A randomized trial comparing vindesine and cisplatinum to vindesine and methotrexate in advanced non small cell lung carcinoma

Platinum-Based Versus Non-Platinum-Based Chemotherapy in Advanced Non-Small-Cell Lung Cancer: A Meta-Analysis of the Published Literature

Purpose

This meta-analysis was performed to compare the activity, efficacy and toxicity of platinum-based versus non-platinum-based chemotherapy in patients with advanced non-small-cell lung cancer.

Methods

Randomized phase II and III clinical trials comparing first-line palliative platinum-based chemotherapy with the same regimen without platinum or with platinum replaced by a nonplatinum agent were identified by electronic searches of Medline, Embase, and Cancerlit, and hand searches of relevant abstract books and reference lists. Response rates, 1-year survival, and toxicity were analyzed. Subgroups of trials using third-generation agents were compared.

Results

Thirty-seven assessable trials were identified including 7,633 patients. A 62% increase in the odds ratio (OR) for response was attributable to platinum-based therapy (OR, 1.62; 95% CI, 1.46 to 1.8; P < .0001). The 1-year survival rate was increased by 5% with platinum-based regimens (34% v 29%; OR, 1.21; 95% CI, 1.09 to 1.35; P = .0003). No statistically significant increase in 1-year survival was found when platinum therapies were compared to third-generation-based combination regimens (OR, 1.11; 95% CI, 0.96 to 1.28; P = .17). The toxicity of platinum-based regimens was significantly higher for hematologic toxicity, nephrotoxicity, and nausea and vomiting, but not for neurotoxicity, febrile neutropenia rate, or toxic death rate.

Conclusion

Response is significantly higher with platinum-containing regimens. One-year survival was not significantly prolonged when platinum-based therapies were compared with third-generation-based combination regimens. Toxicity is generally higher for platinum-based regimens.

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.

The effect of vindesine on methotrexate hydroxylation in the rat

The effect of vindesine (VDS) on methotrexate (MTX) disposition was studied in bile-drained rats administered VDS prior to [3H]MTX, and in isolated rat hepatocytes and rat liver homogenate concomitantly incubated with MTX and VDS at 37 degrees. In vivo, 7-hydroxylation was reduced by 0.65 mg/kg VDS. In VDS-treated animals, biliary recovery of the MTX dose (50 mg/kg) as 7-hydroxymethotrexate (7-OH-MTX) (1.75 +/- 0.2%, mean +/- SEM) was significantly reduced compared to controls (2.83 +/- 0.57%). In vitro, hydroxylation of MTX (10-200 microM) in hepatocytes was reduced by 14.3 and 66.4% (means) at 12.5 and 100 microM VDS, respectively. With increasing VDS concentrations up to 100 microM, a reduction in intracellular MTX accumulation could account for the decreased MTX hydroxylation. Experiments in a cell free system gave no evidence of inhibition of 7-OH-MTX formation by VDS. In vitro MTX transport studies demonstrated that VDS inhibited the hepatocellular influx of MTX, as (1) the accumulation of MTX corresponded inversely to increasing VDS concentrations and (2) the MTX efflux was not increased by VDS. The apparent Ki for VDS inhibition of MTX influx was 57 microM. We suggest that VDS, by reducing the 7-OH-MTX formation in liver cells, may have implications for combination chemotherapy regimens which include MTX.

[Treatment of advanced non-small cell bronchial cancer--a review of the literature of the last 5 years]

In the course of a metaanalysis concerning adjuvant therapy and the therapy of inoperable non-small-cell carcinoma of the lung, undertaken from 1.1. 1985 to 1.5. 1990, 376 publications were evaluated on a point system based on a decision tree. Out of a maximum of 71 obtainable points only 5.4% of the publications on adjuvant therapy and only 7.3% of publications on palliative therapy obtained more than 45 points. Regarding inoperable cases X-ray therapy with a median survival of 11 months and satisfactory life quality demonstrated the best results. Significant increases in survival are also possible with chemotherapy (7.4 months) in standard-dose pair combinations which, however, are associated with negative side effects on the treated patients. Immune and radio-chemotherapy cannot be recommended on account of treatment toxicity without a gain in life quality. Adjuvant therapy shows no life-prolonging effect. Consequently surgical treatment remains the first choice of therapy.

Chemotherapy in advanced non-small cell lung cancer

Chemotherapy in advanced non-small cell lung cancer (NSCLC) has been evaluated with response rate, survival and quality of life as criteria. The data were collected from 142 phase II and III trials. The three main conclusions are: (1) multivariate landmark analyses show that a response to chemotherapy has an independent significant value for prognosis, and all studies of chemotherapy vs. best supportive care show some survival benefit in favour of chemotherapy; (2) NSCLC patients are a heterogeneous group with a large variation of known and unknown prognostic factors, such as the treatment centre, for both response and survival; and (3) retrospective analysis of the data show that response rate and survival are significantly correlated at response rate over 30% and in limited disease patients. The following recommendations are made: (1) new drugs should be compared in randomised phase II trials with a standard active drug; (2) randomised phase III trials of single agents or best supportive care vs. combination chemotherapy should be repeated in a well-defined subgroup of patients with a high performance score and limited tumour load; and (3) the palliative effect of chemotherapy in randomised trials in patients with symptoms should be investigated with relief of symptoms and quality of life as endpoints.