Randomized trial of three combinations of cisplatin with vindesine and/or VP-16-213 in the treatment of advanced non-small-cell lung cancer

Cisplatin plus Vindesine versus Cisplatin plus VP16 versus Doxorubicin plus Cytoxan in Non-Small-Cell Carcinoma of the Lung. A Randomized Study

From March 1981 to January 1984, 116 patienst with advanced non-small-cell carcinoma of the lung (NSCCL) were randomly assigned to 3 combinations as follows: CDDP + DVA, CDDP + VP16 and DXR + CTX. 94 patients were evaluable for response, 106 for toxicity and survival. Of 31 patients, 15 (48%; 3 CRs and 12 PRs) responded to CDDP + DVA; of 33 patients, 12 (36%, 2 CRs and 10 PRs) responded to CDDP + VP16; of 30 patients, 3 (10%) obtained a PR with DXR+CTX (CDDP+DVA vs DXR + CTX, P < 0.005; CDDP + VP16 vs DXR + CTX, P < 0.05; CDDP + DVA vs CDDP + VP16, P = NS). The median duration of response was 22 weeks in the CDDP-DVA group, 17 weeks in the CDDP-VP16 group, and 16 weeks in the DXR+CTX group. No significant difference in survival was observed among the 3 groups (median: 43, 47, 41 weeks, respectively). Hematologic and neurologic toxicities were significantly higher in the DVA-containing regimen. Despite the lack of improvement of overall survival with the CDDP-containing combinations over the DXR + CTX control group, the good response rate makes them suitable to be used in combined therapeutic strategies.

Combination of Sasa quelpaertensis Nakai Leaf Extract and Cisplatin Suppresses the Cancer Stemness and Invasion of Human Lung Cancer Cells

Lung cancer is the leading cause of cancer death worldwide, and most chemotherapeutic drugs have limited success in treating this disease. Furthermore, some drugs show undesirable side effects due to the enrichment of cancer stem cells (CSCs) that are present, leading to resistance to conventional chemotherapy and tumor relapse. CSCs possess self-renewal characteristics, aggressive tumor initiating activity, and ability to facilitate tumor metastasis. Therefore, development of nontoxic agents that can potentiate chemotherapy and eliminate CSCs would be highly desirable. In the present study, we investigated whether Sasa quelpaertensis leaf extracts (SQE) and cisplatin (CIS), individually or in combination, would exert anti-CSC and antimetastatic effect in H1299 and A549 human lung cancer cells. Following these treatments, cell growth, phosphorylation of phosphoinositide-3 kinase, and activation of the mammalian target of rapamycin were inhibited. Decreased serial sphere formation, clonogenicity, and expression of major stem cell markers, such as CD44 and SOX-2, in CD44+ cancer stem cells were also observed. In addition, inhibition of cell migration and invasion in both cell lines as well as inhibition of matrix metalloproteinase-2 activity and expression were detected. Importantly, the anticancer stemness and antimetastasis effects in each of these assays were greater for the combined treatment with SQE and CIS than with each treatment individually. In conclusion, the data suggest that SQE alone, or in combination with CIS, represents a promising therapeutic strategy for eliminating cancer stemness and cell invasion potential of CSCs, thereby treating and preventing metastatic lung cancer cells.

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.

Treatment of advanced non small cell lung cancer in routine care: a retrospective analysis of 212 consecutive patients treated in a community based oncology group practice

Treatment outcome data generated in prospective trials are intrinsically biased due to necessary selection criteria. Therefore the results obtained may not reflect the actual impact of current treatment options for an unselected general population. We analysed the treatment modalities and the outcome in 212 consecutive patients with non small cell lung cancer stages IIIB and IV who were seen in a community based oncology group practice between 6/1995 and 6/2006. 93 presented with stage IIIB and 119 with stage IV. Chemotherapy was given to 194/212 patients (92%), 114 patients (54%) received palliative radiation at one point during treatment. Treatment consisted of chemotherapy only in 86 patients (40%) and radiation only in 6 patients. 12 patients received best supportive care only. Patients with stage IIIB have survival rates at 12, 24 and 36 months of 64%, 27% and 21% respectively and for patients with stage IV the survival rates at 12, 24 and 36 months are 40%, 19% and 11% respectively. The median survival for stages IIIB and IV is 16 and 11 months respectively. In a multivariate analysis incorporating the factors stage (IIIB vs. IV), age (<70 vs. >/=70 years) and performance status (WHO 0/1 vs. 2/3) only stage and performance status were independent factors for survival. These retrospective data concerning analysis of survival, response rates and toxicity in a community setting confirm published results of phase II-III studies and indicate that results generated in prospective trials can be transferred into routine care.

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.

Outcomes among African-American/non-African-American patients with advanced non-small-cell lung carcinoma: report from the Cancer and Leukemia Group B

BACKGROUND

Among patients diagnosed with advanced non-small-cell lung carcinoma (NSCLC), African-Americans have lower survival rates than non-African-Americans. Whether this difference is due to innate characteristics of the disease in the two ethnicities or to disparities in health care is not known. We investigated whether the disparity in survival would persist when patients were treated with similar systemic therapies (i.e., in phase II and phase III Cancer and Leukemia Group B [CALGB] trials).

METHODS

We assessed 504 consecutive patients (458 non-African-American and 46 African-American) receiving systemic chemotherapy in CALGB studies for advanced NSCLC during the period from 1989 through 1998. Clinical and demographic characteristics, treatment received, and survival data were obtained from the CALGB database. Cox's proportional hazards model was used to assess the effect of race/ethnicity on survival after adjustment for other known prognostic factors. All statistical tests were two-sided.

RESULTS

The unadjusted 1-year survival rate was 22% (95% confidence interval [CI] = 13% to 38%) for African-American patients and 30% (95% CI = 26% to 35%) for non-African-American patients, a statistically significant difference (8%; 95% CI on the difference = 5% to 12%; P =.03). Multivariable adjustment for the effect of treatment arm, histology, and metastatic site at presentation did not alter the worse outcome for African-American patients. However, the effect of race/ethnicity disappeared after adjustment for performance status and weight loss. African-American patients were more likely than non-African-Americans to present with a poor performance status (83% versus 60%) and substantial weight loss (41% versus 27%) and to be unmarried (59% versus 28%), disabled (31% versus 15%), unemployed (17% versus 7%), and Medicaid recipients (30% versus 8%).

CONCLUSIONS

The relationship that we observed between poor performance, weight loss, and socioeconomic status suggests that social circumstances lead to African-Americans presenting with poorer prognostic features.

Twenty-two years of phase III trials for patients with advanced non-small-cell lung cancer: sobering results

PURPOSE

To determine the changes in clinical trials and outcomes of patients with advanced-stage non-small-cell lung cancer (NSCLC) treated on phase III randomized trials initiated in North America from 1973 to 1994.

PATIENTS AND METHODS

Phase III trials for patients with advanced-stage NSCLC were identified through a search of the National Cancer Institute's Cancer Therapy Evaluation Program database from 1973 to 1994, contact with Cooperative Groups, and by literature search of MEDLINE. Patients with advanced NSCLC treated during a similar time interval were also examined in the SEER database. Trends were tested in the number of trials, in the number and sex of patients entered on the trials, and in survival over time.

RESULTS

Thirty-three phase III trials were initiated between 1973 and 1994. Twenty-four trials (73%) were initiated within the first half of this period (1973 to 1983) and accounted for 5,359 (64%) of the 8,434 eligible patients. The median number of patients treated per arm of the trials rose from 77 (1973 to 1983) to 121 (1984 to 1994) (P <.001). Five trials (15%) showed a statistically significant difference in survival between treatment arms, with a median prolongation of the median survival of 2 months (range, 0.7 to 2.7 months).

CONCLUSION

Analysis of past trials in North America shows that the prolongation in median survival between two arms of a randomized study was rarely in excess of 2 months. Techniques for improved use of patient resources and appropriate trial design for phase III randomized therapeutic trials with patients with advanced NSCLC need to be developed.

A randomized trial of postoperative adjuvant therapy in patients with completely resected stage II or IIIA non-small-cell lung cancer. Eastern Cooperative Oncology Group

BACKGROUND

We conducted a randomized trial to determine whether combination chemotherapy plus thoracic radiotherapy is superior to thoracic radiotherapy alone in prolonging survival and preventing local recurrence in patients with completely resected stage II or IIIa non-small-cell lung cancer.

METHODS

After surgical staging and resection of the tumor (usually by lobectomy or pneumonectomy), the patients were randomly assigned to receive either four 28-day cycles of cisplatin (60 mg per square meter of body-surface area intravenously on day 1) and etoposide (120 mg per square meter intravenously on days 1, 2, and 3) administered concurrently with radiotherapy (a total of 50.4 Gy, given in 28 daily fractions) or radiotherapy alone (a total of 50.4 Gy, given in 28 daily fractions).

RESULTS

Of the 488 patients who were enrolled in the study, 242 were assigned to receive radiotherapy alone and 246 were assigned to receive chemotherapy and radiotherapy. The median duration of follow-up was 44 months. Treatment-associated mortality was 1.2 percent in the group given radiotherapy alone and 1.6 percent in the group given chemotherapy and radiotherapy. The median survival was 39 months in the group given radiotherapy and 38 months in the group given chemotherapy and radiotherapy (P= 0.56 by the log-rank test). The relative likelihood of survival among patients assigned to receive chemotherapy and radiotherapy, as compared with those assigned to receive radiotherapy alone, was 0.93 (95 percent confidence interval, 0.74 to 1.18). Intrathoracic disease recurred within the radiation field in 30 of 234 patients (13 percent) in the group given radiotherapy and in 28 of 236 patients (12 percent) in the group given chemotherapy and radiotherapy (P=0.84); data on recurrence were not available for 18 patients.

CONCLUSIONS

As compared with radiotherapy alone, adjuvant radiotherapy and chemotherapy with cisplatin and etoposide does not decrease the risk of intrathoracic recurrence or prolong survival in patients with completely resected stage II or IIIa non-small-cell lung cancer.

Novel combination chemotherapy in the treatment of non-small cell lung cancer

Treatment of patients with advanced non-small cell lung cancer (NSCLC) remains a vexing problem and long-term survival beyond 5 years is extremely rare. Five new agents, paclitaxel, docetaxel, vinorelbine, gemcitabine and irinotecan, have been introduced for the treatment of NSCLC and investigated extensively both preclinically and clinically. Monotherapy with one of these agents has produced survival benefits over the best supportive care in Phase III studies. Combination chemotherapy with a new agent and platinum produced a higher response rate than conventional cisplatin-based chemotherapy and improved survival was observed in some randomised trials. There was little difference in efficacy and toxicity between the chemotherapeutic regimens with a new agent and a platinum in Phase III trials, suggesting the clinical utility of these regimens is similar. Many trials have focused on regimens containing two new agents, with or without platinum. Preliminary results of Phase III trials of three drug combinations versus two drug combinations suggested the former to be more promising, in terms of response rates and survival. Whether the era of platinum-based chemotherapy in the treatment of NSCLC should continue or not must be determined by Phase III trials, evaluating the use of a platinum agent with one of the new agent combinations. These aggressive chemotherapeutic combinations will hopefully improve survival and quality of life for patients with advanced NSCLC.

Decision framework for chemotherapeutic interventions for metastatic non-small-cell lung cancer

BACKGROUND

Best supportive care has long been considered to be the standard therapy for metastatic non-small-cell lung cancer (NSCLC). There is now evidence from randomized trials that a number of chemotherapy regimens can palliate cancer-related symptoms and modestly improve survival. We show how cost-effectiveness analyses can be used to make choices between different (ambulatory) chemotherapy regimens.

METHODS

Clinical algorithms describing the diagnosis, staging, and treatment of metastatic NSCLC were incorporated into Statistics Canada's Population Health Model. Using consistent methodology, we assessed the cost-effectiveness of several chemotherapeutic interventions: a combination of vindesine (VDS) plus cisplatin, etoposide (VP-16) plus cisplatin, vinblastine (VLB) plus cisplatin, vinorelbine (Navelbine; NVB) plus cisplatin, paclitaxel (Taxol) plus cisplatin, and gemcitabine (GEM) and NVB alone. We calculated the total chemotherapy costs in 1995 Canadian dollars, the cost per case, the average life-years saved, and the cost per life-year saved. Using the Population Health Model, we then constructed an advanced decision framework that rank-ordered the various treatment regimens so as to optimize benefit below various cost-effectiveness thresholds.

RESULTS

One regimen (VLB plus cisplatin) appears to result in better survival and lower health care expenditures than best supportive care. By use of cost-effectiveness thresholds of $25,000 and $50,000 per life-year gained, NVB plus cisplatin is the preferred regimen. When quality of life is considered, however, GEM is preferred to NVB plus cisplatin at a threshold value of $50,000. At thresholds of $75 000 and $100,000, paclitaxel plus cisplatin at a dose of 135 mg/m(2) is the preferred regimen. At thresholds of $50,000 and above, best supportive care is the least preferred regimen.

CONCLUSIONS

This decision framework allows the comparison of different treatment regimens based on various cost-effectiveness thresholds. Our analysis also supports the use of chemotherapy regimens and the abandonment of best supportive care as the standard of care for patients with advanced NSCLC. [J Natl Cancer Inst 2000;92:1321-9].

The combination of etoposide and cisplatin in non-small-cell lung cancer (NSCLC)

The role of chemotherapy in the treatment of advanced non-small-cell lung cancer (NSCLC) has been a subject of debate for many years. Only recently, cisplatin-based combination chemotherapy has been demonstrated to yield a small but definite survival benefit and to improve symptoms, performance status and quality of life in a substantial proportion of advanced NSCLC patients. The cisplatin-etoposide (PE) regimen was developed in the early 1980s and has been one of the standard chemotherapy programs most extensively used in the clinical practice until a few years ago. More recently, several randomized trials have compared the efficacy of new cisplatin-containing combination chemotherapies including Paclitaxel or Gemcitabine with that of PE or PE-like regimens. Preliminary results are encouraging, indicating a small benefit in favor of the last generation of regimens which might therefore replace PE as 'gold standards' in the treatment of advanced NSCLC. However, the costs of these last generation regimens is higher and the entity of the benefit small. Therefore, PE chemotherapy can still be an option in selected situations.

High dose tamoxifen plus cisplatin and etoposide in the treatment of patients with advanced, inoperable nonsmall cell lung carcinoma

BACKGROUND

Tamoxifen sensitizes cancer cells to chemotherapeutic agents. High dose tamoxifen has been tested in the treatment of patients with melanoma and other cancers. The authors conducted a Phase II study of high dose tamoxifen plus cisplatin and etoposide for patients with advanced, inoperable nonsmall cell lung carcinoma.

METHODS

Patients with Stage IIIB, Stage IV, or recurrent disease; good performance status; measurable lesions; and good organ function were eligible. Tamoxifen 150 mg/m2/day, divided into 4 doses, was given for 8 days. Cisplatin 60 mg/m2 was given on Day 4. Etoposide 60 mg/m2/day was given on Days 4-8. Patients were allowed to remain in the study until either intolerable toxicity was observed or disease progression occurred.

RESULTS

Forty patients were accrued and received a total of 191 cycles of treatment. All patients were evaluable for response and toxicity. One patient had a complete remission and 14 had a partial remission (overall response rate, 37.5%). The median survival was 47 weeks. One-year survival was 44%. Increased thrombotic episodes were noted; all were clinically manageable.

CONCLUSIONS

High dose tamoxifen can be administered safely in combination with cisplatin and etoposide to patients with advanced nonsmall cell lung carcinoma. Favorable response rates and survival times were obtained. The value of high dose tamoxifen in the treatment of patients with nonsmall cell lung carcinoma can be evaluated further in randomized Phase III studies.

A phase II study with vinorelbine, gemcitabine and cisplatin in the treatment of patients with stage IIIb-IV non-small cell lung cancer (NSCLC)

In our phase II study an acceptable and effective agent like cisplatin was used in combination with vinorelbine and gemcitabine in patients with non-small cell lung cancer (NSCLC). These two new cytostatic drugs have demonstrated, when used as a single-agent treatment, effective response rates (vinorelbine) and minimum toxicity (gemcitabine). The following schedule was used: (i) vinorelbine 25 mg/m2 on days 1 and 8; (ii) gemcitabine 1000 mg/m2 on days 1 and 8; and (iii) cisplatin 75 mg/m2 on day 8. The schedule was repeated every 21 days, with a maximum of six cycles per patient. A total of 31 patients with a mean Karnofsky performance status of 90% were evaluated and 29 of them were finally eligible. Of the patients, five (16.1%) were at stage IIIb and the remainder (83.9%) were at stage IV. The overall response rate was 65% (20 patients); six patients (19.4%) had complete response (CR) and 14 (45.2%) had partial response (PR). Two patients (6.5%) had stable disease and seven (22.6%) had progressive disease. The most notable toxicity was hematologic. Leukoneutropenia was mainly revealed after the third or fourth cycle and granulocyte-colony stimulating factor (G-CSF) was administered in 24 patients (77.4%). Mild anemia was found in almost all patients after the third or fourth cycle (Hb 10-11 g/dl) and eight patients (25.8%) required erythropoietin (EPO). Thrombocytopenia was more often observed compared with other known chemotherapeutic regimens; six patients (19.4%) had grade I thrombocytopenia and therapy was delayed in another four patients (12.9%) due to this complication. Non-hematologic toxicity was mild and well tolerated and consisted of alopecia (54.8%), nausea and vomiting (12.9%), constipation (12.9%), peripheral neuropathy (9.6%), diarrhea (6.5%), stomatitis (3.2%) and local phlebitis (3.2%). The examined combination provides us with one of the best overall responses rates reported, however at the cost of remarkable hematologic toxicity. Therefore, it would be better applied in patients with good performance status. The high response rates give us hope of using this combination as a neoadjuvant regimen.

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.

Single-agent gemcitabine versus cisplatin-etoposide: early results of a randomised phase II study in locally advanced or metastatic non-small-cell lung cancer

BACKGROUND

This randomised study was designed to determine the response rate survival and toxicity of single-agent gemcitabine and cisplatin-etoposide in chemo-naïve patients with locally advanced or metastatic non-small-cell lung cancer.

PATIENTS AND METHODS

Gemcitabine 1,000 mg/m2 was given as a 30 min intravenous infusion on days 1, 8, 15 of a 28-day cycle, cisplatin 100 mg/m2 on day 1, and etoposide 100 mg/m2 on days 1 (following cisplatin), 2 and 3. Major eligibility criteria included histologically confirmed non-small-cell lung cancer, measurable disease, Zubrod PS 0-2; no prior chemotherapy, no prior radiation of the measured lesion, and no CNS metastases.

RESULTS

146 patients were enrolled, 71 patients on gemcitabine and 75 patients on cisplatin-etoposide. Patient characteristics were well matched across both arms. Sixty-six gemcitabine patients and 72 cisplatin-etoposide patients were evaluable. Partial responses were seen in 12 gemcitabine patients (18.2%; 95% CI: 9.8-30) and 11 cisplatin-etoposide patients (15.3%; 95% CI: 7.9-25.7). Early indications show no statistical differences between the two treatments with respect to time to disease progression or survival. Haematological and laboratory toxicity were moderate and manageable. However, hospitalisation because of neutropenic fever was required for 6 (8%) cisplatin-etoposide patients but not for any gemcitabine patients. Non-haematological toxicity was more pronounced with significant differences in nausea and vomiting (grade 3 and 4: 11% gemcitabine vs. 29% cisplatin-etoposide; despite the allowance for 5-HT3 antiemetics during the first cycle of cisplatin-etoposide), and alopecia (grade 3 and 4:3% gemcitabine vs. 62% cisplatin-etoposide).

CONCLUSIONS

In this randomised study, single-agent gemcitabine was at least as active but better tolerated than the combination cisplatin-etoposide.

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.

The cost-effectiveness of navelbine alone or in combination with cisplatin in comparison to other chemotherapy regimens and best supportive care in stage IV non-small cell lung cancer

An economic evaluation was undertaken, using data from European and Canadian randomised controlled trials of chemotherapy in advanced non-small cell lung cancer (NSCLC), to determine the cost and cost-effectiveness of single-agent vinorelbine (Navelbine, NVB) therapy and NVB in combination with cisplatin (NVB-P) compared to vindesine in combination with cisplatin (VDS-P), standard regimens including VP-16-cisplatin (VP-16-P) and vinblastine-cisplatin (VLB-P) and best supportive care (BSC). The Population Health Model (POHEM) developed by Statistics Canada was used to model the cost of care per patient, the total burden of cost to the Canadian healthcare system and the cost-effectiveness of the therapeutic interventions relative to BSC and to standard chemotherapy regimens, expressed as the cost per life year gained (LYG). Based on this analysis, VLB-P proved to be the most cost-effective chemotherapy regimen relative to BSC, as it increased average survival by 0.27 years while reducing costs by $3265 per case. NVB-P increased survival to a greater degree (0.44 years/patient) while inpatient administration increased costs by $2451 per case, for a cost-effectiveness ratio of $5551 per LYG. Outpatient administration, which reduced the cost of care per case by $473, was shown in the model to be the most cost-effective way to administer this regimen. Relative to VP-16-P and VLB-P, outpatient NVB-P regimen proved to be cost-effective at $7902 and $16404 per LYG, respectively. Based on our estimates, a variety of chemotherapy regimens, including outpatient NVB-P, are cost-effective in the management of advanced (Stage IV) NSCLC and competitive with some commonly used healthcare interventions. Therefore, cost and cost-effectiveness should not be barriers to the utilisation of NVB-P therapy in Canada.

A phase II study of cisplatin, vindesine and continuously infused 5-fluorouracil in the treatment of advanced non-small-cell lung cancer. Osaka Lung Cancer Chemotherapy Study Group

Fifty-two previously untreated patients with advanced non-small-cell lung cancer (NSCLC) were treated on a 14 day cycle with cisplatin (60 mg m-2 i.v.) and vindesine (3 mg m-2 i.v.) on day 1, followed by a 3 day continuous infusion of 5-fluorouracil (800 mg m-2 day-1) starting on day 8. An overall response rate of 40.4% was observed in 47 evaluable patients, which included one complete response and 18 partial responses. Responses were achieved in 61.1% of stage 3 patients and 27.6% of stage 4 patients. The median progression-free interval was 19.3 weeks, and median survival time was 41.6 weeks (47.1 weeks for patients with stage 3 disease and 38.7 weeks for those with stage 4 disease). Toxicity was well tolerated. Gastrointestinal and renal toxicities did not exceed WHO grade 2. Grade 3 or 4 leucopenia and anaemia occurred in nine (19%) and four (9%) patients respectively, but only grade 2 thrombocytopenia was observed. Phlebitis at the infusion site was observed in 24 patients (53%). This treatment programme achieved a response rate similar to other active combination regimens for the treatment of advanced NSCLC, and was less toxic.

Expression of the multidrug resistance-associated protein (MRP) gene in non-small-cell lung cancer

We examined the levels of expression of the multidrug resistance-associated protein (MRP) gene quantified by Northern blot analysis in comparison with those of the MDR1 gene determined by reverse transcription-polymerase chain reaction (RT-PCR) in 104 non-small-cell lung cancer (NSCLC) specimens [59 adenocarcinoma (Ad), 40 squamous cell carcinoma (Sq), four large cell carcinoma (La) and one adeno-squamous carcinoma (AdSq)]. Thirty-three (31.7%) of the 104 NSCLC expressed the MRP gene at various levels. The NSCLC showing high (++) levels of MRP gene expression (19 out of 33, 57.6%) were predominantly squamous cell carcinomas (Ad, 5; Sq, 13; La, 1) (P < 0.05). Six of the eight NSCLCs expressing high levels of MRP mRNA and no MDR1 (MRP ++, MDR1-) were squamous cell carcinomas. Sixty-one of the 104 NSCLC patients received chemotherapy with MRP-related anti-cancer drugs [vindesine (VDS) and etoposide (VP-16)]. Twenty-three patients (37.7%) with tumour expressing high or moderate levels of MRP showed significantly worse prognoses than those with non- or low-MRP-expressing tumours (P < 0.05). These results suggest that the level of MRP gene expression is related to the histopathology and prognosis of NSCLC.

Superiority of three-drug combination chemotherapy versus cisplatin-etoposide in advanced non-small cell lung cancer: a randomized trial by the Italian Oncology Group for Clinical Research

To evaluate the efficacy of a three-drug regimen vs. a two-drug CDDP based combination in the treatment of NSCLC, we conducted a three-arm randomized parallel trial comparing (a) CDDP (120 mg/m2 day 1) + etoposide (100 mg/m2 days 1-3) every 3 weeks (PE--arm A); (b) CDDP (120 mg/m2 every 4 weeks) + mitomycin (8 mg/m2 days 1, 29, 71) + vindesine (3 mg/m2 days 1, 8, 15, 22 every 2 weeks) (MVP--arm B); and (c) CDDP (120 mg/m2 day 1) + mitomycin (6 mg/m2 day 1) + ifosfamide (3 g/m2 day 2) every 3 weeks (MIC--arm C). From May 1989 to April 1992, 393 consecutive previously untreated patients with NSCLC Stage IIIB and IV entered the trial; 373 were evaluable for survival and 360 for response. The response rate was significantly better for both the three-drug regimens compared with PE (Table 3). Logistic regression model showed a significantly better response in patients with a good P.S. and in Stage IIIB. Main toxicity consisted of myelosuppression: neutropenia Grade III-IV was recorded in 14% (arm A), 15% (arm B) and 21% (arm C). Thrombocytopenia Grade III-IV was worst in arm C: 10% vs. 5% (arm A) and 3% (arm B). Nephrotoxicity Grade III-IV was more common in arm C: 3.5%. Toxic deaths were 11 (3%: three in arm A, five in arm B, three in arm C). From our data, the three-drug containing regimens, MVP and MIC, appear more active than the two-drug combination PE in treatment of advanced NSCLC.

Etoposide: twenty years later

Since the beginning of its clinical development 20 years ago, etoposide has become an important and widely used agent in clinical oncology. Its integral role in the treatment of germ cell tumors and small-cell lung cancer seems unlikely to diminish in the future, and its use in non-Hodgkin's lymphoma and in various high dose regimens will probably continue to increase. Active investigation continues regarding the optimal dose and schedule of etoposide, and it is likely that these investigations will result in further improvement of its clinical activity in patients with sensitive tumor types. Continued clinical investigation may result in the identification of active etoposide containing combination regimens for ovarian cancer, breast cancer, and some of the childhood malignancies. Exciting possibilities for the future include exploration of etoposide in combination with the topoisomerase I inhibitors, as well as the development of drugs to reverse drug resistance. During the next 10 years, the applications and importance of this unique drug will continue to increase.

Expression of the multidrug resistance gene (MDR1) in non-small cell lung cancer

To ezamine the clinical relevance of P-glycoprotein, encoded by the human multidrug resistance gene (MDR1), to multidrug resistance in lung cancer, we examined the expression of MDR1 in 107 non-small cell lung cancer (NSCLC) specimens and 20 corresponding specimens of normal lung tissues. We also evaluated the relationship between MDR1 expression and the histopathology and pathological staging of NSCLC. The tumors consisted of 60 adenocarcinomas, 38 squamous cell carcinomas, 8 large cell carcinomas, and 1 adenosquamous carcinoma. MDR1 expression was semi-quantified by use of the reverse transcriptase-polymerase chain reaction method. We subclassified the NSCLC into 3 grades according to the MDR1 expression level (-, +, ++). Sixty-one of the 107 tumor specimens (57%) and 18 of the normal lung tissue specimens (90%) expressed various levels of the MDR1 gene. Only one tumor specimen showed higher MDR1 expression than the corresponding normal lung tissue. The relationship between pathological stage and MDR1 expression levels was not significant. These results suggest that the level of MDR1 expression in lung cells is decreased as cells progress from the normal to the transformed state.

Cisplatin-fotemustine combination in inoperable non-small cell lung cancer: preliminary report of a French multicentre phase II trial

Fotemustine is a new nitrosourea derivative whose activity has been demonstrated on metastatic melanoma with specific activity on brain metastases and also on poor prognosis lung cancers. Results of in vitro studies of a cisplatin-fotemustine combination seem promising. In order to evaluate the efficacy and safety of this combination, we performed two trials. 6 patients entered a preliminary study whose schedule was cisplatin 120 mg/m2 on day 1 and fotemustine 100 mg/m2 on days 1 and 8. 22 patients were enrolled in a second study which added 120 mg/m2 cisplatin on day 22 followed by a 4-week rest period. In both trials, maintenance therapy consisted of cisplatin 100 mg/m2 and fotemustine 100 mg/m2 every 3 weeks until progression. Despite the poor prognostic factors which characterised our population (metastatic disease 86%, brain metastases 59%, < or = 80% performance status 45%), the results remain attractive with a 23% partial response rate (29% in non-pretreated patients). Moreover, 3 out of 8 patients with evaluable cerebral metastases achieved a partial response (37.5%). Toxicity was mild and related to the cumulative dose of cisplatin (peripheral neuropathy and renal toxicity). We concluded that these results need to be confirmed in a randomised trial.

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.

Carboplatin and vindesine in advanced non-small cell lung cancer. A feasibility study

Twenty-eight patients affected by advanced non-small cell lung cancer (NSCLC) were enrolled in a feasibility study evaluating toxicity and activity of carboplatin-vindesine combination chemotherapy, according to two different schedules. Fourteen patients were treated with carboplatin 350 mg/m2 monthly and vindesine 3 mg/m2 weekly for 5 doses, then every other week (schedule 1). The activity observed was promising with 3 partial remissions, but the toxicity was substantial, preventing full dose administration in 11 out of 14 patients. The subsequent 14 patients were treated with carboplatin 350 mg/m2 monthly and vindesine 3 mg/m2 on days 1 and 8 of each cycle. Activity was maintained with 4 partial remissions and toxicity was quite tolerable, allowing all patients to receive the planned treatment. The combination of carboplatin 350 mg/m2 on day 1 and vindesine 3 mg/m2 on days 1 and 8 seems active and well tolerated in advanced NSCLC patients and deserves further evaluation in a larger phase II study.

Phase II study of cisplatin as a 5-day continuous infusion with vindesine plus recombinant human granulocyte-colony-stimulating factor in the treatment of advanced non-small-cell lung cancer

A total of 36 patients with advanced non-small-cell lung cancer (NSCLC) were treated with a combination of 5-day continuous i.v. infusion of cisplatin (25 mg/m2 daily), bolus infusion of vindesine (3 mg/m2) on days 1 and 8, and s.c. injection of recombinant human granulocyte-colony-stimulating factor (2 micrograms/kg daily) on days 6-21. Treatment was repeated every 3-4 weeks. Responding patients with stage IIIA or IIIB disease received chest radiation therapy (50-60 Gy) after this treatment. One complete response and 23 partial responses were observed, for an overall response rate of 66.7% (24/36; 95% confidence limits, 51.3%-82.1%). The median duration of response was 5.7 months and the median overall survival was 10.1 months. WHO grade 3 or 4 leukopenia and neutropenia occurred in 22 (61%) and 27 (75%) patients, respectively, but the mean duration of leukopenia (< 2,000/mm3) and neutropenia (< 1,000/mm3) was 3.4 and 3.5 days, respectively, and there was no instance of life-threatening infection. Thrombocytopenia and anemia of grade 3 or 4 occurred in 28% and 36% of our subjects, respectively. Grade 2 nausea and vomiting occurred in 47% of the patients. Elevated serum creatinine levels (> 1.5 mg/dl) were observed in 3 (8%) of the 36 patients. One patient died of acute renal failure induced by hemorrhage of a gastric ulcer. This regimen is effective in the treatment of NSCLC and further studies of this combination are warranted.

Phase II study of weekly 5-fluorouracil, cisplatin and vinblastine in advanced non-small cell lung cancer

The scheduling of chemotherapeutic agents may be important in optimising their antitumour actions. This has been explored in non-Hodgkin lymphoma, osteogenic sarcoma and bladder cancer with improved results using intensive, weekly dosing schemas. We began a phase II study of cisplatin, 5-fluorouracil and vinblastine in non-small cell lung cancer (NSCLC) on a weekly schedule. 38 patients with advanced or metastatic NSCLC were entered; 32 are evaluable for response. 11 patients were treated with 5-fluorouracil 1.5 g/m2 and vinblastine 4 mg/m2 by 24-h continuous infusion, and cisplatin 30 mg/m2 over 30 min, 6-8 h after the start of the infusion. Because of prohibitive myelotoxicity, the next 27 patients received 5-fluorouracil 1.2 g/m2 and vinblastine 3 mg/m2. None had had prior chemotherapy while 6 had had previous radiation therapy. Myelosuppression was the predominant toxic effect. Other side-effects included neuropathy, diarrhoea, mucositis, nausea and vomiting. 32 patients are evaluable for response: there have been 14 partial remissions (44%). Responses have occurred chiefly in lung and lymph nodes. The median survival on this study is 7 months, and responders did not live longer than non-responders. While this regimen is well tolerated by the majority of patients and has a response rate comparable to other active regimens identified in single institution studies, survival does not appear to be enhanced. We conclude that the schedule manipulation described here does not enhance the therapeutic index of these drugs in NSCLC.

The clinical pharmacology and use of antimicrotubule agents in cancer chemotherapeutics

Although there has been a rapid expansion of the number of classes of compounds with antineoplastic activity, few have played a more vital role in the curative and palliative treatment of cancers than the antimicrotubule agents. Although the vinca alkaloids have been the only subclass of antimicrotubule agents that have had broad experimental and clinical applications in oncologic therapeutics over the last several decades, the taxanes, led by the prototypic agent taxol, are emerging as another very active class of antimicrotubule agents. After briefly reviewing the mechanisms of antineoplastic action and resistance, this article comprehensively reviews the clinical pharmacology, therapeutic applications, and clinical toxicities of selected antimicrotubule agents.

Edatrexate improves the antitumor effects of cyclophosphamide and cisplatin against non-small cell lung cancer

The authors treated 32 patients with Stage IIIB or IV non-small cell lung cancer (NSCLC) with an outpatient regimen of edatrexate (10-ethyl-10-deaza-aminopterin) (10-EdAM) on days 1 and 8, cyclophosphamide on day 1, and cisplatin on day 1, repeated every 3 weeks with dose modification. The 22 men and 10 women (median age, 57 years of age) had no prior chemotherapy and a Zubrod performance status less than or equal to 2. A schedule with initial doses of 80 mg/m2, 800 mg/m2, and 80 mg/m2, respectively, yielded a 47% major response rate with two complete responses (95% confidence interval [CI], 25% to 70%), but it also yielded significant stomatitis and myelosuppression. A schedule with reduced starting doses (70 mg/m2, 700 mg/m2, and 70 mg/m2) was better tolerated, but dropped the major response rate to 27% with no complete responses (95% CI, 11% to 52%). Median survival time was 39 weeks for all 30 evaluable patients without a significant difference between the treatment groups (which were comparable in patient characteristics). Major response, however, was associated with longer survival time than minor response or no change (P = 0.024) or progressive disease (P = 0.001) (median survival times, 55, 39, and 27 weeks, respectively). When the doses delivered were compared, patients treated with the reduced dose schedule received less mean 10-EdAM per course (P = 0.01), although the doses of cyclophosphamide and cisplatin were comparable to the original dose schedule for the second course and thereafter. These results suggest that this three-drug regimen may have synergistic antitumor effects, with a steep dose-response relationship, particularly with 10-EdAM. With amelioration of the dose-limiting stomatitis of 10-EdAM, it seems possible to maximize the antitumor effects of this regimen.

Non-small cell lung cancer. Part II: Treatment

Squamous, large cell, and adenocarcinoma, collectively termed non-small cell lung cancer (NSCLC), are diagnosed in approximately 75% of patients with lung cancer in the United States. The treatment of these three tumor cell types is approached in virtually identical fashion because, in contrast to small cell carcinoma of the lung, NSCLC more frequently presents with localized disease at the time of diagnosis and is thus more often amenable to surgical resection but less frequently responds to chemotherapy and irradiation. Cigarette smoking is etiologically related to the development of NSCLC in the great majority of cases. Genetic mutations in dominant oncogenes such as K-ras, loss of genetic material on chromosomes 3p, 11p, and 17p, and deletions or mutations in tumor suppressor genes such as rb and p53 have been documented in NSCLC tumors and tumor cell lines. NSCLC is diagnosed because of symptoms related to the primary tumor or regional or distant metastases, as an incidental finding on chest radiograph, or rarely because of a paraneoplastic syndrome such as hypercalcemia or hypertrophic pulmonary osteoarthropathy. Screening smokers with periodic chest radiographs and sputum cytologic examination has not been shown to reduce mortality. The diagnosis of NSCLC is usually established by fiberoptic bronchoscopy or percutaneous fine-needle aspiration, by biopsy of a regional or distant metastatic site, or at the time of thoracotomy. Pathologically, NSCLC arises in a setting of bronchial mucosal metaplasia and dysplasia that progressively increase over time. Squamous carcinoma more often presents as a central endobronchial lesion, while large cell and adenocarcinoma have a tendency to arise in the lung periphery and invade the pleura. Once the diagnosis is made, the extent of tumor dissemination is determined. Since most NSCLC patients who survive 5 years or longer have undergone surgical resection of their cancers, the focus of the staging process is to determine whether the patient is a candidate for thoracotomy with curative intent. The dominant prognostic factors in NSCLC are extent of tumor dissemination, ambulatory or performance status, and degree of weight loss. Stages I and II NSCLC, which are confined within the pleural reflection, are managed by surgical resection whenever possible, with approximate 5-year survival of 45% and 25%, respectively. Patients with stage IIIa cancers, in which the primary tumor has extended through the pleura or metastasized to ipsilateral or subcarinal lymph nodes, can occasionally be surgically resected but are often managed with definitive thoracic irradiation and have 5-year survival of approximately 15%.(ABSTRACT TRUNCATED AT 400 WORDS)

A randomised clinical trial of vindesine plus cisplatin versus mitomycin plus vindesine and cisplatin in advanced non-small cell lung cancer

This trial was carried out to evaluate the therapeutic benefit of the addition of mitomycin to vindesine plus cisplatin (80 mg/m2) in 126 previously untreated non-small cell lung cancer (NSCLC) patients. 124 patients were evaluable for toxicity and survival and 122 for response. No patient achieved complete response. The partial response rate (PR) in the vindesine plus cisplatin (VP) and mitomycin plus vindesine and cisplatin (MVP) groups were 23% (14/62) vs. 35% (21/60) (P = 0.13) with a median duration of response of 23 vs. 37 weeks (P = 0.071), respectively. Time to progression (TTP) and survival time (ST) were similar for both treatment arms [median TTP; 14 vs. 21 weeks (P = 0.10), median ST; 9.1 vs. 10.5 months (P = 0.94), respectively]. No difference in the frequency of side-effects was observed except that WHO grade 3 and 4 leukopenia was higher in the MVP group. In multivariate analysis, the significant predictors of survival were serum albumin, sex, performance status, lactate dehydrogenase and stage. In conclusion, the addition of mitomycin to the VP regimen appears to have limited value in advanced NSCLC.

[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.

Etoposide in the management of non-small cell lung cancer

Etoposide is a phase-specific, schedule-dependent derivative of podophyllotoxin that appears to act by inhibiting DNA-topoisomerase II. Early preclinical work demonstrated sharp activity in mouse leukemias and possible synergy with cisplatin. As a single agent (either orally or intravenously), it demonstrated limited benefit in non-small cell lung cancer (NSCLC), with response rates around 10%. In combination with cisplatin, it has become a mainstay of chemotherapeutic efforts, either as primary therapy or in conjunction with radiation. Response rates in advanced disease average around 30%, climbing to more than 50% in patients with Stage IIIA or IIIB disease. More recent work suggests that the issue of the true synergy of etoposide with cisplatin in NSCLC needs reassessment. The relative roles of etoposide and cisplatin in the combination are unclear, as several studies conflict. Pharmacokinetic data suggest that multiple daily fractions of etoposide are superior to prolonged infusions, warranting several future trials. The current major role for etoposide plus cisplatin would appear to be in multimodality therapy where the combination can be readily combined with radiation and/or surgery. Several other agents have been studied with etoposide or etoposide plus cisplatin (mitomycin, vindesine, doxorubicin, cyclophosphamide, ifosfamide, and carboplatin), but it is unclear whether the addition of any of them offers any response or survival advantage.

Phase II study of carboplatin in untreated, inoperable non-small-cell lung cancer

A total of 51 previously untreated patients with non-small-cell lung cancer (NSCLC) were treated with 130 mg/m2 carboplatin given every 4 weeks as an i.v. infusion on days 1, 3, and 5. Ten patients achieved a partial response and five, a minor response. The overall response rate was 20% (95% confidence limits, 8%-32%). The median duration of response was 3 months and the median overall survival was 4.5 months. Leucopenia, thrombocytopenia and anemia of WHO grade 3 occurred in 4%-6% of patients and grade 3 nausea and vomiting was observed in 8% of our subjects. Grade 4 thrombocytopenia occurred in 3 (6%) patients. Apart from nausea and vomiting, nonhematologic toxicities above grade 2 were not observed. Further trials using carboplatin in NSCLC as a single agent or in combination with other chemotherapeutic agents or radiation are warranted.

Etoposide versus etoposide plus high-dose cisplatin in the management of advanced non-small cell lung cancer. Results of a prospective randomized FONICAP trial. Italian Lung Cancer Task Force

Two hundred sixteen patients with unresectable non-small cell lung carcinoma were randomly allocated to receive etoposide (120 mg/m2, days 1-3) either alone or in combination with high-dose cisplatin (60 mg/m2, days 1-2). The patients' distribution and characteristics were similar in the two treatment arms. The objective response rate for etoposide was 7% versus 25.8% for etoposide plus cisplatin (P less than 0.005). Median progression-free survival in etoposide arm was 3.5 months versus 5 months in the combination arm (P = 0.43). The median survival time for etoposide was 6 months compared with 8 months for etoposide combined with cisplatin (P = 0.87). Significantly more nausea/vomiting (P less than 0.005), serum creatinine elevation (P less than 0.005), hearing loss and/or tinnitus (P less than 0.005), peripheral neuropathy (P less than 0.005), leukopenia (P less than 0.025), and anemia (P less than 0.005) occurred in the etoposide plus cisplatin arm. No statistically significant difference was recorded between the two arms in terms of performance status changes. In conclusion the addition of high-dose cisplatin to single-agent etoposide significantly increases the chance of obtaining tumor response in advanced non-small cell lung cancer at the cost of an increased toxicity without any significant long-term impact on survival and progression-free survival.

Cisplatin, etoposide, and ifosfamide in non-small cell lung carcinoma. A phase II randomized study with cisplatin and etoposide as the control arm

A Phase II randomized study testing the combination of cisplatin, etoposide, and ifosfamide (PEI) in non-small cell lung cancer (NSCLC) was performed. The standard combination of cisplatin and etoposide (PE) was used as the control arm. Since January 1987, 78 patients were enrolled and then stratified for previous treatments and performance status (PS). The response rate (RR) of PEI was 26% (95% confidence limits [95 CL], 12% to 40%), with one complete response (CR). The RR of PE was 26% (95 CL, 13% to 39%), with no CR. The median response duration was 5 months (range, 2 to 13 months) for PEI and 4 months (range, 2 to 6 months) for PE. The median survival time was 6 months (range, 1 to 22+ months) for PEI and 7 months (range, 1 to 21+ months) for PE. Leukopenia at recycling was similar in both arms (25% for PEI and 29% of PE). The median leukocyte nadir was 2100/microliters (range, 430 to 4870/microliters) for PEI patients and 3150/microliters (range, 500 to 5000/microliters) for PE patients. Three patients had a drug-related death secondary to infections. This Phase II randomized study suggested that the combination of cisplatin plus etoposide and ifosfamide produces results similar to those obtainable with cisplatin and etoposide.

A randomised trial of cisplatin and vindesine versus supportive care only in advanced non-small cell lung cancer

The value of chemotherapy in advanced non-small cell lung cancer (NSCLC) remains contentious. Because of this two separate but very similar trials were set up in Australia and Southampton (UK). Two hundred and one patients with stage IIIb or IV NSCLC were randomly assigned to cisplatin 120 mg m-2 on days 1 and 29 and vindesine 3 mg m-2 weekly x 6 or to no chemotherapy. Both groups were eligible to receive radiotherapy or other palliative treatment as required. Of 188 evaluable patients, 97 received chemotherapy and 91 were in the control arm. Response was assessed between days 42 and 49. Responders continued chemotherapy at the same doses though cisplatin being given 6 weekly x 4 and the vindesine 2 weekly x 12. The overall response rate to chemotherapy was 28%; there were no significant differences according to major prognostic criteria. Although the overall survival of the chemotherapy group (median 27 weeks) was longer than that of the no chemotherapy group (median 17 weeks) this was not statistically significant (log rank P = 0.33). For patients without dissemination (IIIb), median survival was 45 weeks in the chemotherapy arm and 26 weeks in the non-chemotherapy (log rank P = 0.075). Toxicity was universal and frequently severe: of 17 patients discontinuing chemotherapy after one cycle, 13 did so because of unacceptable toxicity. This chemotherapy cannot be recommended as routine treatment. Further phase III studies of chemotherapy in advanced NSCLC should continue to use a no chemotherapy control and should also attempt to measure quality of life, an issue not addressed effectively in this or other recent trials.

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.

Combination versus sequential single-agent chemotherapy in the treatment of patients with advanced non-small cell lung cancer

We have carried out a randomized phase III study in 105 patients with advanced non-small cell lung cancer, comparing a four-drug cisplatin-mitomycin-based combination chemotherapy regimen to sequential single-agent therapy. The combination chemotherapy regimen consisted of mitomycin C (10 mg/m2), vinblastine (5 mg/m2), methotrexate (40 mg/m2), and cisplatin (40 mg/m2) given every 28 days. Sequential single-agent chemotherapy consisted of mitomycin C (10 mg/m2) monthly until progression followed by vinblastine (5 mg/m2) every 2 weeks until progression followed by methotrexate (40 mg/m2) weekly until relapse. Patients failing either regimen were followed with supportive care. The objective response rate for the sequential single-agent therapy was 19% versus 25% for the combination chemotherapy group (P greater than .5). The median survival for the single-agent group was 166 days and 191 days for the combination chemotherapy group. Overall survival was not statistically different between the two groups (P greater than .5). Leucopenia, anemia, and prolonged anorexia with nausea and vomiting were more common in the combination chemotherapy group compared to the single-agent group. This study failed to demonstrate a sufficient therapeutic benefit in the face of the added toxicity for the combination chemotherapy regimen compared to sequential single-agent therapy.

Treatment of advanced non-small cell lung cancer with cisplatin, 5-fluorouracil, and mitomycin C

Thirty patients with advanced non-small cell lung cancer (NSCLC) were treated with cisplatin (P), mitomycin C (M), and 5-fluorouracil (5-FU) chemotherapy. Twelve patients (40%) achieved major responses to therapy (11 partial, one regression). The median duration of partial response was 20 weeks. Median survival for the entire group was 29 weeks. Toxicity with this combination was moderate, with myelosuppression being the most significant toxic effect. Acute hematologic toxicity was generally mild, with 74% of patients having a leukocyte nadir greater than or equal to 2000/microliter and 67% with a platelet count nadir of greater than or equal to 100,000/microliter. There were, however, two toxic deaths during periods of treatment-induced cytopenia, 40% of patients developed significant anemia necessitating blood transfusions, and 33% had episodes of prolonged neutropenia. Nonhematologic toxicities were generally mild, although one patient developed a cardiac arrest of unclear etiology during day 4 of cycle 3 of treatment and died, for a total treatment mortality rate of 10% (three of 30). This drug combination produced a response rate comparable to those noted with other two or three drug cisplatin-based regimens in NSCLC but does not appear to offer any substantial advantage given its moderate toxicity, short duration of response, and necessity for substantial hospitalization.

Multimodality treatment of non-small cell lung cancer: response to cisplatin, VP-16, and 5-FU chemotherapy and to surgery and radiation therapy

Twenty-one patients with unresectable non-small cell lung cancer (NSCLC), 11 with stage III M0, five with malignant pleural effusion, and five with a single resectable metastasis were treated with multimodality therapy. All received two to three cycles of preoperative chemotherapy with a new sequential combination of cisplatin (50 mg/m2 IV X 1) followed by 5-FU infusion (40 mg/m2/hr X 72) and etoposide (80 mg/m2/day X 3). Thirteen of 21 (62%) had a partial response, and three (14%) had a minor response to chemotherapy. Of the 19 who underwent surgical exploration, 17 were confirmed to have NSCLC. Ten patients with NSCLC and one with choriocarcinoma were rendered disease free by resection of the primary tumor and lymph nodes. Six received intra- and/or perioperative interstitial therapy with 125I and/or 192Ir. Another patient was treated with 32P. Postoperative external radiotherapy was administered in 15 patients, and adjuvant chemotherapy was administered in ten. This multimodality therapy was well tolerated, safe, and highly effective, resulting in excellent palliation even in patients with pleural effusion and metastasis. The most promising results were in unresectable stage III M0 with a partial response rate of 82% following neoadjuvant chemotherapy and a complete response rate of 73% after surgery. In this group, median survival has not yet been reached and will exceed 12 months.

Toxicity, physical function and everyday activity reported by patients with inoperable non-small cell lung cancer in a randomized trial (chemotherapy versus radiotherapy)

In a randomized trial, patients with inoperable non-small cell lung cancer with limited disease were randomly given either radiotherapy (42 Gy) or combination chemotherapy with cisplatin, 70 mg/m2, and etoposide, 100 mg/m2, given every third week with a maximum of 4 cycles. The patients were asked to fill in a questionnaire concerning psychosocial well-being, medical and treatment related symptoms, physical function and everyday activity. Of the chemotherapy patients 61% reported nausea 5 weeks after their last chemotherapy session and 44% had spells of vomiting. Only 14% of the radiotherapy patients had nausea and 5% vomited 14 weeks after start of treatment. Of the radiotherapy patients 64% experienced dysphagia compared to 8% of the chemotherapy patients 6 weeks after the start of treatment.

Prognostic factors in non-small cell lung cancer: multiregression analysis in the National Cancer Center Hospital (Japan)

A total of 190 patients with unresectable non-small cell lung cancer (NSCLC) were analyzed retrospectively using eight pretreatment and three treatment-related prognostic factors in terms of influence on survival. All the patients received chemotherapy with or without chest irradiation, according to the protocol of phase II or phase III trials of the National Cancer Center Hospital Tokyo between April 1980 and December 1985. The eight pretreatment factors selected were performance status, sex, stage, age, histology, and metastasis to brain, bone or, liver. Three treatment-related factors were radiation therapy to the primary site, response to chemotherapy, and treatment period, before or after clinical administration of cis-diamminedichloroplatinum (II) (CDDP). Of the 190 patients, 71 (37.4%) were alive for more than 1 year, but only 17 patients (8.9%) survived 2 years after the initiation of chemotherapy. By univariate analysis, performance status 0-1, female, no metastasis to bone or liver, response to chemotherapy, and treatment period after CDDP were considered to be favorable prognostic factors. By multiregression analysis, performance status, sex, and treatment period after CDDP proved to be important factors for long-term survival. Consideration of these prognostic factors could enable the results of chemotherapy to be more accurately evaluated, and stratification of patients with advanced NSCLC based on performance status and sex before entry into a randomized controlled trial is recommended.

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

Combination chemotherapy using vindesine and cisplatinum has been reported to be active in non-small cell lung carcinoma (NSCLC). In an attempt to reduce the potential neurotoxicity of this combination, and to assess the role of cisplatinum, a randomized trial has compared vindesine and cisplatinum to vindesine and methotrexate in 48 patients with advanced symptomatic NSCLC. Patient characteristics were similar in the two treatment arms. Objective tumour response and survival were similar for both treatments. No complete response occurred. Four patients receiving vindesine/cisplatinum (16%) and three patients receiving vindesine/methotrexate (13%) had a partial response. All responses occurred in patients with a performance status of 70% or more and no response was seen in patients with squamous cell carcinoma. Median survival for both regimens was 16 weeks. Toxicity was considerable and only six patients (12.5%) felt better on treatment. Nausea and vomiting were more frequent in the vindesine/cisplatinum arm, but mild neurotoxicity was more common in the vindesine/methotrexate arm. The low response rates, short survival and significant toxicity suggest that the role of combination chemotherapy in NSCLC remains to be established.

Clinical value of the creatinine clearance before the administration of chemotherapy with cisplatin

The creatinine clearance was calculated in standard fashion from a timed urine specimen (measured creatinine clearance [MCC]) and from a previously published formula (estimated creatinine clearance [ECC]), in 55 instances, in 19 consecutive patients who were admitted to the hospital for treatment with cisplatin. Using creatinine excretion as an index of completeness of urine collection, there were 19 (35%) inaccurate collections. The correlation between creatinine clearances calculated by both methods was excellent (r = 0.684, P less than .001) and improved when inaccurate collections were excluded (r = 0.922, P less than 0.001). A discrepancy between the two methods of 25% or more was found in 19 collections. Using data from patients with two or more collections to test whether or not the two methods produced equally variable results, indicated that the MCC is a more variable, less reliable method than the ECC. In eight of 55 urine collections, the results of MCC were not used as a guide to chemotherapy and, in an additional 16 should have not been used because of inaccuracy in the urine collection. These results suggest that the creatinine clearance as calculated by an alternative method (ECC) should replace the use of MCC when assessment of the renal function is needed before the administration of nephrotoxic agents.