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

Molecular Hydrogen as a Novel Antitumor Agent: Possible Mechanisms Underlying Gene Expression

While many antitumor drugs have yielded unsatisfactory therapeutic results, drugs are one of the most prevalent therapeutic measures for the treatment of cancer. The development of cancer largely results from mutations in nuclear DNA, as well as from those in mitochondrial DNA (mtDNA). Molecular hydrogen (H₂), an inert molecule, can scavenge hydroxyl radicals (·OH), which are known to be the strongest oxidizing reactive oxygen species (ROS) in the body that causes these DNA mutations. It has been reported that H₂ has no side effects, unlike conventional antitumor drugs, and that it is effective against many diseases caused by oxidative stress and chronic inflammation. Recently, there has been an increasing number of papers on the efficacy of H₂ against cancer and its effects in mitigating the side effects of cancer treatment. In this review, we demonstrate the efficacy and safety of H₂ as a novel antitumor agent and show that its mechanisms may not only involve the direct scavenging of ·OH, but also other indirect biological defense mechanisms via the regulation of gene expression.

Maximizing quality of life remains an ultimate goal in the era of precision medicine: exemplified by lung cancer

An ultimate goal of precision medicine in lung cancer treatment is to restore patient health with maximized quality of life (QOL). Results from Mayo Clinic studies show that a significant improvement in fatigue, dyspnea, and pain scales could lead to better overall QOL. Although treatments and guidelines for clinical implementation to alleviate these key symptoms are available, few cancer patients receive adequate therapy, mostly because of limitations in current care delivery systems and unclear clinicians’ roles. For optimal care of lung cancer survivors in different subpopulations, three barriers must be overcome: physicians’ lack of knowledge, unwarranted practice variation, and uncertainty regarding care provider roles. Appropriate culturally adapted, tested and validated tools for QOL measures must be developed, rather than directly translating existing tools between different languages and across cultures or diverse subpopulations. Finally, lack of sensitive, adequate, and relevant tools in measuring health-related QOL (HRQOL) has long been an issue for effective data collection, demanding a global consensus on a set of core components that reflect the needs of all critical parties for the best cure and care, supporting patients to achieve optimal HRQOL.

The Clinical Efficacy and Safety of Four-Weekly Docetaxel as First-Line Therapy in Elderly Lung Cancer Patients with Squamous Cell Carcinoma

Background

Docetaxel is one of the standard treatments for advanced non-small cell lung cancer. Docetaxel is usually administered in a 3-week schedule, but there is significant toxicity. In this phase II clinical study, we investigated the efficacy and safety of a 4-weekly schedule of docetaxel monotherapy, as first-line chemotherapy for advanced squamous cell carcinoma in elderly lung cancer patients.

Methods

Patients with stage IIIB/ IV lung squamous-cell carcinoma age 70 or older, that had not undergone cytotoxic chemotherapy were enrolled. Patients received docetaxel 25 mg/m² on days 1, 8, and 15, every 4 weeks. Primary endpoint was the objective response rate (ORR). Secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity profiles.

Results

A total of 19 patients were enrolled. Among 19 patients, 17 were for evaluated efficacy and safety. In the intent-to-treat population, ORR and disease control rate (DCR) were 11.8% and 47.1%, respectively. In the response evaluable population, ORR was 16.7% and DCR was 66.7%. Median PFS and OS were 3.1 months and 3.3 months, respectively. There were three adverse grade 3/4 events. Grade 1 neutropenia was reported in one patient.

Conclusion

Our data failed to demonstrate efficacy of a 4-weekly docetaxel regimen, in elderly patients with a poor performance status. However, incidence of side effects, including neutropenia, was lower than with a 3-week docetaxel regimen, as previously reported.

A novel model for identification of prognostic indicator for clinical outcome of squamous cell lung carcinoma

Squamous cell carcinoma of the lung (SCCL) is the most common and aggressive lung tumor with poor clinical outcome. Identification and development of potential genes in prognostic process could be beneficial for clinical management. Sequencing data of 300 SCCL samples at level 3 were downloaded from The Cancer Genome Atlas (TCGA) data portal. Single-factor survival analysis was performed by the Kaplan-Meier method. Functional annotation was conducted on the high-frequency genes filtered out by 1000 times of the least absolute shrinkage and selectionator operator regression analysis. Meanwhile, multi-factor survival analysis was conducted and ROC curve were produced. Risk coefficient and expression level of each gene were used in the division of high-risk and low-risk genes. The number of high-risk genes of each sample was obtained, and the survival condition of different samples was analyzed. Finally, the number of optimal high-risk genes was obtained. Seven thousand nine hundred ninety-eight differential expressed mRNAs were obtained, and 2041 potential prognostic genes were screened out. Twenty one of the 22 high-frequency genes were showed to have significant impact on prognostic process. Single-factor analysis was performed on the 22 models, and eight efficient models were obtained, and seven among them were proven to be significant. By random testing, ≥5 genes and ≥6 genes were proven to be most stable and ≥6 genes were finally recognized as the beneficial indicator to distinguish lung squamous cell carcinoma. Twenty-two potential genes differentially expressed in lung squamous cell carcinoma were identified as potential prognostic indicator in clinical outcome, and the novel model in this study could be applied in other cancer types.

Problems with registration-directed clinical trials for lung cancer in Japan

New anticancer agents against lung cancer are needed because efficacy of chemotherapy is limited. The long time required, low quality, and considerable costs of registration-directed clinical trials in Japan ("Chiken") have been pointed out. The quality of 24 phase I and 41 phase II trials of an anticancer drug for lung cancer were analyzed according to the approval year of the drug. The human resources and infrastructure to support oncology clinical practice and clinical trials were compared between Japan and the USA. A maximum tolerated dose was not defined in any of seven phase I trials before 1989, and was determined in two of six trials between 1989 and 1996 and in seven of 10 trials thereafter. Before 1989, 29 (20%) of 142 patients registered in two trials were ineligible, and the number of ineligible patients was not reported in the five trials. Sample size calculations were not performed in any of seven phase II trials before 1989 and were performed in only four of 10 trials between 1989 and 1996 and in all 23 trials conducted thereafter. The shortage of human resources, including medical oncologists, oncology nurse practitioners and clinical research coordinators, is serious and acute. The infrastructure to support clinical trials also remains insufficient in Japan. In conclusion, registration-directed clinical trials of anticancer agents have advanced significantly during last three decades but remain unsatisfactory. The development of infrastructure and human resources is an urgent task to ensure high-quality clinical trials without unnecessary delays.

Genes Regulating the Sensitivity of Solid Tumor Cell Lines to Cytotoxic Agents: A Literature Review

In order to review gene alterations associated with drug responses in vitro to identify candidate genes for predictive chemosensitivity testing, we selected from literature genes fulfilling at least one of the following criteria for the definition of 'in vitro chemosensitivity associated gene': (i) alterations of the gene can be identified in human solid tumor cell lines exhibiting drug-induced resistance; (ii) transfection of the gene induces drug resistance; (iii) down-regulation of the gene increases the drug sensitivity. We then performed Medline searches for papers on the association between gene alterations of the selected genes and chemosensitivity of cancer cell lines, using the name of the gene as a keyword. A total of 80 genes were identified, which were categorized according to the protein encoded by them as follows: transporters (n = 15), drug targets (n = 8), target-associated proteins (n = 7), intracellular detoxifiers (n = 7), DNA repair proteins (n = 10), DNA damage recognition proteins (n = 2), cell cycle regulators (n = 6), mitogenic and survival signal regulators (n = 7), transcription factors (n = 4), cell adhesion-mediated drug resistance protein (n = 1), and apoptosis regulators (n = 13). The association between the gene alterations and chemosensitivity of cancer cell lines was evaluated in 50 studies for 35 genes. The genes for which the association above was shown in two or more studies were those encoding the major vault protein, thymidylate synthetase, glutathione S-transferase pi, metallothionein, tumor suppressor p53, and bcl-2. We conclude that a total of 80 in vitro chemosensitivity associated genes identified in the literature are potential candidates for clinical predictive chemosensitivity testing.

Squamous cell carcinoma of the lung compared with other histotypes shows higher messenger RNA and protein levels for thymidylate synthase

BACKGROUND

In patients with cancer, one of the main mechanism of resistance to antimetabolite drugs is related to higher levels of thymidylate synthase (TS) activity.

METHODS

To investigate the association between TS expression and histopathologic data, 56 resection specimens from patients with nonsmall cell lung carcinoma (NSCLC) were collected consecutively. TS messenger RNA (mRNA) was evaluated in tumor specimens by using real-time polymerase chain reaction (PCR) analysis; protein expression was evaluated by using immunohistochemistry (IHC) in formalin-fixed, paraffin-embedded (FFPE) specimens; and the analysis of TS transcriptional regulation activity was performed by using real-time PCR analysis in snap-frozen normal and tumor specimens.

RESULTS

The amplification of the TS gene from FFPE tissues was obtained from all samples, with a median level (unit-less ratio) of 1.45 (range, 0.34-5.24); whereas positive TS status at IHC (>10% positive cells) was detected in 56% of samples. It is noteworthy that TS expression was significantly higher in squamous cell carcinoma compared with adenocarcinoma when both mRNA levels (2.17 vs. 1.16; P < .0001) and protein levels (P = .0269) were considered in FFPE specimens, and a strong association was observed between mRNA and protein expression (P = .00017). Moreover, higher TS levels were observed in high-grade tumors (P = .0389 and P = .0068 for mRNA and protein quantification, respectively). The analysis in snap-frozen samples revealed that the TS gene was up-regulated strongly in tumors (P = 3.8 x 10(-12)), and an 8-fold increase (as a cut-off value) in the TS mRNA ratio between tumor and corresponding normal tissue was detected in 32 of 56 patients (57%) bearing preferentially squamous cell tumors (P = .0022) and high-grade tumors (P < .001).

CONCLUSIONS

Data from the current study consistently indicated higher TS expression levels in squamous cell and in high-grade carcinomas. This information may be useful in selecting which patients with NSCLC should receive treatment with TS-inhibiting agents.

Common arm analysis: one approach to develop the basis for global standardization in clinical trials of non-small cell lung cancer

The global development of new anticancer treatments is desirable. However, whether results of clinical trials performed in one population can be fully extrapolated to another population remains in question. We retrospectively compared "common arms" of platinum-based doublet phase III trials among Japanese, European, and American patients with non-small cell lung cancer to develop the basis for global standardization in clinical trials. Patient demographics were very similar through all studies, indicating that extrinsic ethnic factors including socioeconomic factors, medical service background, and patient selection process for clinical trials may be consistent between geographically different oncology groups. The doses of docetaxel, gemcitabine, and vinorelbine were lower in Japanese studies. The toxicity profile was generally acceptable and similar among many studies. Thus, the dose and schedule of anticancer agents established in prior phase I and II studies conducted in each country were appropriate and applicable to large patient populations in these countries. Response rates seemed to be distributed randomly from one study to another, whereas patient survival might be better in Japanese studies. In conclusion, geographical differences in the dose of anticancer agents, response, survival and toxicity of lung cancer chemotherapy were actually observed. However, extrapolation of clinical data obtained in one country to another population and global clinical trials were considered possible with adequate dose adjustment based on dose finding studies using a carefully projected protocol.

Phase I study of cisplatin, vinorelbine, and concurrent thoracic radiotherapy for unresectable stage III non-small cell lung cancer

To determine the recommended phase II dose of vinorelbine in combination with cisplatin and thoracic radiotherapy (TRT) in patients with unresectable stage III non-small cell lung cancer (NSCLC), 18 patients received cisplatin (80 mg/m2) on day 1 and vinorelbine (20 mg/m2 in level 1, and 25 mg/m2 in level 2) on days 1 and 8 every 4 weeks for 4 cycles. TRT consisted of a single dose of 2 Gy once daily for 3 weeks followed by a rest of 4 days, and then the same TRT for 3 weeks to a total dose of 60 Gy. Fifteen (83%) patients received 60 Gy of TRT and 14 (78%) patients received 4 cycles of chemotherapy. Ten (77%) of 13 patients at level 1 and all 5 patients at level 2 developed grade 3-4 neutropenia. Four (31%) patients at level 1 and 3 (60%) patients at level 2 developed grade 3-4 infection. None developed > or = grade 3 esophagitis or lung toxicity. Dose-limiting toxicity was noted in 33% of the patients in level 1 and in 60% of the patients in level 2. The overall response rate (95% confidence interval) was 83% (59-96%) with 15 partial responses. The median survival time was 30.4 months, and the 1-year, 2-year, and 3-year survival rates were 72%, 61%, and 50%, respectively. In conclusion, the recommended dose is the level 1 dose, and this regimen is feasible and promising in patients with stage III NSCLC.

Phase I trial of weekly docetaxel in elderly patients with non-small cell lung cancer

Recent experience with weekly administration of docetaxel has demonstrated less myelotoxicity and suggested that this regimen holds promise for elderly patients at the high risk of myelosuppression. However, in this phase I trial of weekly docetaxel conducted only in elderly patients (70 years old or more) with non-small cell lung cancer (NSCLC), the toxicity profile was markedly different from that in previous reports. The dose-limiting toxicities were neutropenia, diarrhea and infection, all of which were observed at a dose of 30 mg/m(2)/week and the maximum-tolerated dose by protocol definition was 30 mg/m(2)/week. Although other hematological and non-hematological toxicities observed in this treatment were generally moderate and were well tolerated by elderly patients with NSCLC, the risk of myelosuppression still requires careful attention.