treatment of stage IIIb non-small-cell lung carcinoma

Docetaxel has shown remarkable radiosensitizing in vitro properties. In a previous phase I/II dose escalation study in non-small-cell lung cancer (NSCLC) we observed a high response rate after concomitant boost radiotherapy and weekly docetaxel. The maximum tolerated dose was 30 mg m(-2) week(-1). In the present phase II study we evaluated whether weekly docetaxel and conventionally fractionated radiotherapy could be better tolerated and equally effective in the treatment of locally advanced NSCLC. Thirty-five patients with T3, T4/N2, T3/M0-staged disease were recruited. Docetaxel (30 mg m(-2)) was given as a 30 min infusion once a week. Asthenia and radiation-induced oesophagitis were the main side-effects of the regimen enforcing 2-week treatment delay in 6/35 (17%) patients and minor delay (3-7 days) in another 11/35 (31%) patients. Neutrophil, platelet and haemoglobin toxicity was minimal, but pronounced lymphocytopenia was observed. Complete response (CR) of the chest disease was observed in 12/35 (34%) patients and partial response in 16/35 (46%). Although not statistically significant (P=0.19), a higher CR rate (8/18; 44%) was observed in patients who accomplished their therapy within the scheduled treatment time (44-47 days) as compared to patients that interrupted their treatment for several days due to treatment-related toxicity (CR 4/17; 23%). The overall survival and the local progression-free survival at 1 year was 48% and 60% respectively. We conclude that docetaxel combination with radiotherapy is a promising approach for the management of locally advanced NSCLC that results in high CR rate. Further trials with docetaxel-based radiochemotherapy should integrate accelerated radiotherapy together with cytoprotection.

Phase II trial of docetaxel with dexamethasone premedication in patients with advanced non-small cell lung cancer: the Canadian experience

We performed a Phase II trial to evaluate the activity and tolerability of docetaxel as a single agent in the treatment of advanced non-small cell lung cancer (NSCLC). Forty-four patients with metastatic and/or locally advanced NSCLC received i.v. docetaxel 100 mg/m2 every 3 weeks for a median of 4 (range 1-11) cycles. All patients received premedication with oral dexamethasone 8 mg twice daily for 5 days starting the day before chemotherapy. Seven partial responses were observed among 35 evaluable patients, and the overall response rate was 20% (95% CI 8-37). The median response duration was 5 months, median survival time was 10 months and the estimated 1-year survival rate was 42%. Treatment was generally well tolerated. Febrile neutropenia occurred in 10 patients (23%); neutropenic infection occurred in 4 patients, and led to 2 toxic deaths (both patients had borderline exclusion criteria). The corticosteroid premedication effectively reduced the overall incidence (34%) and severity (4% severe) of fluid retention, and delayed the median time to onset from cycle 4 to cycle 7. This study shows the promising efficacy of docetaxel as monotherapy in advanced NSCLC, and combination chemotherapy regimens incorporating docetaxel are now being evaluated in this clinical setting.

Cost-effectivenes of paclitaxel plus cisplatin in advanced non-small-cell lung cancer

The aim of this study was to assess the cost-effectiveness of combination chemotherapy with paclitaxel/cisplatin, compared with standard etoposide/cisplatin in patients with advanced non-small cell lung cancer (NSCLC). We obtained the primary survival and resource utilization data from a large three-arm randomized trial comparing: paclitaxel 135 mg m(-2) by 24-h intravenous (i.v.) infusion + cisplatin; paclitaxel 250 mg m(-2) by 24-h i.v. infusion + cisplatin + granulocyte colony-stimulating factor (G-CSF); and standard etoposide/cisplatin in patients with stage IIIb or IV NSCLC. We also modelled the regimens with paclitaxel 135 mg m(-2) + cisplatin administered as an outpatient by 3-h infusion, as clinical data suggest that this is equivalent to 24-h infusion. We collected costing data from the Ottawa Regional Cancer Centre and applied it to the resources consumed in the randomized trial. We integrated these data into the Statistics Canada POpulation HEalth Model (POHEM), which generated hypothetical cohorts of patients treated with each regimen. The POHEM model assigned diagnostic work-up, treatment, disease progression and survival characteristics to each individual in these cohorts and tabulated the costs associated with each. We did sensitivity analyses around the costs of chemotherapy and its administration, and the survival differences between the two regimens. All costs are in 1997 Canadian dollars ($1.00 Canadian approximately Pound 0.39 sterling). The perspective is that of the Canadian health care system. In the trial, the two paclitaxel-containing arms had almost identical survival curves with a median survival of 9.7 months compared with 7.4 months for etoposide/cisplatin. As administered in the trial, paclitaxel/cisplatin cost $76,370 per life-year gained (LYG) and paclitaxel/cisplatin/G-CSF $138,578 per LYG relative to etoposide/cisplatin. However, when modelled as an outpatient 3-h infusion, paclitaxel/cisplatin was moderately cost-effective at $30,619 per LYG. When compared with historical controls treated with best supportive care, this regimen of paclitaxel/cisplatin cost $4539 per LYG. Assuming a 3-h paclitaxel infusion yields the same survival advantage as the 24-h infusion did in the randomized trial, paclitaxel/cisplatin is a cost-effective improvement over standard etoposide/cisplatin for patients with advanced non-small cell lung cancer.

Front-line treatment of advanced non-small-cell lung cancer with docetaxel and gemcitabine: a multicenter phase II trial

PURPOSE

To evaluate the tolerance and efficacy of the combination of docetaxel and gemcitabine in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Fifty-one chemotherapy-naive patients with NSCLC were treated with gemcitabine 900 mg/m2 intravenously on days 1 and 8 and docetaxel 100 mg/m2 intravenously on day 8 with granulocyte colony-stimulating factor (150 microg/m2, subcutaneously) support from day 9 to day 15. Treatment was repeated every 3 weeks.

RESULTS

The patients' median age was 64 years. The World Health Organization performance status was 0 to 1 in 39 patients and 2 in 12 patients. Fifteen patients (29%) had stage IIIB disease, and 36 (71%) had stage IV; histology was mainly squamous cell carcinoma (59%). A partial response was achieved in 19 patients (37.5%; 95% confidence interval, 24% to 50%); stable disease and progressive disease were each observed in 16 patients (31.4%). The median duration of response and the time to tumor progression were 5 and 6 months, respectively. The median survival was 13 months, and the actuarial 1-year survival was 50.7%. Grade 4 anemia and thrombocytopenia were rare (2%). Four patients (8%) developed grade 3 or 4 neutropenia, and all were complicated with fever; there was no treatment-related death. Grade 3 or 4 diarrhea occurred in three patients (6%), grade 2 or 3 neurotoxicity in four patients (8%), grade 2 or 3 asthenia in 10 patients (20%), and grade 2 or 3 edema in 10 patients (20%).

CONCLUSION

The combination of docetaxel/gemcitabine is well tolerated, can be used for outpatients, and is active for the treatment of advanced NSCLC. This treatment merits further comparison with other cisplatin- or carboplatin-based combinations.

Response rate as an endpoint for evaluating new cytotoxic agents in phase II trials of non-small-cell lung cancer

BACKGROUND

Response rate (RR) has been used as a defining endpoint of new-agent phase II trials for non-small-cell lung cancer (NSCLC). However, tumor responses to chemotherapy do not always result in prolonged survival of patients with this disease.

DESIGN

Single-agent phase II trials were identified by a MEDLINE search of the period from 1976 to 1995. Associations between RR, median survival time (MST) and characteristics of patients who entered the trial, including tumor extent, performance status and prior chemotherapy, were studied by using the logistic regression model.

RESULTS

A total of 183 treatment arms in 176 trials (including 10 randomized phase II trials) were identified. The overall RR in the 6768 evaluable patients was 11%. Eleven drugs, cisplatin, epirubicin, ifosfamide, edatrexate, irinotecan, vinorelbine, docetaxel, paclitaxel, etoposide, vindesine, and 254-S, produced a RR of more than 20%. An MST of eight months or longer was obtained with 12 drugs, but there were cases in which no objective responses were produced by these drugs. MST was correlated with RR (r = 0.504, P < 0.0001), but ranged broadly at a given level of RR. Multiple linear regression analysis showed a significant correlation between RR and MST (regression coefficient = 0.60, P = 0.00003) after adjustment for other variables.

CONCLUSIONS

RR was significantly correlated with MST in single-agent phase II trials for NSCLC, but there is room for further consideration of the endpoint of these trials.

[Docetaxel (taxotere): current status of clinical development in non-small-cell bronchial carcinoma (NSCLC)]

BACKGROUND

Docetaxel (Taxotere) as a "stabilizing antitubulin" has in the last few years gained the reputation of being one of the most effective cytotoxic drugs in the therapy of NSCLC. Up until now it has primarily been used in clinical studies for both single agent- and combination chemotherapy being tested in a variety of different treatment regimens not only for advanced disease but also for early stage NSCLC.

RESULTS OF STUDIES

Clinical investigations of Docetaxel in NSCLC continue and currently focus upon randomized studies, new combination chemotherapy regimens, its simultaneous use in combination with radiotherapy as well as trials within multi-modality treatment concepts. The preliminary results of these studies underline the importance of Docetaxel for NSCLC and confirm the positive results stemming from previous single agent- and combination therapy investigations.

Combination chemotherapy with docetaxel, vinorelbine and cisplatin as first-line treatment of advanced non-small-cell lung cancer: a multicenter phase II study of the Greek Cooperative Group for Lung Cancer

Vinorelbine, docetaxel and cisplatin have documented single-agent activity in non-small-cell lung cancer (NSCLC); a multicenter phase II trial was initiated in order to evaluate the tolerance and efficacy of their combination. A total of 24 chemotherapy-naive patients with measurable stage IIIB or IV NSCLC and performance status (PS; WHO) 0-2 entered the study. Vinorelbine (20 mg/m2 i.v.) was given on days 1 and 15, cisplatin (60 mg/m2) on day 1, and docetaxel (100 mg/m2) on day 16, in cycles of 28 days. Recombinant human granulocyte colony-stimulating factor (150 microg/m2 s.c.) was administered prophylactically from day 17 to day 27. One pathological complete (4%) and six partial responses (25%) were documented (overall response 29%; 95% CI 11.6-49.2%). A total of five patients (21%) had stable and 12 (50%) progressive disease. The median duration of response was 28 weeks and the median time to tumor progression 36 weeks; the median survival was 20 weeks. Grade 3-4 neutropenia occurred in 16 patients (67%) while 13 of them (54%) developed febrile neutropenia. Grade 4 mucositis occurred in two patients (8%) and one of them also presented grade 4 diarrhea. There were four treatment-related deaths: two from sepsis, one from massive hemoptysis due to a pulmonary abscess and one from acute myocardial ischemia 7 days post-chemotherapy. In conclusion, the high incidence of neutropenic episodes and treatment-related deaths led to an early discontinuation of patient enrollment. This combination, in the schedule and the doses used, could not be recommended for off protocol treatment of patients with advanced NSCLC.

Perceptions of prognosis, treatment, and treatment impact on prognosis in non-small cell lung cancer

STUDY OBJECTIVES

We designed and performed a survey to assess the roles and knowledge level of physicians, by specialty, in the management of non-small cell lung cancer (NSCLC). The primary objective was to evaluate the potential variability of physician perceptions of prognosis, recommended treatments, and the impact of treatment on prognosis for each stage of NSCLC.

DESIGN

A random national sample of physicians from one of five specialties (primary care, pulmonary medicine, medical oncology, radiation oncology, or thoracic surgery) were invited to complete a 15-min questionnaire. Five case scenarios were presented, each representing a different stage of NSCLC. Participants were asked to state the expected prognosis, recommended treatment, and expected impact of the recommended treatment on prognosis for each scenario.

MEASUREMENTS AND RESULTS

Of the 442 physicians contacted, 350 completed the survey (86% response rate). In general, physicians agreed that the primary treatment of patients with stage I disease should be surgery. For all other stages of disease, however, there was a wide range of opinion regarding the treatment of choice and expected impact of treatment on prognosis. In particular, a significant proportion of physicians recommended only supportive care for patients with stage IV disease, despite demonstrated benefits of chemotherapy.

CONCLUSIONS

Physicians from differing specialties have varied opinions on the management of NSCLC, particularly stages II to IV. Education regarding state-of-the-art therapy should be directed not only at traditional audiences (ie, medical oncologists) but also the major physician specialties involved in the care of NSCLC patients. Wider implementation of treatment advances in late-stage disease could significantly increase the numbers of patients living for a longer time.

Weekly docetaxel and concomitant boost radiotherapy for non-small cell lung cancer. A phase I/II dose escalation trial

In this phase I/II study, we investigated the radiosensitising effects of docetaxel in non-small cell lung cancer (NSCLC). 30 patients with stage IIIb (18 patients) and IV (12 patients) NSCLC were treated with 64 Gy of accelerated chest radiotherapy (5-week schedule using a concomitant boost technique) and docetaxel on a weekly basis. The docetaxel starting dose level was 20 mg/m2/week and was escalated by 10 mg/m2 increments in cohorts of 10 patients. Dose-limiting toxicity (grade 3 asthenia) was observed in 6 of 10 patients treated at the 40 mg/m2/week dose level, enforcing a 50% dose reduction in 4 patients. Grade 3 neutropenia was observed in 5 of 30 patients (17%), 3 of which were treated at the high dose level. Peripheral neuropathy occurred in 3 (10%) patients. A significant decrease in the absolute lymphocyte count was observed in all patients; the nadir was reached on day 28 (mean +/- standard deviation (S.D.) = 539 +/- 363/ml) compared with pretreatment values (mean +/- S.D. = 1842 +/- 863/ml; P = 0.002). 6 out of 30 patients (20%) experienced grade 3 oesophagitis, resulting in a 1-2 week delay in overall treatment time. Complete response of the primary tumour was observed in 8 (27%) patients assessed 2 months after treatment. 4 of these patients had disease resistant to previous docetaxel-containing chemotherapy. A partial response occurred in 15 of 30 patients (50%) for an overall response rate of 77% (95% confidence interval (CI) 60-92%). Radiosensitisation with docetaxel is feasible and the recommended dose for further phase II studies is 30 mg/m2/week. Further phase II studies are required to confirm the remarkably high response rate observed in the present trial.

First-line treatment of advanced non-small-cell lung cancer with docetaxel and cisplatin: a multicenter phase II study

PURPOSE

To evaluate the efficacy and safety of the docetaxel-cisplatin combination in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemotherapy-naïve patients with histologically confirmed, measurable stage IIIB or IV NSCLC, a World Health Organization (WHO) performance status of 0-2 and adequate bone marrow, renal, hepatic and cardiac function were eligible for the study. Patients received docetaxel (100 mg/m2) as an one-hour infusion on day 1 and cisplatin (80 mg/m2) as a 30-min infusion with appropriate hydration on day 2. Granulocyte colony-stimulating factor (G-CSF; 150 micrograms/m2, SC) was given on days 3 to 13. Treatment was repeated every three weeks.

RESULTS

Fifty-three patients were enrolled (28 with stage IIIB and 25 with stage IV). One complete and 23 partial responses were observed (overall response rate (OR): 45%; 95% CI: 34.1%-61.8%). The response rate was 57% and 32% in patients with stages IIIB and IV disease (P = NS). The median time to progression was 36 weeks and the median survival 48 weeks; the one-year survival was 48%. Grade 3-4 neutropenia occurred in 23 patients, 15 of whom were hospitalized for neutropenic fever; two patients died of sepsis. Grade 2 neurotoxicity was observed in six patients and grade 3 in five patients; grade 3 fatigue occurred in seven patients, grade 3-4 mucositis in four patients and grade 3-4 diarrhea in six patients. Mild allergic reactions and oedema were observed in five and four patients, respectively. The median dose intensity was 30 mg/m2/week for docetaxel and 24 mg/m2/week for cisplatin, corresponding to 91% and 89% of the specified protocol doses, respectively.

CONCLUSIONS

The docetaxel-cisplatin combination is an active regimen in advanced NSCLC, but hematologic toxicity remains high despite the prophylactic use of G-CSF.

Treatment of advanced (stages III and IV) non-small-cell lung cancer

Lung cancer is the leading cause of cancer deaths, and approximately 85% of patients in whom this neoplasm is diagnosed will die of this disease as a result of micrometastatic disease from tumors that appeared surgically resectable or of surgically unresectable disease that is either locally advanced or metastatic. It will affect approximately 171,000 people in the United States in 1998 and about 75% of these cases will be non-small-cell lung cancer (NSCLC). In only 25% of cases can complete surgical resection and cure be considered. Despite this grim outlook, advances have recently been made that beckon in an era of cautious optimism. In this review, a discussion of the latest developments in the management of locally advanced and metastatic NSCLC will be presented in detail. One of the significant developments has been the modifications to the staging system after the natural history of various stages was better characterized by reviewing the outcome of more than 5000 patients. Advances have also been seen in the diagnostic field. Specifically, positron emission tomography and endoscopic ultrasonography and biopsy are being evaluated to determine their role in diagnosing and staging lung cancer. At the present, however, history and physical examination, serum evaluation, computed tomography, and conventional approaches for obtaining a histologic diagnosis are standard practice. The role of adjuvant therapy, both postoperatively and in the neoadjuvant setting, has been studied. There are no data to support the use of radiotherapy or chemotherapy, with or without radiotherapy, in the postoperative setting. In the neoadjuvant setting, some intriguing results in favor of adjuvant chemotherapy have been observed. As discussed in detail these results provide preliminary data and need to be evaluated on a larger scale. Before the 1990s radiotherapy was the principal treatment modality used in the treatment of patients with locally advanced NSCLC. However, the results of several studies have shown the superiority of chemotherapy and radiotherapy in combination for patients with unresectable stage III NSCLC. Many questions regarding the optimal modes of chemotherapy and radiotherapy and the timing of these two modalities have yet to be answered. Concurrent with these advances has been the development of new chemotherapeutic agents that have been extensively evaluated in phase I and II trials. These agents include gemcitabine, paclitaxel, docetaxel, vinorelbine, and irinotecan. These agents have shown significant activity and acceptable toxicity when used in combination with cisplatin or carboplatin, but the results from the large cooperative trials that are ongoing are eagerly awaited to help define the optimal regimen. Further studies are either planned or ongoing to further define the role of these newer agents in the treatment of metastatic disease, in combination with radiotherapy for unresectable disease, and in the surgical adjuvant setting.

New chemotherapeutic agents for the treatment of non-small cell lung cancer: the Japanese experience

Non-small cell lung cancer (NSCLC) is refractory to systemic chemotherapy, compared with small cell lung cancer. Until recently, only five drugs--cisplatin, vindesine, mitomycin, ifosfamide, and vinblastine--could produce overall response rates of 15% against NSCLC. However, recent efforts have contributed to the development of new drugs with activity against NSCLC, including irinotecan hydrochloride (CPT-11), paclitaxel, docetaxel, vinorelbine, and gemcitabine. Combination chemotherapy against NSCLC using these agents has demonstrated high response rates. In Japan, various combination chemotherapy and combined-modality regimens employing CPT-11 have been evaluated for their efficacy. Randomized controlled trials to establish new state-of-the-art treatments for NSCLC are ongoing.

[Docetaxel (taxotere) in non-small-cell bronchial carcinoma]

BACKGROUND

Various new drugs with different mechanisms of action are presently under investigation for the field of solid tumors. The taxanes, Taxotere and Taxol, are among those drugs possessing a unique mechanism of action but showing pharmacological differences.

CONCLUSION

The results of several phase I and II studies of Taxotere in monotherapy as well as in combination schedules with chemotherapy and Radiotherapy show Taxotere to be active in non small cell lung cancer and build the basis for further evaluation in clinical trials.

Management Issues for Stage IV Non-Small Cell Lung Cancer

BACKGROUND:The management of stage IV non-small-cell lung cancer (NSCLC) has been a controversial subject over the past several decades. Data from randomized trials and from phase II trials on new cancer agents are changing physician attitudes and treatment practices. METHODS: The literature on the management of metastatic lung cancer was reviewed and interpreted. RESULTS: There is good evidence from randomized controlled trials and meta-analyses that chemotherapy provides a modest survival benefit in stage IV NSCLC. There is indirect evidence of improvement in quality of life, as systemic chemotherapy palliates cancer-related symptoms in the majority of patients. New drug combinations are likely to improve recent treatment results with less morbidity than older chemotherapy regimens. Despite the relatively high cost of these treatments, chemotherapy is cost effective in the Canadian health care environment relative to other accepted medical interventions. CONCLUSIONS: Chemotherapy will play an increasing role in the management of patients with advanced NSCLC.

New Agents in the Management of Non-Small Cell Lung Cancer

BACKGROUND: Non-small-cell carcinoma of the lung has long been considered a chemotherapeutically resistant neoplasm. Newer agents and combinations are being tested. METHODS: The authors have reviewed data on recent and active phase I and phase II trials of several new agents and combinations. RESULTS: New drugs that affect both response rates and survival include vinorelbine, paclitaxel, docetaxel, gemcitabine, topotecan, and irinotecan. CONCLUSIONS: The advent of several relatively well-tolerated agents that alone have beneficial effects in advanced non-small-cell lung cancer provides reasonable hope that more effective drug combinations will soon be available for this disease.

Chemotherapy for advanced non-small cell lung cancer

Lung cancer is the most lethal cancer in both men and women. Given that chemotherapy for advanced disease is marginally beneficial and noncurative, its use must be governed judiciously, with each decision being evaluated individually for each patient. Chemotherapy for lung cancer has progressed over the past decade, and with the advent of new agents, its future looks promising.

Clinical characteristics of severe peripheral neuropathy induced by docetaxel (Taxotere)

BACKGROUND

Docetaxel, a semi-synthetic taxane may cause a usually mild sensory neuropathy. We describe the clinical characteristics of five patients who developed a more severe neuropathy following treatment with docetaxel.

PATIENTS AND METHODS

All patients were treated in phase II studies with 100 mg/m2 docetaxel in three weekly cycles, without steroid administration.

RESULTS

The clinical picture in these patients was dominated by a sensory neuropathy, but in one case severe weakness was present. Another patient developed Lhermitte's sign. Signs and symptoms are usually reversible after discontinuation of docetaxel administration, but in three patients symptoms worsened for some time after the end of treatment before improvement occurred.

CONCLUSION

Severe docetaxel neuropathy may especially occur following treatment with cumulative dosage over 600 mg/m2; in patients treated with this dosage a moderate or severe neuropathy may not be rare.

Non-small cell lung cancer: an overview of current management

Non-small cell lung cancer (NSCLC) will remain a worldwide health problem for the foreseeable future. Unfortunately, local treatment of this disease is disappointing as most patients develop uncontrollable locally advanced or distant metastatic disease. The recent meta-analysis using updated patient data has suggested a potential role for adjuvant cisplatin-based chemotherapy (CT) in early stage disease, and has shown a significant, albeit modest, improvement in survival when combined with radiotherapy in locally advanced disease and as a single modality in metastatic disease. Although quality and cost of extra life with this more aggressive treatment need to be defined in prospective studies, CT should be considered standard treatment for patients with locally advanced and metastatic NSCLC able to receive cisplatin-based CT. Its role in stage I and II disease is under current investigation. Ongoing clinical studies with more active agents, novel combined modality treatment strategies and laboratory discoveries continue to emerge which may lead to valuable new treatment options to extend this survival advantage.

Peripheral neuropathy induced by combination chemotherapy of docetaxel and cisplatin

Docetaxel, a new semisynthetic taxoid that has demonstrated promising activity as an antineoplastic agent, was administered in combination with cisplatin to 63 patients in a dose-escalating study. As both drugs were known to be potentially neurotoxic, peripheral neurotoxicity was prospectively assessed in detail. Neuropathy was evaluated by clinical sum-score for signs and symptoms and by measurement of the vibration perception threshold (VPT). The severity of neuropathy was graded according to the National Cancer Institute's 'Common Toxicity Criteria'. The docetaxel-cisplatin combination chemotherapy induced a predominantly sensory neuropathy in 29 (53%) out of 55 evaluable patients. At cumulative doses of both cisplatin and docetaxel above 200 mg m(-2), 26 (74%) out of 35 patients developed a neuropathy which was mild in 15, moderate in ten and severe in one patient. Significant correlations were present between both the cumulative dose of docetaxel and cisplatin and the post-treatment sum-score of neuropathy (P < 0.01) as well as the post-treatment VPT (P < 0.01). The neurotoxic effects of this combination were more severe than either cisplatin or docetaxel as single agent at similar doses.

The development and clinical utility of the taxane class of antimicrotubule chemotherapy agents

The taxane class of antimicrotubule anticancer agents is perhaps the most important addition to the chemotherapeutic armamentarium against cancer over the past several decades. After only a brief period, the taxanes have not only demonstrated a unique ability to palliate the symptoms of many types of advanced cancers, including carcinoma of the ovary, lung, head and neck, bladder, and esophagus, they have also demonstrated effectiveness in the initial therapy of earlier stages of cancer, a setting in which any new therapy is likely to make its greatest impact. The challenge now facing investigators is to develop strategies to maximize therapeutic benefits with the taxanes in the early stages, as well as the advanced stages, of many cancers. This review describes the preclinical features and clinical results of the two major taxanes, paclitaxel (Taxol, Bristol-Myers Squibb) and docetaxel (Taxotere, Rhone-Poulenc Rhorer).

Non-small cell lung cancer: an overview of diagnosis, staging, and treatment

OBJECTIVES

To review the current status, recent advances and ongoing research efforts related to screening, diagnosis and staging, and treatment of non-small cell lung cancer (NSCLC).

DATA SOURCES

Research studies, review articles, and abstracts relating to NSCLC.

CONCLUSIONS

Surgery is curative in a small number of patients. Radiation therapy can often control local disease and palliate symptoms; however, it does not impact overall survival. Current chemotherapy regimens have demonstrated ability to prolong survival when compared to "best supportive care"; however, survival benefit is limited to a period of a few weeks or months.

IMPLICATIONS FOR NURSING PRACTICE

An understanding of treatment modalities and new therapies for NSCLC will help nurses assist patients to make educated decisions about the potential risks and benefits of their therapeutic options.

Phase II study of vinorelbine/ifosfamide/cisplatin for the treatment of advanced non-small-cell lung cancer

PURPOSE

To evaluate the combination of vinorelbine, ifosfamide and cisplatin (VIP) in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Seventy-six untreated patients with stages IIIB-IV NSCLC; the chemotherapy regimen consisted of vinorelbine (25 mg/sqm on days 1 and 8), ifosfamide (3 g/sqm on day 1 with uroprotective mesna), and cisplatin (80 mg/sqm on day 1). The cycles were administered on an outpatient basis every 3 weeks.

RESULTS

Leukopenia was the most frequent toxicity: grades 3-4 neutropenia was observed in 26% of the cycles and 19 episodes of febrile neutropenia were reported in 289 evaluable courses. Filgrastim 5 micrograms/kg was administered in 27% of the courses. Sixty-seven of 76 patients were evaluable for response: the overall response rate was 51% (95% confidence interval 35%-77%) with 2 complete responses (3%) and 32 (48%) partial responses. No significant differences in response rate were observed according to histology or stage of disease. The median time to progression was 6 months (range 1 to 29+) and the median overall survival 10 months (range 1-33+).

CONCLUSION

The combination of vinorelbine, ifosfamide and cisplatin in the dose and schedule employed in this trial shows an interesting response rate with acceptable toxicities. This regimen should be tested in the multimodality therapy of stage IIIA/B NSCLC.

Phase I trial of extracellular adenosine 5'-triphosphate in patients with advanced cancer

Adenosine 5'-triphosphate (ATP) has antineoplastic activity in vitro and in murine tumor systems, but there are no data in humans defining its potential use as an antineoplastic agent. We conducted a phase I study to determine the spectrum of toxicity, maximum safely tolerated dose (MTD), and pharmacokinetics of intravenous ATP. Fourteen men with advanced cancer received 96-hour infusions of ATP once monthly in doses ranging from 50 to 100 micrograms/kg/minute. Toxicity was assessed by standard National Cancer Institute (NCI) criteria, cardiac function was monitored serially by two-dimensional echocardiography, and whole blood ATP was measured serially in a subset of patients. ATP was generally well tolerated and no significant hematologic toxicity was noted. The dose-limiting toxicity was a cardiopulmonary reaction characterized by chest tightness and dyspnea that resolved within seconds of discontinuing ATP. Dose-limiting cardiopulmonary toxicity occurred in 3 of 3 patients at 100 micrograms/kg/minute, in 3 of 6 patients at 75 micrograms/kg/minute, and 4 of 11 patients at 50 micrograms/kg/minute. Whole blood ATP levels significantly increased with treatment, reaching a steady state by 24 hours and returning to or near baseline by 1 week after treatment. Plateau levels were 63%, 67%, and 116% above base-line at 50, 75, and 100 micrograms/kg/min, respectively. We conclude that prolonged infusions of ATP are feasible with acceptable toxicity and that 50 micrograms/kg/minute is both the MTD and the most appropriate dose rate for subsequent Phase II testing of 96-hour infusions of ATP in patients with advanced cancer.

Phase II trial of docetaxel (Taxotere) in patients with adenocarcinoma of the upper gastrointestinal tract previously untreated with cytotoxic chemotherapy: the Eastern Cooperative Oncology Group (ECOG) results of protocol E1293

The aim of this study was to evaluate the clinical efficacy and safety of docetaxel (Taxotere) in patients with adenocarcinoma of the upper gastrointestinal tract previously untreated with cytotoxic chemotherapy. Docetaxel 100 mg m-2 was administered as a 1 hour intravenous (IV) infusion every 3 weeks to 41 patients. Patients were premedicated prior to each course with dexamethasone, diphenhydramine and cimetidine. Clinical response and toxicity were determined. Objective responses were seen in seven of 41 eligible patients (two complete responses [CRs] and five partial responses [PRs], for an objective response rate of 17% (90% confidence interval [CI], 8% to 30%). The most common toxicity was grade 4 neutropenia, which occurred in 88% of patients; 46% of patients required a dose reduction following an episode of neutropenic fever requiring antibiotic therapy. Additional patients have had reversible grade 3-4 toxicities including nausea, vomiting, stomatitis, diarrhea, fatigue and peripheral neuropathy. Ten patients have had grade 1-3 hypersensitivity reactions. Alopecia has been seen in the majority of patients. Fluid retention grade 1-3 has been observed in patients. Docetaxel administered on this schedule is an active agent in adenocarcinomas of the upper gastrointestinal tract. Further investigation of this drug should be conducted in multi-drug combination programs.

Phase II trial of docetaxel (Taxotere) in patients with metastatic melanoma previously untreated with cytotoxic chemotherapy

A phase II study was undertaken to evaluate the clinical efficacy and safety of docetaxel in patients with malignant melanoma. Between April 1992 and February 1996, 37 patients with metastatic malignant melanoma and no prior chemotherapy were treated with docetaxel 100 mg m-2 administered intravenously over 1 hour every 21 days. Patients were premedicated prior to each course with dexamethasone and diphenhydramine. Toxicity and follow-up were provided. Objective responses were seen in two out of 35 patients evaluable for response, one complete response and one partial response. These two responses were of a duration of greater than two years. The most common toxicity was grade 4 neutropenia, which occurred in 92% of patients; 49% required hospitalization for an episode of neutropenic fever. Additional patients had reversible grade 3-4 toxicities including nausea, vomiting, diarrhea, stomatitis, arthralgias, myalgias, peripheral neuropathy and fatigue. Eighteen patients had hypersensitivity reactions, two were grade 3-4. Fluid retention, grade 1-3 was observed in seven patients. Alopecia occurred in most patients. Docetaxel has definite but low-level activity against malignant melanoma. Further investigation of this drug should be considered in multidrug combination programs.

Promising new agents in the treatment of non-small cell lung cancer

A number of new drugs and drug classes have recently become available for clinical testing which demonstrate significant antitumor activity in non-small cell lung cancer. The preclinical rationale, mechanism of action, toxicity profile and results of early trials of paclitaxel, docetaxel, edatrexate, CPT-11, topotecan, vinorelbine and gemcitabine in non-small cell lung cancer are reviewed.

Successful parenteral desensitization to paclitaxel

BACKGROUND

Paclitaxel, a member of a new class of antineoplastic agents called the taxanes, has been associated with anaphylactoid reactions.

OBJECTIVE

We report a case of successful parental desensitization to paclitaxel.

METHODS

Desensitization was performed with serial 10-fold dilutions (up to 1:100,000) of paclitaxel in sufficient volume to administer successive doses of 1, 2, 4, and 8 ml. Basophil histamine release tests were performed with paclitaxel alone, vehicle alone, and paclitaxel and vehicle combined to determine which agent was responsible for the anaphylactoid reactions.

RESULTS

After parental desensitization was performed, the patient was able to tolerate infusion of paclitaxel without complications or need for antihistamines or steroids. Basophil histamine release occurred only with paclitaxel and not with the vehicle.

CONCLUSIONS

Successful parenteral desensitization to paclitaxel can be achieved; it is paclitaxel, and not its vehicle, that is most likely responsible for anaphylactoid reactions in patients undergoing treatment.