Combination chemotherapy of advanced lung cancer: a randomized trial

Oncogenic mutations are associated with histological subtypes but do not have an independent prognostic value in lung adenocarcinoma

Lung adenocarcinomas have diverse genetic and morphological backgrounds and are usually classified according to their distinct oncogenic mutations (or so-called driver mutations) and histological subtypes (the de novo classification proposed by the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society [IASLC/ATS/ERS]). Although both these classifications are essential for personalized treatment, their integrated clinical effect remains unclear. Therefore, we analyzed 981 lung adenocarcinomas to detect the potential correlation and combined effect of oncogenic mutations and histological subtype on prognosis. Analysis for oncogenic mutations included the direct sequencing of EGFR, KRAS, HER2, BRAF, PIK3CA, ALK, and RET for oncogenic mutations/rearrangements, and a rereview of the IASLC/ATS/ERS classification was undertaken. Eligible tumors included 13 atypical adenomatous hyperplasia/adenocarcinoma in situ, 20 minimally invasive adenocarcinomas, 901 invasive adenocarcinomas, 44 invasive mucinous adenocarcinomas, and three other variants. The invasive mucinous adenocarcinomas had a lower prevalence of EGFR mutations but a higher prevalence of KRAS, ALK, and HER2 mutations than invasive adenocarcinomas. Smoking, a solid predominant pattern, and a mucinous component were independently associated with fewer EGFR mutations. The ALK rearrangements were more frequently observed in tumors with a minor mucinous component, while the KRAS mutations were more prevalent in smokers. In addition, 503 patients with stage I-IIIA tumors were analyzed for overall survival (OS) and relapse-free survival. The stage and histological pattern were independent predictors of relapse-free survival, and the pathological stage was the only independent predictor for the OS. Although patients with the EGFR mutations had better OS than those without the mutations, no oncogenic mutation was an independent predictor of survival. Oncogenic mutations were associated with the novel IASLC/ATS/ERS classification, which facilitates a morphology-based mutational analysis strategy. The combination of these two classifications might not increase the prognostic ability, but it provides essential information for personalized treatment.

The cyclophosphamide equivalent dose as an approach for quantifying alkylating agent exposure: a report from the Childhood Cancer Survivor Study

BACKGROUND

Estimation of the risk of adverse long-term outcomes such as second malignant neoplasms and infertility often requires reproducible quantification of exposures. The method for quantification should be easily utilized and valid across different study populations. The widely used Alkylating Agent Dose (AAD) score is derived from the drug dose distribution of the study population and thus cannot be used for comparisons across populations as each will have a unique distribution of drug doses.

METHODS

We compared the performance of the Cyclophosphamide Equivalent Dose (CED), a unit for quantifying alkylating agent exposure independent of study population, to the AAD. Comparisons included associations from three Childhood Cancer Survivor Study (CCSS) outcome analyses, receiver operator characteristic (ROC) curves and goodness of fit based on the Akaike's Information Criterion (AIC).

RESULTS

The CED and AAD performed essentially identically in analyses of risk for pregnancy among the partners of male CCSS participants, risk for adverse dental outcomes among all CCSS participants and risk for premature menopause among female CCSS participants, based on similar associations, lack of statistically significant differences between the areas under the ROC curves and similar model fit values for the AIC between models including the two measures of exposure.

CONCLUSION

The CED is easily calculated, facilitating its use for patient counseling. It is independent of the drug dose distribution of a particular patient population, a characteristic that will allow direct comparisons of outcomes among epidemiological cohorts. We recommend the use of the CED in future research assessing cumulative alkylating agent exposure.

WITHDRAWN: Second or third additional chemotherapy drug for non-small cell lung cancer in patients with advanced disease

BACKGROUND

Randomized trials have demonstrated that adding a drug to a single-agent or to a two-agent regimen increased the tumor response rate in patients with advanced non-small cell lung cancer (NSCLC), although its impact on survival remains controversial.

OBJECTIVES

To evaluate the clinical benefit of adding a drug to a single-agent or two-agent chemotherapy regimen in terms of tumor response rate, survival, and toxicity in patients with advanced NSCLC.

SEARCH METHODS

There were no language restrictions. Searches of MEDLINE and EMBASE were performed using the search terms non-small cell lung carcinoma/drug therapy, adenocarcinoma, large-cell carcinoma, squamous-cell carcinoma, lung, neoplasms, clinical trial phase III, and randomized trial. Manual searches were also performed to find conference proceedings published between January 1982 and June 2006.

SELECTION CRITERIA

Data from all randomized controlled trials performed between 1980 and 2006 (published between January 1980 and June 2006) comparing a doublet regimen with a single-agent regimen or comparing a triplet regimen with a doublet regimen in patients with advanced NSCLC.

DATA COLLECTION AND ANALYSIS

Two independent investigators reviewed the publications and extracted the data. Pooled odds ratios (ORs) for the objective tumor response rate, one-year survival rate, and toxicity rate were calculated using the fixed-effect model. Pooled median ratios (MRs) for median survival also were calculated using the fixed-effect model. ORs and MRs lower than unity (< 1.0) indicate a benefit of a doublet regimen compared with a single-agent regimen (or a triplet regimen compared with a doublet regimen).

MAIN RESULTS

Sixty-five trials (13601 patients) were eligible. In the trials comparing a doublet regimen with a single-agent regimen, a significant increase was observed in tumor response (OR 0.42, 95% confidence interval [CI] 0.37 to 0.47, P < 0.001) and one-year survival (OR 0.80, 95% CI 0.70 to 0.91, P < 0.001) in favor of the doublet regimen. The median survival ratio was 0.83 (95% CI 0.79 to 0.89, P < 0.001). An increase also was observed in the tumor response rate (OR 0.66, 95% CI 0.58 to 0.75, P < 0.001) in favor of the triplet regimen, but not for one-year survival (OR 1.01, 95% CI 0.85 to 1.21, P = 0.88). The median survival ratio was 1.00 (95% CI 0.94 to 1.06, P = 0.97).

AUTHORS' CONCLUSIONS

Adding a second drug improved tumor response and survival rate. Adding a third drug had a weaker effect on tumor response and no effect on survival.

An Evidence-Based Approach to the Use of Predictive Biomarkers in the Treatment of Non- Small Cell Lung Cancer (NSCLC)

Recent advances in the treatment of non-small cell lung cancer (NSCLC) have led to improvements in patient survival and quality of life. It is unclear whether molecular abnormalities associated with NSCLC cell survival, growth and proliferation are useful in predicting treatment benefit. We conducted a systematic review to establish which biomarkers contribute meaningfully to the management of NSCLC. A team of researchers searched PubMed and conference proceedings (ASCO, ESMO, IASLC, USCAP) using MESH terms for NSCLC and randomized trials (RCT), plus keywords for variables of interest. Evidence from multiple RCTs confirmed that histologic subtype is prognostic for survival and predictive of treatment efficacy and/or toxicity in NSCLC. Likewise, activating mutations of the epidermal growth factor receptor (EGFR) are associated with benefit from EGFR tyrosine kinase inhibitors in patients with advanced non-squamous NSCLC and should be assessed routinely. No biomarkers to date reliably predict response to anti-Vascular Endothelial Growth Factor (VEGF) therapies. There are inconsistent data on the role of ERCC1, BRCA, Beta tubulin III, RRM1, K-RAS, or TP-53 in treatment decisions. These tests should not be routinely used in selecting treatment at this time, whereas EML4/ALK translocations predict responses to specific targeted agents, the optimal assessment of this molecular abnormality has yet to be established. Personalized care of patients with NSCLC based on biomarkers is increasingly important to both clinical practice and research.

Rational, biologically based treatment of EGFR-mutant non-small-cell lung cancer

Epidermal growth factor receptor (EGFR)-mutant non-small-cell lung cancer (NSCLC) was first recognized in 2004 as a distinct, clinically relevant molecular subset of lung cancer. The disease has been the subject of intensive research at both the basic scientific and clinical levels, becoming a paradigm for how to understand and treat oncogene-driven carcinomas. Although patients with EGFR-mutant tumours have increased sensitivity to tyrosine kinase inhibitors (TKIs), primary and acquired resistance to these agents remains a major clinical problem. This Review summarizes recent developments aimed at treating and ultimately curing the disease.

Second or third additional chemotherapy drug for non-small cell lung cancer in patients with advanced disease

BACKGROUND

Randomized trials have demonstrated that adding a drug to a single-agent or to a two-agent regimen increased the tumor response rate in patients with advanced non-small cell lung cancer (NSCLC), although its impact on survival remains controversial.

OBJECTIVES

To evaluate the clinical benefit of adding a drug to a single-agent or two-agent chemotherapy regimen in terms of tumor response rate, survival, and toxicity in patients with advanced NSCLC.

SEARCH STRATEGY

There were no language restrictions. Searches of MEDLINE and EMBASE were performed using the search terms non-small cell lung carcinoma/drug therapy, adenocarcinoma, large-cell carcinoma, squamous-cell carcinoma, lung, neoplasms, clinical trial phase III, and randomized trial. Manual searches were also performed to find conference proceedings published between January 1982 and June 2006.

SELECTION CRITERIA

Data from all randomized controlled trials performed between 1980 and 2006 (published between January 1980 and June 2006) comparing a doublet regimen with a single-agent regimen or comparing a triplet regimen with a doublet regimen in patients with advanced NSCLC.

DATA COLLECTION AND ANALYSIS

Two independent investigators reviewed the publications and extracted the data. Pooled odds ratios (ORs) for the objective tumor response rate, one-year survival rate, and toxicity rate were calculated using the fixed-effect model. Pooled median ratios (MRs) for median survival also were calculated using the fixed-effect model. ORs and MRs lower than unity (< 1.0) indicate a benefit of a doublet regimen compared with a single-agent regimen (or a triplet regimen compared with a doublet regimen).

MAIN RESULTS

Sixty-five trials (13601 patients) were eligible. In the trials comparing a doublet regimen with a single-agent regimen, a significant increase was observed in tumor response (OR 0.42, 95% confidence interval [CI] 0.37 to 0.47, P < 0.001) and one-year survival (OR 0.80, 95% CI 0.70 to 0.91, P < 0.001) in favor of the doublet regimen. The median survival ratio was 0.83 (95% CI 0.79 to 0.89, P < 0.001). An increase also was observed in the tumor response rate (OR 0.66, 95% CI 0.58 to 0.75, P < 0.001) in favor of the triplet regimen, but not for one-year survival (OR 1.01, 95% CI 0.85 to 1.21, P = 0.88). The median survival ratio was 1.00 (95% CI 0.94 to 1.06, P = 0.97).

AUTHORS' CONCLUSIONS

Adding a second drug improved tumor response and survival rate. Adding a third drug had a weaker effect on tumor response and no effect on survival.

Basic treatment considerations: chemotherapy

Lung cancer represents a major global health problem, with more than a million deaths reported each year. Because there are no effective screening tools to date, diagnosis of the disease at an advanced stage is a common feature. Over the past 20 years, elegant strides have been made in the treatment of patients with advanced NSCLC. Several novel chemotherapy agents that are efficacious and possess favorable toxicity profiles have been developed recently. In addition to evaluating novel combinations, alternative schedules to improve toxicity profiles are subjects of clinical trials. Much work needs to be done, however, to improve the outcome for patients with lung cancer. Chemotherapy extends life and improves quality of life for patients with stage IIIB/IV NSCLC. Combined modality therapy with radiation and chemotherapy improves the outcome for patients with locally advanced NSCLC and is associated with a curative potential. Molecularly targeted therapies are under rigorous evaluation, although the initial results have been disappointing. In the upcoming years, we will learn effective means to incorporate molecularly targeted therapies to existing treatment paradigms in lung cancer.

Standard combination versus alternating chemotherapy in small cell lung cancer: a randomised clinical trial including 394 patients. 'Petites Cellules' Group

PURPOSE

to compare standard and alternating administration of chemotherapy combinations in small cell lung cancer (SCLC) patients.

MATERIAL AND METHODS

in a multicenter clinical trial, 394 previously untreated SCLC patients were randomised to receive, every 4 weeks, eight courses of either a standard regimen with CCNU, cyclophosphamide, adriamycin (CCA) and VP16 or an alternating regimen (CCA regimen alternating with cisplatin-vindesine-VP16).

RESULTS

overall response rate was higher in the standard group (78%) than in the alternating group (64%) (P = 0.0001). Complete response rate was also higher in the standard group (32%) than in the alternating group (18%) (P = 0.004). The median survival in the overall SCLC population was 306 days in the standard group and 272 days in the alternating group (P = 0.08). In limited SCLC patients, median survival was higher in the standard group (421 days) than in the alternating group (328 days) (P = 0.01). Grade III/IV haematological toxicity was lower in patients in the alternating group (25 versus 47%) (P < 0.001).

CONCLUSION

the standard regimen was better than the alternating regimen for patients with limited forms of SCLC. The alternating regimen, associated with better haematological safety and ensuring a fairly similar survival, may be considered in patients with extensive SCLC. Pleiomorphic resistance mechanisms to chemotherapy make it difficult to define a non-cross-resistant chemotherapy regimen.

Neurologic disorders in 203 consecutive patients with small cell lung cancer. Results of a longitudinal study

BACKGROUND

Neurologic complications of small cell lung cancer (SCLC) are manifold. The incidence and course of the various metastatic and nonmetastatic neurologic disorders were studied prospectively in a cohort of SCLC patients.

METHODS

The 203 patients underwent neurologic examinations on a regular basis, prior to therapy, during and after treatment, from 1983 through 1994. Routine computer tomography or magnetic resonance imaging of the brain was performed before therapy and after 2 years' survival. Other auxiliary diagnostic tests were performed as required.

RESULTS

The majority of the 174 neurologic disorders, diagnosed in 132 patients, were associated with metastases. A total of 79 patients developed brain metastases. The cumulative risk of brain metastases reached 47% for limited and 69% for extensive disease patients at 2 years from diagnosis. Survival following the diagnosis of brain metastases was significantly longer for patients with brain metastases at the initial diagnosis of SCLC than for patients with delayed brain metastases (P < 0.01, long rank test). The most frequent paraneoplastic syndrome with neurologic symptoms was that of inappropriate secretion of antidiuretic hormone (SIADH), which was diagnosed in 11 patients. Antibody-mediated paraneoplastic neurologic syndromes were diagnosed in five patients. Chemotherapy for SCLC caused SIADH to subside in most patients. In contrast, the antibody-mediated syndromes did not respond to SCLC therapy. Adverse effects of treatment included peripheral neuropathy, encephalopathy, radiation plexopathy, and steroid myopathy. However, unlike the other complications, peripheral neuropathy was reversible.

CONCLUSIONS

This clinical investigation confirmed the frequency of central nervous system metastatic involvement as well as the diversity of the neurologic complications in SCLC. The high frequency of brain metastases justifies a reappraisal of prophylactic cranial irradiation in this patient group.

Is there a role for vindesine in the treatment of non-small cell lung cancer?

Vindesine is a semisynthetic derivative of vinblastine which has been evaluated in clinical studies since the late 1970's. The literature on vindesine in the treatment of non-small cell lung cancer has been reviewed and all aspects of vindesine treatment in this disease has been covered. It is concluded that vindesine as a single agent yields a response rate of 18% based on the treatment of 295 patients included in phase II trials (95% confidence limits 13%-22%). No difference was observed among the three major histologic types of non-small cell lung cancer. In phase III trials, the response rate and confidence limits are at a similar level. Combination chemotherapy including vindesine plus cisplatin ranks among the most active treatments in non-small cell lung cancer and is as active as etoposide plus cisplatin, both with respect to response rate and survival. It has not been documented that the addition of one or two other drugs to the combination of vindesine yields an increase in survival. When best supportive care was compared with a combination of vindesine plus cisplatin, the group with chemotherapy was attributed a survival advantage in all three studies published, and the difference was statistically significant in two of these three studies. Thus, vindesine has a well documented activity in non-small cell lung cancer and ranks among the most active single agents in this disease. Vindesine is also part of several active combination chemotherapies among which the combination of vindesine plus cisplatin is particularly interesting, because it has been repeatedly shown to prolong survival as compared to supportive care. Especially this latter point leads to the conclusion that there is a role for vindesine in the treatment of non-small cell lung cancer. However, the concept of chemotherapy in this disease remains investigational even though the advances seen in recent years clearly merit further studies.

Unexpected high toxicity in a phase II study of teniposide (VM-26) in elderly patients with untreated small cell lung cancer (SCLC)

Teniposide (VM 26) as a single agent has shown promising results in the treatment of patients with small cell lung cancer. We treated 32 (30 evaluable) non-pretreated elderly and poor prognosis patients with small cell lung cancer with teniposide 100 mg/day (30 min infusion) days 1-5, every 3-4 weeks. Overall initial performance status was poor (WHO 2 or 3 in 62%). Extensive disease (ED) was documented in 50% including five patients with CNS metastases all of whom received simultaneous cranial irradiation. There was an unexpected high early death rate of 30% (9/30) including five patients with early toxic death due to severe bone marrow suppression leading to fatal septicaemia. The overall response rate was only 33% with no complete response. Where appropriate non-responding or relapsing patients received second line treatment with multidrug regimens +/- radiotherapy. The overall median survival was 5.6 months [ED: 1.7, limited disease (LD): 7.5 months]. Median response duration was 5.4 months (ED: 5.1, LD: 6.7 months). For responding patients median survival was 8.8 months (ED) and 11.5 months (LD). We conclude that in elderly and poor performance status patients single agent teniposide as used in this study has an unacceptable high early death rate and that the response rate is inferior to modern standard multidrug regimens.

A randomized study of radiation treatment in small cell bronchial carcinoma treated with two types of four-drug chemotherapy regimens

Of an unselected series of 133 patients with small cell bronchial carcinoma, 110 patients (54 with extensive disease and 56 with limited disease) were randomly allocated to receive either chemotherapy with cyclophosphamide, doxorubicin, vincristine, and methotrexate, alternating after four cycles with cyclophosphamide, lomustine, vincristine, and methotrexate, or the same chemotherapy combinations together with irradiation at 40 Gy to the primary tumor area and the adjacent mediastinum. In patients with extensive disease the total response rates were 70% and 86% and the median survival 7.6 and 9.2 months, respectively. There were no long-term survivors, and no advantage was gained from radiation combination treatment. The results confirm previously reported findings. In limited disease the complete remission rates were 68% and 64%, the partial remission rates 26% and 28%, and the median survival was 14.8 and 15.4 months, respectively. There were no statistically significant differences favoring either treatment regimen. The disease-free survival exceeding 2 years in the two respective groups was 6.5% and 25%; this difference was not statistically significant. A slight advantage of combined radiation and chemotherapy in the direction of better long-term survival was confirmed by the 4-year disease-free survival rate of 12% as compared with 0% in the nonirradiation group. This difference was statistically significant. There was considerable toxicity with both treatment regimens. The addition of radiation treatment to the chemotherapy most likely benefits patients with limited disease. The overall median survival of all the unselected 133 patients (nonrandomized included) was 10.3 months, and the cure rate was 3%.

Potentiation of combination chemotherapy by nitroheterocyclics

The effect of including a nitroimidazole in a treatment regimen combining two alkylating chemotherapeutic agents was evaluated in a mouse tumor model. KHT sarcoma-bearing female C3H/HeJ mice were treated with a single dose of 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU) either alone or in combination with the radiosensitizer misonidazole (MISO) prior to a range of cyclophosphamide (CY) doses. CCNU (5 mg/kg) preceded CY treatment by 3 hr. MISO (1 mmol/kg) was given 1 hr after CCNU (2 hr prior to CY). Tumor response was assessed using either an in vitro to in vivo clonogenic cell survival assay 22-24 hr after treatment or an in situ delay of tumor regrowth assay. The results demonstrated that the inclusion of MISO at a dose of 1.0 mmol/kg increased tumor cell kill resulting from the combination of CCNU-CY by a factor of 1.4-1.5 compared to that seen in the absence of the nitroimidazole. Normal tissue toxicity resulting from the CCNU-CY or CCNU-MISO-CY combinations was determined by measuring bone marrow stem cell (CFU-S or CFU-GM) toxicity. Compared to CCNU-CY alone, the addition of MISO did not enhance this normal tissue toxicity. These findings indicate that the inclusion of MISO in a combination chemotherapy protocol may yield a significant therapeutic benefit.

5-Fluorouracil, doxorubicin, and mitomycin-C in the treatment of adenocarcinoma and large cell carcinoma of the lung

Fifty-four patients with adenocarcinoma and large cell carcinoma of the lung, 16 with localized surgically resected disease and 38 with metastatic disease, were treated with 5-fluorouracil, doxorubicin, and mitomycin-C (FAM), in an attempt to prolong previously reported survival times in the patients. The postsurgical patients were given elective chemotherapy. Eighteen received radiation therapy for control of local disease. Tumor regression, attributable to chemotherapy alone, was noted in ten of 20 cases in whom there was measurable disease. The median survival time of all patients was 32 weeks, ranging from 25 weeks in those with distant metastases to 56 weeks in patients with surgically resected disease. FAM did not seem to produce any beneficial survival advantages.

Current status of therapy for small cell carcinoma of the lung

Small cell carcinoma of the lung (SCCL) is distinguished from other types of lung cancer by its propensity for early development of distant metastases and its rapidly fatal clinical course in the absence of treatment. The introduction of chemotherapy into the management of SCCL has led to a four- to five-fold improvement in median survival and to the cure of a small proportion of patients with this disease. Employment of three- or four-drug regimens with or without chest irradiation in moderately intensive doses for periods of 12 months or less has proven to be the optimal therapeutic strategy with currently available agents. Despite these substantial gains, it is obvious that the vast majority of SCCL patients are continuing to die from their cancer, and a slowing in the pace of treatment advances has become apparent over the past 5 years. This article reviews current areas of active clinical investigation in SCCL and some information developed in the cell biology laboratory that may have eventual application in the clinic.

Cyclic alternating combination chemotherapy for small cell lung cancer

Sixty-two patients with small cell carcinoma of lung received cyclic alternating non-cross-resistant combination chemotherapy. Radiation to the chest was given to all the patients. Patients were given a course of VP16, adriamycin and vincristine (VAV) followed by radiation (3,000 rads) to the chest and then a second course of VAV. Three weeks later, a course of cytoxan, CCNU, and methotrexate (CCM) was given (6 weeks). Subsequently, the treatment was cycled between two courses of VAV (6 weeks) and one course of CCM (6 weeks). Overall objective response rate of 73%, with 45% complete response, was noted. Overall median survival was 50 weeks, with 83 weeks for complete responders. Median survival for patients with regional disease was 58 weeks compared to 40 weeks for extensive disease. All the patients headed for complete response did so prior to receiving CCM. These results were not superior to conventional combination chemotherapy regimens.

High-dose methotrexate in small cell lung cancer. Lack of efficacy in preventing CNS relapse

Few studies have incorporated high-dose methotrexate (MTX) with leucovorin rescue in the treatment of small cell lung cancer (SCLC). Potentially therapeutic levels of MTX can be achieved in the central nervous system (CNS) by systemic administration of high doses of this drug. Utilizing a combination chemotherapy program of Adriamycin, vincristine, cyclophosphamide, and methotrexate, 31 patients were sequentially assigned to receive either low-dose MTX (40 mg/m2), or high-dose MTX (500 mg/m2) with leucovorin rescue. Radiation therapy to the primary site was also administered. At these dosage levels there were no statistically significant differences in response rate or survival between the two groups. High-dose MTX did not prevent the appearance of CNS disease; there being 2/15 and 3/15 CNS relapses in the HD MTX and LD MTX treated groups, respectively. The occurrence of CNS disease did not significantly affect overall survival as compared to patients not similarly affected.

Small-cell lung cancer: initial treatment with sequential hemi-body irradiation VS 3-drug systemic chemotherapy

The therapeutic value of sequential hemi-body irradiation (HBI) as a primary treatment for small-cell lung cancer (SCLC) was compared to 3-drug cyclic chemotherapy (CC) in a group of 64 patients with early and advanced disease. Thirty patients were randomized to receive sequential HBI and 34 to receive CC. All patients received a local radiation boost to the primary lesion. An overall response rate of 87% was obtained in patients treated with sequential HBI and 88% in patients treated with CC. In patients with early disease, the estimated median survival was 43 weeks when treated with HBI and 42 weeks when treated with CC, but in advanced disease the estimated median survival was 15 weeks and 44 weeks respectively. Of the patients with an initial complete response, the estimated median survival was 51 weeks for HBI and 62 weeks for CC. From these observations we suggest that sequential HBI treatment technique with local radiation boost is an efficient method of tumour control in patients with early small-cell lung cancer.

Radiotherapy alone or with chemotherapy in the treatment of small-cell carcinoma of the lung: the results at 36 months. 2nd report to the Medical Research Council on the 2nd small-cell study

This report compares the results at 36 months for 121 patients treated with radiotherapy alone (R) and 115 with radiotherapy followed by 3-drug chemotherapy (RC) for small-cell carcinoma of the lung of "limited" extent. The RC patients had an increased survival (P = 0.009 by log-rank test). The median survival was 25 weeks for the R patients and 43 weeks for the RC patients, but at 36 months, only 4 (3%) of the R patients and 5 (4%) of the RC patients were still alive. There was evidence of recurrence of the primary cancer in 41 (35%) of the 117 R and 35 (32%) of the 110 RC patients who died. Distant metastases were more frequent in the R series, being reported in 99 (82%) compared with 82 (71%) of the RC patients (P less than 0.05 by log-rank test). The numbers of R patients alive and considered free of metastases were 10 (8%) at 12 months, 3 (2%) at 24 months and 3 (2%) at 36 months; the corresponding figures for the RC patients being 30 (26%), 9 (8%), and 4 (3%).

Progress in the chemotherapy of small cell carcinoma of the lung

A comparison was made between six different approaches to the chemotherapy of small cell carcinoma of the lung. The value of single-agent chemotherapy was compared to combination chemotherapy and radiation therapy, and with cyclic alternating combination chemotherapy in 161 patients. Cyclic alternating chemotherapy with modest radiation therapy to the primary site provided significant advantages over single-agent or combination chemotherapy. A combination of VP-16 + Adriamycin + vincristine seemed particularly effective in inducing an initial objective tumor response rate of 83%, with a projected median survival of 13.2 months. Of patients treated with cyclic alternating therapy, 51% were alive at one year. It thus appears that where complete response is achieved, prolonged disease-free survival can be expected.

Combination chemotherapy with cyclophosphamide, adriamycin, intermediate dose methotrexate, and folinic acid rescue (CAMF) in advanced lung cancer

Combination chemotherapy appears superior to single-agent therapy in treating a wide variety of tumors. Encouraged by this data, we conducted a pilot study using cyclophosphamide, adriamycin, intermediate dose methotrexate and folinic acid rescue (CAMF) in patients with advanced lung cancer. Forty-eight patients with unresectable tumors were entered on this trial, and treated with 500 mg/m2 intravenously administered cyclophosphamide, 50 mg/m2 intravenously administered adriamycin, 40--200 mg/m2 orally administered methotrexate (4 doses/24 hrs), and 5 mg orally administered folinic acid (6 doses/36 hrs); this regimen was repeated every three weeks if tolerable. There were 43 patients evaluable for toxicity and 34 (non-small types) for response. The major toxicities were myelosuppression and nausea and vomiting. The overall response rate (complete and partial responses) was 29.4% (10/34) and in 13 patients (38%), the disease was stabilized. Those responding had a median survival time of 10.5 months versus 4 months for nonresponders. Patients in whom the disease was stabilized had a median survival time of 8 months. CAMF is a well-tolerated drug combination with promising results in patients with advanced lung cancer.

Radiotherapy alone or with chemotherapy in the treatment of small-cell carcinoma of the lung. Medical Research Council Lung Cancer Working Party

This report gives the complete findings at one year of a study comparing radiotherapy (Rt) with radiotherapy followed by 3-drug chemotherapy (RtC3) in the treatment of histologically proven small-cell carcinoma of the lung of limited extent. Over the 12-month period there was a significantly increased survival for the RtC3 patients (P = 0.002) and at 12 months 18% of the 121 Rt but 34% of the 115 RtC3 patients were alive (P = 0.009). The median survival for the Rt series was 25 weeks and for the RtC3 series 43 weeks. There was evidence of recurrence of the primary cancer in 32 (32%) of the 99 Rt and 20 (26%) of the 76 RtC3 patients who died. Distant metastases appeared earlier and were more frequent in the Rt series (P less than 0.0001) and over the 12-month period 79% of the Rt and 57% of the RtC3 patients developed distant metastases (P less than 0.0005). At 12 months only 8% of the Rt but 26% of the RtC3 patients were alive and free of metastases. Adverse reactions occurred much more frequently in the RtC3 series; 32% of the Rt series as against 83% of the RtC3 series had reactions, the most common being nausea and vomiting (13% Rt, 71% RtC3) and the most serious being marrow depression (23% Rt, 54% RtC3). No important differences were found among the survivors in the 2 series at 3, 6 or 12 months, in general condition, physical activity or respiratory function. It is concluded that radiotherapy plus chemotherapy was superior to radiotherapy alone, although chemotherapy did not protect patients from recurrence of primary growth.

5-Fluorouracil, adriamycin, and mitomycin-C (FAM) chemotherapy for adenocarcinoma of the lung

Twenty-five patients with advanced measurable adenocarcinoma of the lung were treated with combination chemotherapy consisting of 5-fluorouracil, adriamycin, and mitomycin-C (FAM). Objective response (1CR, 8PR) was obtained in 36% of patients. The median duration of response was 7.0 months and the median survival for responders is greater than 8.5 months. Five responders are alive 5.5 to 23.5 months after starting therapy. Three of four patients evidencing stabilization of disease are alive at 10-23 months. Non-responding patients had a median survival of 2.5 months and none lived beyond seven months. Tumor response and survival suggested correlation with initial performance status and limited disease. The FAM regimen was tolerated well, with moderate bone marrow suppression and gastrointestinal symptoms being the only clinically significant toxicities. These results indicate that patients with advanced pulmonary adenocarcinoma can obtain objective tumor regression with FAM chemotherapy.

Chemotherapy of small cell carcinoma of the lung with V.P. 16-213

A Phase II study of V.P. 16-213 administered to 47 patients suffering from small cell carcinoma of the bronchus. V.P. 16-213 was given as an intravenous infusion over 15 minutes daily for five consecutive days using 60 mg/m2/d at 14-day intervals. Oral V.P. in 100 mg doses was given twice a week between the intravenous courses. Objective response rate for this drug compared favourably with that of other single agents reported. All but two patients showed a degree of response to treatment and 24 of 47 patients showed a true objective response to treatment. The overall median survival of these patients was 225 days and localized disease 278 days. The quality of survival was such that responders lived relatively normal lives up to the latter stages of their disease. The majority of patients had a marked response in performance status, 37 out of 47 showing an improvement. Three patients are alive and well at more than 27 months. In all cases the side effects were minimal. Alopecia was common and reversible haematological complications occurred. Severe toxicity was not encountered and the drug was well tolerated with supportive antiemetic therapy at onset of treatment.

CCNU-adriamycin therapy in bronchogenic carcinoma

Forty-eight patients with advanced bronchogenic carcinoma were treated with a combination of CCNU and Adriamycin. There was an overall objective response rate of 38%. This consisted of 1 of 12 (8%) patients with epidermoid carcinoma, 5 of 15 (33%) with adenocarcinoma, 2 of 5 (40%) with large cell undifferentiated carcinoma and 10 of 16 (63%) with small cell undifferentiated carcinoma. The overall median survival time (MST) from initiation of therapy was 28 weeks. The MST was 18 weeks for patients with epidermoid carcinoma, 30 weeks for those with adenocarcinoma, 39 weeks for those with large cell carcinoma, and 30+ weeks for those with small cell carcinoma. Objective tumor response was associated with prolonged survival. There were no drug related deaths and toxicity was minimal.

Combined chemotherapy and radiotherapy for the treatment of small cell carcinoma of the lung

Twenty-nine (88%) of 33 patients who were treated with multiple drug chemotherapy and radiotherapy for small cell carcinoma of the lung showed significant improvement in their clinical condition and quality of life. Treatment was well tolerated and toxicity was acceptable.

Oral high-dose methotrexate with citrovorum factor rescue in metastastic squamous cell carcinoma of the lung

Thirteen patients with metastatic squamous cell cancer of the lung were treated, in a nonrandomized study, with an oral high-dose methotrexate and citrovorum factor rescue regimen. There was some response and/or stabilization of disease for at least three months in six (46%) of 13 cases. The median survival time of the study group was double (365 vs. 180 days) that of a retrospectively matched control group. This suggests a possible therapeutic effect of this treatment program in metastatic squamous cell cancer of the lung.