Randomized trial comparing weekly versus 3-week chemotherapy in small-cell lung cancer: a Cancer Research Campaign trial

Small Cell Lung Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Small Cell Lung Cancer (SCLC) provide recommended management for patients with SCLC, including diagnosis, primary treatment, surveillance for relapse, and subsequent treatment. This selection for the journal focuses on metastatic (known as extensive-stage) SCLC, which is more common than limited-stage SCLC. Systemic therapy alone can palliate symptoms and prolong survival in most patients with extensive-stage disease. Smoking cessation counseling and intervention should be strongly promoted in patients with SCLC and other high-grade neuroendocrine carcinomas. The "Summary of the Guidelines Updates" section in the SCLC algorithm outlines the most recent revisions for the 2022 update, which are described in greater detail in this revised Discussion text.

Health-related quality of life in small-cell lung cancer: a systematic review on reporting of methods and clinical issues in randomised controlled trials

Small-cell lung cancer represents about 15% of all lung cancers; increasingly, randomised controlled trials of this disease measure the health-related quality of life of patients. In this Systematic Review we assess the adequacy of reporting of health-related quality-of-life methods in randomised controlled trials of small-cell lung cancer, and the potential effect of this reporting on clinical decision making. Although overall reporting of health-related quality of life was acceptable, improvements are needed to optimise the use of health-related quality of life in randomised controlled trials.

Small cell lung cancer

Neuroendocrine tumors account for approximately 20% of lung cancers; most (≈15%) are small cell lung cancer (SCLC). These NCCN Clinical Practice Guidelines in Oncology for SCLC focus on extensive-stage SCLC because it occurs more frequently than limited-stage disease. SCLC is highly sensitive to initial therapy; however, most patients eventually die of recurrent disease. In patients with extensive-stage disease, chemotherapy alone can palliate symptoms and prolong survival in most patients; however, long-term survival is rare. Most cases of SCLC are attributable to cigarette smoking; therefore, smoking cessation should be strongly promoted.

Small-Cell Lung Cancer: An Unusual Therapeutic Approach with More than 10-year Overall Survival. Case Report and Review of the Literature

Small-cell lung cancer is the most aggressive lung cancer, with a dismal prognosis. The authors present a case report of a patient with limited-stage small-cell lung cancer who underwent a thoracotomy for diagnostic purposes, with the diagnosis being made after surgical excision. Combination chemotherapy remains the cornerstone of treatment for both limited and extensive disease. Radiotherapy has been established as an adjunct to chemotherapy in limited-stage disease, while in extensive-stage disease it is mostly reserved for the treatment of brain metastases. As for surgery, the potential benefits of resection are predominantly seen in patients who present with a solitary pulmonary nodule. Since small-cell lung cancer becomes highly resistant to chemotherapy, second-line chemotherapeutic schemes are used for disease progression, with topotecan being the highlighted agent. Despite the unusual therapeutic approach, where surgery was preferred over the standard diagnostic and staging procedures, the patient's more than ten years’ survival makes this case presentation a very interesting one.

Early compared with late radiotherapy in combined modality treatment for limited disease small-cell lung cancer: a London Lung Cancer Group multicenter randomized clinical trial and meta-analysis

PURPOSE

To replicate an earlier National Cancer Institute of Canada (NCIC) trial that examined the effect on survival of the timing of thoracic radiotherapy (TRT) in patients with limited disease small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Patients received three cycles of cyclophosphamide, doxorubicin, and vincristine alternating with three cycles of etoposide and cisplatin. Three hundred twenty five chemotherapy- and radiotherapy-naïve patients were randomly assigned to either early TRT administered concurrently in the second cycle or late TRT administered concurrently with the sixth cycle; the dose was 40 Gy in 15 fractions over 3 weeks.

RESULTS

TRT was received by 92% and 82% of patients in the early and late arms, respectively (P = .01). Sixty-nine percent of patients in the early arm received all six courses of chemotherapy compared with 80% in the late arm (P = .003). There was no evidence of a survival difference; median overall survival time was 13.7 and 15.1 months in the early and late arms, respectively (P = .23). In a meta-analysis of all eight trials that compared early and late TRT, there were three in which the proportion of patients who completed their planned chemotherapy was similar between the TRT arms (hazard ratio [HR] = 0.73; 95% CI, 0.62 to 0.86) and five in which proportionally fewer patients in the early TRT arm completed their chemotherapy (HR = 1.06; 95% CI, 0.97 to 1.17).

CONCLUSION

This study failed to show a survival advantage for early TRT with chemotherapy in limited-stage SCLC, unlike the NCIC trial. However, the results of a meta-analysis suggest that it is essential to ensure that the delivery of chemotherapy is optimal when administered with early TRT.

A phase I trial of carboplatin and etoposide for elderly (≥75 year-old) patients with small-cell lung cancer

PURPOSE

The combination of carboplatin and etoposide is currently considered the most appropriate regimen for treating elderly patients with small-cell lung cancer (SCLC). Previous reports on elderly patients, 70 years or older, found that the recommended dose was close to that of younger patients. Then, we conducted a phase I study of carboplatin and etoposide in elderly patients, 75 years or older, with SCLC. This study aimed to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT).

METHODS

Twenty-six patients fulfilling the eligibility criteria, chemotherapy-naive, performance status (PS) of 0-2, age>or=75, and adequate organ functions were enrolled. Patients' characteristics were: male/female=21/5; PS 0/1/2=9/11/6; median age (range)=78 (75-82); and limited/extensive stage=16/10. The patients intravenously received carboplatin with a target AUC of 4 or 5 mg min/ml (Chatelut formula) on day 1 and etoposide at 80-120 mg/m2 on days 1, 2 and 3. Therapy was repeated four times in every 4 weeks.

RESULTS

The MTD of carboplatin/etoposide was AUC=5/80, 4/110, and 4/120. The DLTs were thrombocytopenia, neutropenia, leukopenia, and febrile neutropenia. Overall, grade 4 thrombocytopenia, neutropenia (>or=4 days), leukopenia (>or=4 days), and febrile neutropenia occurred in 27, 20, 7, and 13% of cases at MTD levels, respectively, and 0% at other levels. Twenty of 26 patients showed objective responses (2CR, 18PR; RR=77%).

CONCLUSION

A dose of carboplatin of AUC=4 and etoposide of 100 mg/m2 was recommended in this regimen.

Second-line chemotherapy in small cell lung cancer in a modified administration of topotecan combined with paclitaxel: a phase II study

PURPOSE

Our main objective was to investigate the response rate in pretreated patients with small cell lung cancer (SCLC) who received a weekly administration of topotecan and paclitaxel; our secondary objectives were to assess toxicity and survival.

METHODS

Topotecan 1.75 mg/m2 was combined with paclitaxel 70 mg/m2; these cytotoxic agents were administered once every week (day 1) for 3 consecutive weeks (one cycle), and repeated every 28 days (three infusions per cycle) for a minimum of three cycles.

RESULTS

Forty-five patients were enrolled, 41 of whom were evaluable for response and toxicity. The median number of cycles was two (range 1-6). Eleven/forty-one (26.83%) patients responded: one complete response and ten partial responses; the median duration of response was 4 months (range 2-8 months); the median overall survival was 7 months (95% CI: 4.2-9.8). Myelotoxicity was the most common adverse reaction (grade 3 neutropenia in 19.5% of the patients and grade 4 in 7.32%). Non-hematologic toxicities varied from 2.44% to 9.76%. No patient had to stop treatment due to toxicity.

CONCLUSION

Topotecan combined with paclitaxel, given on day 1 on a weekly basis, produced a response rate of 26.83% in pretreated patients with SCLC. Myelotoxicity, particularly neutropenia, was the main adverse reaction, but in a minority of patients.

Concurrent weekly cisplatin and radiotherapy in routine management of cervical cancer: a report on patient compliance and acute toxicity

PURPOSE

To evaluate patient compliance and acute toxicity accompanying concurrent weekly cisplatin and radiotherapy (RT) in the routine management of cervical cancer.

METHODS AND MATERIALS

Locally advanced or high-risk early-stage cervical cancer patients treated with RT and concurrent weekly cisplatin at a dose of 40 mg/m(2) i.v. (maximum dose, 70 mg) for five cycles. Definitive RT included whole pelvis external beam RT to the International Commission on Radiation Units and Measurements reference dose of 40 Gy plus a 10-Gy boost to the parametrium and two brachytherapy applications of 20 Gy to point A each. Postoperative RT consisted of pelvic external beam RT to the International Commission on Radiation Units and Measurements reference dose of 50 Gy and one brachytherapy application of 30 Gy at a depth of 0.5 cm from the applicator surface.

RESULTS

Included in this analysis were 112 consecutive cervical cancer patients treated at one institution with concurrent cisplatin and RT between May 1999 and September 2002. The median age was 48 years (range, 28-79 years). Definitive RT was administered to 57 International Federation of Gynecology and Obstetrics "bulky" Stage IB or IIB-IVA patients, and 53 patients underwent postoperative RT; 2 patients underwent RT for stump carcinoma. All but 2 patients (both administered definitive RT) completed RT. A total of 454 cisplatin cycles were administered (median 4 cycles/patient, range 1-6). Overall, 74% of patients received at least four cycles of cisplatin. The planned five cisplatin cycles were administered to 50 patients (45%); 42% were irradiated definitively and 47% postoperatively. The full and timely planned cisplatin dose was administered to 29 patients (26%). For 29% of patients, the interval between cycles was prolonged because of toxicity (n = 11; 10%) or for reasons not related to toxicity (n = 10; 9%). Of the 112 patients, 62 (55%) did not undergo the planned five cycles of cisplatin because of treatment toxicity (n = 35; 31%) or noncompliance with the treatment schedule because of delayed administration of the first cycle or omission of a cycle for reasons other than toxicity (n = 23; 21%). The most common side effects resulting in chemotherapy discontinuation included GI complications (n = 7) and impaired renal function (n = 5). Of the 112 patients, 49 (44%) experienced Grade 1 or 2 leukopenia and 6 (5%) Grade 3 or 4 leukopenia.

CONCLUSION

Our results show that pelvic RT combined with weekly cisplatin in cervical cancer patients is accompanied by considerable acute toxicity. Furthermore, a number of patients were unable to comply with the treatment schedule owing to reasons unrelated to treatment toxicity. Thus, administration of the full chemotherapy dose may be difficult, although the delivery of planned RT was generally not compromised. Additional follow-up is needed to assess the late toxicity of combined modality treatment.

Recent advances in management of small-cell lung cancer

Small-cell lung cancer (SCLC) is a smoking-related disease with a poor prognosis. While SCLC is usually initially sensitive to chemotherapy and radiotherapy, responses are rarely long lasting. Frustratingly, most patients ultimately relapse, often with increasingly treatment resistant disease. Many strategies have been developed in an attempt to improve treatment outcomes, which have plateaued since the introduction of combination chemotherapy in the 1980s. These include trials of maintenance therapy, and dose intensification, the latter by means of increasing dose density, growth factor support and high dose chemotherapy with autologous stem cell rescue. None have been shown to improve patient survival. On the other hand, the integration of concurrent thoracic radiation and prophylactic cranial irradiation has improved the survival outcomes in patients with limited disease. In extensive disease, irinotecan combined with cisplatin has shown promise in improving survival over conventional platinum/etoposide chemotherapy schedules and a confirmatory study is awaited. The future of SCLC treatment may however lie with molecularly targeted therapies, such as antiangiogenesis agents and signal transduction inhibitors, which are being studied at present.

First-line chemotherapy in metastatic small-cell lung cancer (SCLC)

The overall treatment results in metastatic small-cell lung cancer have not been changed in the last decades. The prognosis of the disease is still poor with median survival times of less than one year and nearly no chance of cure. This article intends to summarize the current status of treatment in m-SCLC and especially focuses on the aspects of choice of drugs and efforts of treatment intensification either by dose escalation or shortening of treatment intervals. Furthermore the currently available data about the activity of newer drugs, including taxanes and topoisomerase I inhibitors are reported. These cytostatic agents widen the therapeutic options in the treatment of SCLC and will hopefully improve the outcome of the patients in the next years.

Randomized phase II study of cisplatin, irinotecan and etoposide combinations administered weekly or every 4 weeks for extensive small-cell lung cancer (JCOG9902-DI)

BACKGROUND

The purpose of this study was to evaluate the toxicity and antitumor effect of cisplatin, irinotecan and etoposide combinations on two schedules, arms A and B, for previously untreated extensive small-cell lung cancer (E-SCLC), and to select the right arm for phase III trials.

PATIENTS AND METHODS

Sixty patients were randomized to receive either arm A (cisplatin 25 mg/m(2) day 1, weekly for 9 weeks, irinotecan 90 mg/m(2) day 1, on weeks 1, 3, 5, 7 and 9, and etoposide 60 mg/m(2) days 1-3, on weeks 2, 4, 6, 8), or arm B (cisplatin 60 mg/m(2) day 1, irinotecan 60 mg/m(2) days 1, 8, 15, and etoposide 50 mg/m(2) days 1-3, every 4 weeks for four cycles). Prophylactic granulocyte colony-stimulating factor support was provided in both arms.

RESULTS

Full cycles were delivered to 73% and 70% of patients in arms A and B, respectively. Incidences of grade 3-4 neutropenia, anemia, thrombocytopenia, infection and diarrhea were 57, 43, 27, 7 and 7%, respectively, in arm A, and 87, 47, 10, 13 and 10%, respectively, in arm B. A treatment-related death developed in one patient in arm A. Complete and partial response rates were 7% and 77%, respectively, in arm A, and 17% and 60%, respectively, in arm B. Median survival time was 8.9 months in arm A, and 12.9 months in arm B.

CONCLUSIONS

Arm B showed a promising complete response rate and median survival with acceptable toxicity in patients with E-SCLC, and should be selected for the investigational arm in phase III trials.

A model for decision making for the use of radiotherapy in lung cancer

To develop an evidence-based benchmark for the use of radiotherapy in lung cancer, we did a systematic review of treatment guidelines on radiotherapy for lung cancer. We then constructed an optimum use of radiotherapy "tree" from epidemiological data, which shows the proportion of patients with clinical attributes indicating that they would benefit from radiotherapy. We calculated that the proportion of patients with lung cancer in whom radiotherapy is indicated (according to the best available evidence) is 76%. We then compared this ideal rate with the actual rates of use of radiotherapy for lung cancer in Australia, and internationally, in the past decade. A substantial discrepancy was found between the evidence-based recommended rate of use and the actual rates reported in clinical practice. We hope this model will be used to plan efficient and cost-effective radiotherapy services.

Small cell lung cancer

Among patients with lung cancers, the proportion of those with small cell lung cancer (SCLC) has decreased over the last decade. SCLC is staged as limited-stage disease and extensive-stage disease. Standard staging procedures for SCLC include CT scans of the chest and abdomen, bone scan, and CT scan or MRI of the brain. The role for positron emission tomography scanning in the staging of SCLC has yet to be defined. Limited-stage disease is treated with curative intent with chemotherapy and radiation therapy, with approximately 20% of patients achieving a cure. The median survival time for patients with limited-stage disease is approximately 18 months. Extensive-stage disease is treated primarily with chemotherapy, with a high initial response rate of 60 to 70% and a complete response rate of 20 to 30%, but with a median survival time of approximately 9 months. Patients achieving a complete remission should be offered prophylactic cranial irradiation. Currently, there is no role for maintenance treatment or bone marrow transplantation in the treatment of patients with SCLC. Relapsed or refractory SCLC has a uniformly poor prognosis. In this section, evidence-based guidelines for the staging and treatment of SCLC are outlined.

Dose intensive chemotherapy in small cell lung cancer

The rationale for treatment intensification is to overcome the occurrence of drug resistance and to improve the outcome in SCLC. Several different approaches have been tested in the past two decades. Increasing the dose of conventional chemotherapy has failed to improve survival in extensive stage. In limited stage patients one randomized trial demonstrated a significant survival advantage by a 20% increase of the dose of cisplatin and cyclophosphamide given during the first cycle of chemotherapy. Shortening treatment intervals is achievable by weekly chemotherapy or by use of hematopoietic growth factors. Neither weekly chemotherapy, tested in four randomized trials, nor the application of hematopoietic growth factors significantly improved survival. However, two studies described a better survival for patients receiving chemotherapy in shorter treatment intervals. In one trial a 3-week interval was superior to a 4-week interval, and in a second one a 2-week interval superior to a 3-week interval. One smaller study, comparing a 4-week interval with a 2-week interval with stem cell augmentation by whole blood, revealed no difference in survival between both groups. A randomized trial comparing chemotherapy in intervals as short as possible with or without growth factor application showed no difference for the two groups. Thus, growth factor application seems not to be essential for treatment in short intervals and was not associated with superior survival in randomized trials. To achieve a more than two-fold increase in dose intensity some kind of stem cell support is mandatory. Several phase II trials with small patient numbers tested the concept of late intensification with bone marrow support in the 1980s. These trials did not show any convincing benefit. There is one randomized trial available testing the late intensification approach in which a superior progression free survival and a trend for better survival was demonstrated, but this difference was not statistically significant due to a high mortality rate and a substantial number of local relapses in the high dose arm. Newer concepts involving high dose therapy are combining high dose strategies with approaches for better local tumor control, administer high dose regimens earlier in the treatment course, or use multiple sequential high dose cycles. With these approaches 3-year survival rates of up to 40% have been reported. So up to date, the superiority of an intensified treatment strategy has not been demonstrated in a convincing way and further controlled trials will be necessary to clarify the role of dose intense chemotherapy in SCLC.

A phase II study of weekly alternating chemotherapy in extensive-stage small cell lung cancer

Despite the recent development of new chemotherapeutic agents with activity in small cell lung cancer (SCLC), the long-term prognosis of patients with extensive-stage disease remains poor and has not improved in the past 20 years. The present study was designed to evaluate the activity and toxicity of weekly, alternating-regimen chemotherapy in patients with extensive-stage SCLC. Patients with previously untreated extensive-stage SCLC and performance status 0-2 were treated with cyclophosphamide 250 mg/m2, etoposide 100 mg/m2, and cisplatin 50 mg/m2 on day 1; vincristine 1 mg/m2 on day 8; and ifosfamide 1.2 gm/m2 on days 8 and 9 with the entire treatment repeated every 14 days. Eighteen patients received chemotherapy for a median of 14 weeks (range, 1-35 weeks). Seventeen patients (94%) required dose delays and 16 patients (89%) required at least one dose reduction due to toxicity. Twelve patients (67%) exhibited an objective response (1 complete response, 11 partial response) with a median duration of response of 18 weeks (range, 8-32 weeks). Median survival was 33 weeks (range, 1-57 weeks) with a 1-year survival rate of 22%. Toxicity was primarily hematologic, including grade 3-4 leukopenia (82% of patients) and anemia (53% of patients). Only 2 patients developed grade 3 peripheral neuropathy and none exhibited grade 3-4 renal insufficiency. This regimen of weekly alternating combination chemotherapy resulted in tolerable toxicity as well as response and survival rates comparable to those achieved with standard chemotherapy in patients with extensive-stage SCLC. However, weekly chemotherapy regimens for the treatment of SCLC remain investigational.

Predictive and prognostic factors in small cell lung cancer: current status

Clinical and laboratory parameters can predict response to chemotherapy and long term survival in small cell lung cancer, and may predict those at risk of early treatment related toxicity. This paper reviews the predictive models that have been developed to divide patients into prognostic groups for response and survival on the basis of clinical and laboratory parameters. These factors may be used for the stratification of patients in clinical trials and to help clinicians make appropriate treatment decisions for individual patients. A number of treatment-related factors can also affect outcomes. The evidence for interventions to prevent treatment deaths in high risk patients, such as prophylactic antibiotics, dosage modification or colony stimulating factor support are also reviewed.

Is òne cycle every three or four weeks' obsolete? A critical review of dose-dense chemotherapy in solid neoplasms

BACKGROUND

Shortening the interval between cycles is one means of increasing the dose intensity of chemotherapy, and can be supported by biological and mathematical rationales. Our objective was to assess the clinical relevance of the rapid repetition of regimens (so-called 'dose-dense chemotherapy') in various solid neoplasms.

DESIGN

The medical literature was reviewed in accord with Mulrow's recommendations. Randomised studies comparing frequently-repeated chemotherapy to standard regimens as well as open studies are described and critically examined.

RESULTS

Dose-dense regimens were widely found to be feasible. In small-cell lung cancer, survival of patients receiving dose-dense regimens was better than that of patients treated by standard chemotherapy in three trials, two of which reached significance, when these intensive regimens allowed better dose intensity. In poor-prognosis germ-cell tumors, a dose-dense regimen was not better than standard therapy, perhaps because of an excessively high toxicity-related death rate. However, recent phase II studies have provided encouraging results. In early breast cancer, the one published randomized study in the adjuvant setting showed only a trend towards better disease-free survival in node-positive women receiving a weekly-repeated regimen. Two randomized trials failed to show any benefit in the neoadjuvant setting with a dose-dense regimen. No evidence of a benefit was provided in metastatic breast cancer. In advanced colorectal cancer, evidence of an improvement in survival with weekly or bi-weekly 5-FU-leucovorin compared to a classic monthly schedule has recently been shown in two randomized trials, and dose-dense regimens are recognized as standard therapy in many countries. Phase II studies of dose-dense regimens have also shown high response rates and long survival in many neoplasms, including Ewing's sarcoma, gestational trophoblastic disease, ovarian carcinoma and gastric cancer.

CONCLUSIONS

A considerable amount of experience has been gained with frequently-repeated regimens. A few randomized trials have demonstrated a benefit for survival on standard chemotherapy in small-cell lung cancer and advanced colorectal cancer. However, this benefit appears to be weak. The combination of dose-dense chemotherapy regimens with new anti-cancer strategies based on our insights into the mechanisms of oncogenesis is a challenge on the eve of the millennium.

Small-Cell Lung Cancer at the Millennium: Radiotherapy Innovations Improve Survival While New Chemotherapy Treatments Remain Unproven

Because of the systemic nature of small-cell lung cancer, one could predict that treatment advances would mainly come from innovations of chemotherapy. Although combination chemotherapy is better than monotherapy, a clearly superior multidrug regimen has not emerged. Investigations of more intensive chemotherapy with increased drug diversity and delivery have not prospered, and advantages of regimens including new agents have not yet been demonstrated in controlled trials. As we enter the new millennium, twenty-five years have passed since the publication of studies describing the combined used of cyclophosphamide, doxorubicin, and vincristine for small-cell lung cancer. It has been almost 20 years since the publication of the combination of etoposide and cisplatin became the widely accepted standard for the treatment of small-cell lung cancer. Today, both treatment regimens continue to be widely used as standard therapy. Ironically, proven advances in this systemic disease have been associated with innovations of local therapy. Data from limited-stage small-cell lung cancer clinical trials published during the 1990s demonstrated that a number of radiotherapy interventions had significant survival benefits. These radiotherapy interventions include addition of thoracic irradiation to chemotherapy, early delivery of thoracic irradiation concurrently with chemotherapy, more intense thoracic irradiation, and prophylactic cranial irradiation. As we await improved systemic therapy in the next millennium, the prognosis for extensive-stage disease remains guarded, and adherence to optimal radiotherapy detail remains crucial for routine management of limited-stage patients.

Hematopoietic stem cell transplantation for small cell lung cancer

Treatment for small cell lung cancer has not improved substantially in the past 15 years. Some advances are being made in supportive care and by use of more intense concurrent thoracic radiotherapy. New agents such as the taxanes and the topoisomerase I inhibitors hold promise and are currently in phase III evaluation. The question whether dose intensity can improve the outcome of patients with small cell lung cancer has been raised for many years. Improving supportive care enhances our ability to test this question more thoroughly. This paper reviews the historical and current experience using high-dose therapy with hematopoietic stem cell support for the treatment of small lung cancer. Future directions are identified.

Management of small cell lung cancer: current state of the art

Small cell lung cancer (SCLC) is a common malignancy that is rapidly fatal if left untreated, with most patients surviving < 6 months. Currently, patients with SCLC are treated with chemotherapy with or without thoracic radiotherapy. Randomized trials have demonstrated the superiority of multiagent regimens over single-agent therapies, with the combination of cisplatin and etoposide being the initial regimen of choice for most patients, regardless of stage at presentation. Dose escalation, weekly chemotherapy, alternating noncross-resistant chemotherapy, and maintenance chemotherapy have been evaluated in SCLC, with no convincing data to date demonstrating an advantage for these strategies over conventional treatment strategies. Second-line therapy may be effective in selected patients, depending on the interval between primary treatment and recurrence, response to primary therapy, and the agents used for initial treatment. Radiotherapy is generally accepted as an essential component of optimal management of limited-stage disease, although sequencing, timing, fractionation, dose, and field size remain less than adequately defined. Finally, the routine use of prophylactic cranial irradiation remains controversial, and currently should be reserved for patients in complete remission.

Randomized study of CODE versus alternating CAV/EP for extensive-stage small-cell lung cancer: an Intergroup Study of the National Cancer Institute of Canada Clinical Trials Group and the Southwest Oncology Group

PURPOSE

To determine whether an intensive weekly chemotherapy regimen plus thoracic irradiation is superior to standard chemotherapy in the treatment of extensive-stage small-cell lung cancer (ESCLC).

PATIENTS AND METHODS

Patients with ESCLC were considered eligible for the study if they were younger than 68 years, had a performance status of 0 to 2, and were free of brain metastases. Patients were randomized to receive cisplatin, vincristine, doxorubicin, and etoposide (CODE) or alternating cyclophosphamide, doxorubicin, vincristine/etoposide and cisplatin (CAV/EP). Consolidative thoracic irradiation and prophylactic cranial irradiation were given to patients responding to CODE and according to investigator discretion on the CAV/EP arm.

RESULTS

The fidelity of drug delivery on both drug regimens was equal, and more than 70% of all patients received the intended protocol chemotherapy. Although rates of neutropenic fever were similar, nine (8.2%) of 110 patients on the CODE arm died during chemotherapy, whereas one (0.9%) of 109 patients died on the CAV/EP arm. Response rates after chemotherapy were higher (P =.006) with CODE (87%) than with CAV/EP (70%). However, progression-free survival (median of 0.66 years on both arms) and overall survival (median, 0.98 years for CODE and 0. 91 years for CAV/EP) were not statistically different.

CONCLUSION

The CODE regimen increased two-fold the received dose-intensity of four of the most active drugs in small-cell lung cancer compared with the standard CAV/EP regimen while maintaining an approximately equal total dose. Despite supportive care (but not routine prophylactic use of granulocyte colony-stimulating factor), there was excessive toxic mortality with the CODE regimen. The response rate with CODE was higher than that of CAV/EP, but progression-free and overall survival were not significantly improved. In view of increased toxicity and similar efficacy, the CODE chemotherapy regimen is not recommended for treatment of ESCLC.

Weekly alternating non-cross-resistant chemotherapy for small cell lung cancer with a good prognosis: a study of the Hellenic Cooperative Oncology Group

This trial was conducted by the Hellenic Cooperative Oncology Group to improve the responses and survival in small cell lung cancer with a good prognosis, using a weekly intensive chemotherapy with alternated non-cross-resistant myelosuppressive agents. Patients were classified into two groups; group A consisted of those who received the initial designed regimen (29 patients), and group B consisted of those who received the more intensified regimen that increased by 25% the doses of carboplatin, epirubicin, and ifosfamide, and by 33% the doses of etoposide given on days 1, 2, and 3 with prophylactic granulocyte colony-stimulating factor support. Chemotherapy in group A consisted of carboplatin 150 mg/m2 in 250 ml of 5% dextrose in water as an 1-hour infusion on day 1, etoposide 75 mg/m2 in 250 ml normal saline as an 1-hour infusion on days 1 and 2 alternating with epirubicin 30 mg/m2 intravenous push on day 8, and ifosfamide 2 g/m2 in 500 ml 5% dextrose in water as a 2-hour infusion with mesna protection on day 8. Responding patients with limited disease were also treated with thoracic irradiation. Those who achieved complete response received prophylactic cranial radiotherapy. In group A, the overall response rate was 79.3%, with a 27.6% complete response rate, a median time to progression of 5.71 months, and a median survival of 8.3 months. For patients with limited disease, the response rate was 75%, with a 40% complete response rate, a median time to progression of 5.87 months, and a median survival of 10.98 months. The respective numbers for extensive disease were 89% (only partial responses), 4.82 months, and 5.67 months. The toxicity was mild and manageable. There were no dose reductions or treatment delays. In view of the excellent tolerability and the rather low efficacy of the initial regimen, we decided to administer the more intensified one with granulocyte colony-stimulating factor support. In Group B, the overall response rate was 91.8%, with a 45.9% complete response rate, a median time to progression of 7.05 months, and a median survival of 10.16 months. For limited disease, the response rate was 93%, with a 52% complete response rate, a median time to progression of 7.05 months, and a median survival of 10.49 months. The respective numbers for extensive disease were 88% (25% complete response), 6.82 months, and 9.02 months. The toxicity of this more intensified regimen was more severe but acceptable. Myelosuppression was the main toxicity. However, grade 3-4 febrile neutropenia requiring hospitalization occurred only in 6% of patients. The relative dose intensity was 91%, probably the result of the prophylactic use of granulocyte colony-stimulating factor. The differences in response rate, time to progression, and survival were not statistically significant between the two groups. There were statistically significant differences in the response rate (p = 0.019) and survival rate (p = 0.001) between limited disease and extensive disease only in group A. In conclusion, this weekly, alternated regimen, specifically the intensified regimen, appears to be very active and well tolerated in patient who have small cell lung cancer with a good prognosis. However, despite the high efficacy, this study failed to show any survival advantage as compared with that obtained with the standard treatment for small cell lung cancer.

A survey of the ethical considerations in randomised trials for lung cancer

BACKGROUND

In order to promote a more productive debate on the ethics of randomised clinical trials (RCTs), we present a survey on the ethical aspects of published RCTs for lung cancer.

METHODS

Data from 92 published reports of RCTs for lung cancer, as identified from the Cancerlit 1993-1995 database were supplemented by a questionnaire mailed to the authors of those publications. The analysis focused on respect of autonomy, non-maleficence, beneficence, and justice as the ethical principles applicable to society, patients in trials, patients not included in RCTs and physicians. ETHICAL ANALYSIS: The benefits to society include an objective evaluation of new treatments. The principle of autonomy was often violated for patients who were inadequately informed about the disease or about RCT. In some trials with prolonged recruitment, the principle of non-maleficence was not fully respected since patients continued to be randomised in spite of an obvious advantage of one of the treatments. When compared to those not included in a trial, patients in RCTs were reported to benefit from more precise standards, superior quality assurance of diagnostic and therapeutic procedures, more attention from the physician, easier appointments and easier access to hospitalisation. However, these benefits diminish patients' autonomy and lead to injustice towards patients not included in the trials. While benefits to physicians were usually modest and in proportion to their contribution, an influence upon their autonomy cannot be excluded.

CONCLUSION

More attention to the aforementioned ethical caveats of RCTs should alleviate the ethical costs and might also bring more patients into future trials.

Indomethacin enhances the cytotoxicity of VCR and ADR in human pulmonary adenocarcinoma cells

The ability of anti-inflammatory agents to modulate cellular sensitivity to anticancer drugs was investigated for pulmonary carcinoma cells in vitro. We examined the drug sensitivity of two pulmonary adenocarcinoma cell lines (76-2, 77-4) in the presence of two drugs, an anticancer drug and an anti-inflammatory agent, for 72 hr by the 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay with 96 well plates. Anticancer drugs used for screening test were cyclophosphamide (CPM), mitomycin C (MMC), adriamycin (ADR), 5-fluorouracil (5FU), vindesine (VDS), cisplatin (CDDP), cytarabine (Ara C), methotrexate (MTX), etoposide (VP-16), and vincristine (VCR). Anti-inflammatory agents examined as modulators to anticancer drugs were aspirin, mefenamic acid, ibuprofen, sulindac, piroxicam, phenacetin, dicrofenac, ketoprofen, tolmetin and indomethacin. Screening tests showed indomethacin to be the most effective modulator, resulting in more than a 3-fold increase in cytotoxicity of VCR as compared with that produced by VCR alone. Study of each of the ten anticancer drugs in combination with indomethacin showed VCR to be the most effective anticancer drug in this combination. In 76-2 cells, the concentration of VCR producing 50% growth inhibition (IC50) for VCR alone and VCR in combination with 2 micrograms/ml indomethacin were 1.58 +/- 0.16 and 0.52 +/- 0.1 ng/ml respectively, which represents a 3-fold decrease. In 77-4 cells, the IC50 for VCR alone and VCR in combination with 2 micrograms/ml indomethacin were 2.86 +/- 0.2 and 0.52 +/- 0.11 ng/ml respectively, which represents a 3.8-fold decrease. Our studies indicate that clinically achievable concentrations of indomethacin may be useful in modulating VCR resistance in human pulmonary adenocarcinoma cells, so that combined use of VCR and indomethacin may be of potential clinical significance in the treatment of lung cancer.

Small cell carcinoma of the lung: an "updated" overview

OBJECTIVES

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

DATA SOURCES

Review articles, book chapters, research studies, and abstracts relating to SCLC.

CONCLUSIONS

SCLC is the most aggressive type of lung cancer with many patients having widespread disease at the time of diagnosis. It is the most treatment responsive lung cancer to both chemotherapy and radiotherapy, with aggressive chemotherapy the cornerstone of treatment. Yet, the survival rate is limited. Several new drugs have been found to be active and it is hoped that they will lead to improved results.

IMPLICATIONS FOR NURSING PRACTICE

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

A randomised trial of low-dose/high-frequency chemotherapy as palliative treatment of poor-prognosis small-cell lung cancer: a Cancer research Campaign trial

We report the results of a randomised trial in extensive small-cell lung cancer (SCLC) of a novel approach to palliative chemotherapy. A widely used 3 weekly regimen was compared with the same drugs given at half the dose but twice the frequency with the same intended overall dose intensity (DI). A total of 167 patients defined as having extensive SCLC with adverse prognostic features were randomised to receive either a 3 weekly regimen of cisplatin 60 mg m-2 i.v. on day 1 and etoposide 120 mg m-2 i.v. on day 1 and 100 mg b.d. orally on days 2 and 3 alternating with cyclophosphamide 600 mg m-2 i.v., doxorubicin 50 mg m-2 i.v. and vincristine 2 mg i.v. all on day 1 for a maximum of six courses (3 weekly); or treatment with the same drugs but with each course consisting of half the 3 weekly dose given every 10 or 11 days for a maximum of 12 courses. In the 10/11 day regimen overall response rate was 58.9% (95% CI, 47.9-69.2%) with 12.8% complete responses (CR). For the 3 weekly treatment the overall response rate was 44.9% (95% CI, 35.0-55.5%) with 10.1% CR. Median survival was similar in the two arms at 6.4 months (95% CI, 4.9-7.3 months) and 5.8 months (95% CI, 4.0-6.6 months) respectively. Survival at 1 year was 9.9% (95% CI, 5.0-18.5%) and 8.9% (95% CI, 4.6-16.6%). The 95% CI for the difference in survival at 1 year is -7.09% to +9.09%. Haematological toxicity and treatment delays owing to infection were more frequent with the 10/11 day regimen but other toxicities were equal in both arms. Other aspects of quality of life were measured in a small representative cohort of patients using a daily diary card (DDC). There was a trend of improved quality of life on the 10/11 day arm, but there was little difference between the two treatments. The trial shows that a low-dose/high-frequency regimen with the same DI as conventionally scheduled chemotherapy gives similar response rates and survival. This and other modifications of the schedule may offer new approaches to palliative treatment of advanced cancer. However, in this trial there was no significant benefit in toxicity or other aspects of quality of life.

Assessment of 'quality of life' using a daily diary card in a randomised trial of chemotherapy in small-cell lung cancer

BACKGROUND

Quality of life (QOL) was assessed using a daily diary-card within a multicentre randomised trial of treatment of small-cell lung cancer. The trial compared a weekly dose-intensive regimen with a 3-weekly conventional treatment in good prognosis patients, that is patients with limited disease or extensive disease with a good performance status (ECOG 0or 1) and alkaline phosphatase of less than one and a half times the upper limit of normal. The trial which has been previously reported detected no difference in response or survival.

PATIENTS AND METHODS

Daily diary cards (DDCs) were collected for up to eight months from the first day of chemotherapy in a cohort of 75 patients at one centre. Percentages of scores over a specified level were calculated for each of the eight diary card questions and comparisons were made between treatment arms.

RESULTS

During the period of chemotherapy compliance in completing DDCs was 72.5% in the weekly arm and 77.2% in the 3 weekly. Significantly worse scores were reported with weekly chemotherapy during this period for six of the eight parameters, namely: ;nausea, vomiting, happiness, appetite, general well-being and sleep. Recognised problems of QOL data collection, in particular, compliance, attrition and generalisability are highlighted by this study and are discussed in the paper.

CONCLUSIONS

The QOL measurements indicate that 3 weekly chemotherapy is the preferred treatment. This study demonstrates that QOL measurements may be helpful in choosing between treatment alternatives where no difference in outcome is observed.