International Tailored Chemotherapy Adjuvant (ITACA) trial, a phase III multicenter randomized trial comparing adjuvant pharmacogenomic-driven chemotherapy versus standard adjuvant chemotherapy in completely resected stage II-IIIA non-small-cell lung cancer

BACKGROUND

Several strategies have been investigated to improve the 4% survival advantage of adjuvant chemotherapy in early-stage non-small-cell lung cancer (NSCLC). In this investigator-initiated study we aimed to evaluate the predictive utility of the messenger RNA (mRNA) expression levels of excision repair cross complementation group 1 (ERCC1) and thymidylate synthase (TS) as assessed in resected tumor.

PATIENTS AND METHODS

Seven hundred and seventy-three completely resected stage II-III NSCLC patients were enrolled and randomly assigned in each of the four genomic subgroups to investigator's choice of platinum-based chemotherapy (C, n = 389) or tailored chemotherapy (T, n = 384). All anticancer drugs were administered according to standard doses and schedules. Stratification factors included stage and smoking status. The primary endpoint of the study was overall survival (OS).

RESULTS

Six hundred and ninety patients were included in the primary analysis. At a median follow-up of 45.9 months, 85 (24.6%) and 70 (20.3%) patients died in arms C and T, respectively. Five-year survival for patients in arms C and T was of 65.4% (95% CI (confidence interval): 58.5% to 71.4%) and 72.9% (95% CI: 66.5% to 78.3%), respectively. The estimated hazard ratio (HR) was 0.77 (95% CI: 0.56-1.06, P value: 0.109) for arm T versus arm C. HR for recurrence-free survival was 0.89 (95% CI: 0.69-1.14, P value: 0.341) for arm T versus arm C. Grade 3-5 toxicities were more frequently reported in arm C than in arm T.

CONCLUSION

In completely resected stage II-III NSCLC tailoring adjuvant chemotherapy conferred a non-statistically significant trend for OS favoring the T arm. In terms of safety, the T arm was associated with better efficacy/toxicity ratio related to the different therapeutic choices in the experimental arm.

Health information technology in oncology practice: a literature review

The adoption and implementation of information technology are dramatically remodeling healthcare services all over the world, resulting in an unstoppable and sometimes overwhelming process. After the introduction of the main elements of electronic health records and a description of what every cancer-care professional should be familiar with, we present a narrative review focusing on the current use of computerized clinical information and decision systems in oncology practice. Following a detailed analysis of the many coveted goals that oncologists have reached while embracing informatics progress, the authors suggest how to overcome the main obstacles for a complete physicians' engagement and for a full information technology adoption, and try to forecast what the future holds.

Second-line chemotherapy in malignant pleural mesothelioma: results of a retrospective multicenter survey

The pemetrexed-cisplatin chemotherapy is standard of care in first-line (FL) treatment of malignant pleural mesothelioma (MPM). The second-line (SL) chemotherapy is considered, but the optimal treatment has not been defined yet. The aim of this study was to evaluate the clinical outcomes of SL-therapy in a series of MPM-patients included in a retrospective multicenter database. Clinical records of MPM-patients who received SL-treatment from 1996 to 2008 were reviewed. Study endpoints were response, overall-survival (OS), and progression-free-survival (PFS) for SL, stratified for patient characteristics, FL-outcomes, and type of SL. Out of 423 patients, 181 with full clinical data were identified. Patients' characteristics: median-age 64 years (range: 36-85); male gender 115 (63.5%); good EORTC-score 109 (60.2%); epithelial histology 135 (74.6%). After FL, 147 (81.2%) patients achieved disease-control (DC) and 45 had a time-to-progression≥12 months (TTP≥12). After SL, 95 patients (52.6%) achieved DC (21 response; 74 stable-disease); median PFS and OS were 4.3 and 8.7 months, respectively. According to multivariate analysis, DC after SL-therapy was significantly related to pemetrexed-based treatment (OR: 2.46; p=0.017) and FL-TTP≥12 (OR: 3.50; p=0.006). PFS was related to younger age (<65 years) (HR: 0.70; p=0.045), ECOG-PS0 (HR: 0.67; p=0.022), and FL-TTP≥12 (HR: 0.45; p<0.001). OS was significantly related to ECOG-PS0 (HR: 0.43; p<0.001) and to FL-TTP≥12 (HR: 0.54; p=0.005). In pemetrexed pre-treated patients, re-treatment with a pemetrexed/platinum combination significantly reduced the risk-of-death than pemetrexed alone (HR: 0.11; p<0.001). In conclusion, SL-chemotherapy seems to be active in MPM-patients, particularly in younger patients with ECOG-PS0 and prolonged TTP after FL-pemetrexed-based chemotherapy. In selected patients, re-challenge with pemetrexed-based regimens, preferentially associated with platinum-compound, appears to be an option for SL-setting. Considering the important limitations of this study, due to retrospective nature and the possible selection bias, prospective clinical trials are warranted to clarify these issues.

Optimal duration of chemotherapy (CT) for advanced non-small cell lung cancer (NSCLC) in the first- and second-line settings

e19037

Background: No difference in efficacy has been observed between 3 or 4 vs 6 cycles of 1st line CT in patients (pts) with advanced NSCLC. Although longer treatment may improve progression-free survival, this must be weighed against increased toxicity and potential for worse quality of life. There are no prospective, randomized data on the optimal duration of 2nd line CT. The aims of this retrospective study were to (i) confirm the lack of impact of treatment duration on response rate in 1st line NSCLC and (ii) investigate the impact of treatment duration in the 2nd line setting. Methods: Eligible pts had received at least 4 cycles of 1st line (n=95) or 2nd line (n=55) CT for stage IIIB/IV NSCLC in clinical trials of the ATOM group, Udine, Italy, or the National Cancer Institute, Genoa, Italy and achieved stable disease or responded to treatment; trials included one in the elderly, and the addition of biological agents to CT. Response was assessed according to RECIST after alternate CT cycles and tumor dimensions recorded. The proportion of pts achieving a complete or partial response, as well as its timing and any subsequent tumor shrinkage, were analyzed by treatment line. Results: In the 1st line setting, 48 of 95 pts responded; they did so after 2 (29 pts, 61%), 4 (15 pts, 31%) and 6 cycles (4 pts, 8%). In these pts, 16 (55%) and 9 (41%) pts who had responded by the 2nd and 4th cycle respectively and continued on treatment showed further tumor shrinkage; the median further reduction in tumor size was 16% (range 1–52%) and 6% (range 1–11%), respectively. In the 2nd line setting, 12 of 55 pts responded; they did so after 2 (3 pts, 25%), 4 (7 pts, 58%), and 6 cycles (2 pts, 17%). One and two pts who had responded by the 2nd and 4th cycle respectively and continued on treatment showed further tumor shrinkage of 25%, 5% and 24%, respectively. Conclusions: Approximately 90% of CT-naive pts who responded did so by the 4th cycle; most such pts achieved only minor tumor reduction with further CT and did so at the likely expense of increased toxicity. In the 2nd line setting the achievement of response appeared slower. These results support the discontinuation of 1st CT after 4 cycles and suggest the same is true for 2nd line CT.

No significant financial relationships to disclose.

A reasonable methodology to estimate the relationship between workload and human resources demand in a cancer unit

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Background: Costs of cancer care account for a growing proportion of European health care spending. Despite the rising price of new cancer drugs draws the attention of medical oncologists and decision makers, personnel spending takes the largest share of health care costs. Nonetheless, few data exist about the relationship between workload and human resources demand in a cancer unit. Here we describe an empirical model to determine staffing requirements according to the annual number of patients. Methods: The Department of Oncology at the University Hospital of Udine, Italy, is a computerized Unit within the regional cancer network taking care of about 1,500 pts/year. Each clinical episode is recorded on a centralized database. Standard time limits are set for different types of consultation. We queried the database to obtain the total number of consultations for every pt taken charge of by the Unit during 2006. Considering both the time scheduled for each type of visit and the number of yearly working hours per employee, we could reach a reasonable estimate of the annual physician and nurse hours per pt and of the number of needed personnel. Results: In 2006, each case generated an average of 16 clinical evaluations, with small differences among breast, lung and colorectal cancer. Corresponding physician- and nurse-time per pt was of 8 and 16 hours, respectively. For the first year - in Units with a mean number of 1,500 pts/year - this translates into a global amount of about 12,000 physician- and 24,000 nurse-hours and a needed number of 7 physicians and 13 nurses, respectively. In the second year, the same cases induced a mean of 4.5 consultations; using a similar approach, the demand for additional time and resources could be estimated as well. Conclusions: A preliminary assessment of the time required for different types of consultation, together with a centralized recording of each clinical episode, allows a reasoned estimate of needed time and personnel resources, thus providing a simple tool to determine the total staff expenditure of a cancer unit.

No significant financial relationships to disclose.

Final report of a randomized phase II study of docetaxel/oxaliplatin (DO) and docetaxel (D) in previously treated non-small cell lung cancer (NSCLC) patients (pts). A novel design, Alpe-Adria Thoracic Oncology Multidisciplinary group study (ATOM 019)

e19010

Background: No combination regimen has proven superior to single agent chemotherapy as 2nd-line treatment for NSCLC. The absence of cross-resistance with cisplatin/carboplatin, favorable toxicity profile, along with both pre-clinical and clinical evidence of activity make O a good candidate for combination with D as 2nd-line therapy of NSCLC. We evaluated the activity of DO in this setting using a novel phase II trial design. Methods: This multicenter, non-comparative randomized phase II trial evaluated the activity of D (75 mg/m2 d1) and O (70 mg/m2 d2) every 3 weeks in previously treated NSCLC pts; the comparator arm was D (75 mg/m2 d1 every 3 weeks). This one-stage, three-outcome phase II trial design (Sargent, Control Clin Trials 2001) had 21 evaluable pts/arm. All had histologically confirmed NSCLC that progressed during/after platinum-based chemotherapy. Primary endpoint was response rate; secondary endpoints were toxicity, time to progression (TTP), 1-yr survival. Results: Fifty pts were enrolled. Pts characteristics: M/F, 76/24%; median age 62 yrs (range 43–69); ECOG PS 0/1, 36/64%; adenocarcinoma/other, 36/64%. With 48 pts evaluable, partial response was seen in 20% and 8% of pts; stable disease in 52% and 32% and progressive disease in 24% and 56% for DO and D, respectively; 1 pt was inevaluable due to early death (D arm). Main grade 3–4 toxicities were: neutropenia 56% and 64%; febrile neutropenia 4% and 8%; diarrhea 12% and 4% for DO and D, respectively. Median TTP was 4.9 and 1.8 months, median survival 10.9 and 6.9 months, and 1-yr survival 41% and 16% for DO and D, respectively. Conclusions: This study shows how novel phase II trial designs enrolling a limited number of pts may help identify promising regimens for subsequent study in phase III trials. The level of activity for DO we observed satisfied the pre-defined study primary endpoint and warrants further evaluation of this combination as 2nd-line therapy for NSCLC. Protocol developed at the 6th FECS/AACR/ASCO Workshop on Methods in Clinical Cancer Research, Flims 2004, with Professors Marc Buyse and Chris Twelves.

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Cost containment in oncology: A single-centre model for drug waste reduction

6557

Background: To control costs while maintaining or improving the quality of patient care is challenging for physicians and health care managers. The problem has become critical in oncology, due to the increasing number of cancer cases and the recent availability of new drugs, with a dramatic rise in health care expenditure. Here we report the experience of our Medical Oncology Department, where centralization of chemotherapy (CT) manufacturing and development of a computerized physician order-entry (CPOE) system allowed an effective planning of CT services with a substantial waste minimization and a significant cost saving. Methods: Starting January 2005 we collected data about drug demand, real consuming and resulting wastes and quantified the economic value of drug leftovers. Finally, based on a web literature search and a survey among other Cancer Services, an internal protocol for waste limitation was developed. Main adopted measures were: 1) a rational, per pathology distribution of CT sessions over the week, allowing waste recovery while respecting drug stability; 2) the use of multi-dose vials, that maintain microbial and chemical stability for up to 28 days; 3) a reasonable dose rounding, to fit with available vial sizes/leftovers; 4) the selection of the most convenient vial size when more options are available. Results: The baseline analysis focused on 29 drugs over a 1-year period. Considering their price per milligram and the amount of wastes, we found that 74% of the expense was attributable to six compounds only (cetuximab, docetaxel, gemcitabine, oxaliplatin, pemetrexed and trastuzumab) and that the economic loss due to their waste equaled 4.5% of the annual drug expenditure. Following the application of the above listed measures, the monetary loss due to unused drugs showed an impressive 45% reduction throughout 2006. Conclusions: Our experience may represent an accessible model in addressing the issue of cost rising in oncology. A critical evaluation and planning of CT daily workload, provided by CPOE, and a multidisciplinary effort to pursue specific waste reduction strategies produce a relevant cost saving.

No significant financial relationships to disclose.

Second line chemotherapy with topotecan and gemcitabine in small cell lung cancer (SCLC) patients: An Alpe-Adria Thoracic Oncology Multidisciplinary group phase II study (ATOM 012)

17014

Background: Topotecan is the only single agent currently approved for the treatment of relapsed or recurrent SCLC, showing activity both in chemotherapy-refractory (RR 2–14%) and in chemotherapy-sensitive patients (RR 14–38%). The role of topotecan in combination with other active agents is still under investigation. Methods: Aim of this phase II study is to assess the activity and safety of topotecan (1mg/sqm iv d1–5) plus gemcitabine (1250 mg/sqm iv d1) in relapsed or recurrent SCLC patients. Treatment is repeated every 4 weeks, up to a maximum of 6 cycles. Eligibility criteria: histologically or cytologically confirmed SCLC; documented progressive disease after ≥ 1 chemotherapy regimen; age ≥ 18 yrs; ECOG PS 0–2; measurable disease (RECIST); no prior treatment with topotecan or gemcitabine; adequate hematologic, hepatic and renal function; brain metastases are allowed. Results: A total of 44 patients have been enrolled. Patient characteristics are as follows: median age, 64 yrs (range 35–77); male/female, 35/9; ECOG PS 0/1/2, 12/21/11 patients; 68% patients had sensitive disease (recurrence > 3 months after first-line chemotherapy) and 32% patients had refractory disease (failure ≤3 months after first-line chemotherapy). One-hundred and seventeen chemotherapy courses have been administered (median 2, range 1–6). The following preliminary results refer to 37 patients. Grade 3–4 toxicities: 54% neutropenia, 16% anemia, 46% thrombocytopenia, 13% neutropenic fever, 27% fatigue. One toxic death was observed. Objective responses have been documented in 9 patients, for an overall response rate of 24% (3% CR, 21% PR); SD was observed in 7 patients (19%), PD in 17 patients (46%). Four early deaths were reported. Median time to progression is 8.9 weeks. Median survival time is 16.3 weeks, and 1-year survival rate is 14%. Conclusions: Based on these preliminary results, the combination of topotecan plus gemcitabine shows moderate activity and an acceptable toxicity profile in previously treated SCLC patients. However, it is unlikely that the addition of gemcitabine improves the outcome compared to single agent topotecan.

No significant financial relationships to disclose.

Development of an information technology system to assist oncologists in daily clinical practice

16028

Background: Daily documentation and maintenance of medical record quality is a crucial issue in oncology. Computerization can offer many advantages, but needs training and motivation of operators and fitting of clinical processes and administrative rules to technological requirements. The electronic medical record (EMR) system, a software application for the entry, retrieval, and display of patients information into a digital database, could quantitatively and qualitatively improve medical recording. Methods: We developed an application system, named G2-clin, including EMR and computerized physician order-entry (CPOE). It was integrated into the hospital information system, for documentation and therapy planning to support physicians in daily clinical practice. G2-clin was developed by internal committee of oncologists, nurses and computer scientists, with an assured information technology during the learning curve and over the years. After training, staff physicians and nurses have routinely used the G2-clin starting on March 2002. Medical records collect all data concerning management of inpatient and outpatient care. Results: To date, 317 chemotherapy protocols are available in the CPOE pick list, including experimental regimens. In 2005, G2-clin registered 1550 new patients, with 7730 chemotherapy courses and was able to provide the following data: drug storage, administration and safety procedures, assessment of adverse events according CTC, specific patient safety policies, monitoring of resources and costs, data analysis for clinical research. Main benefits are improvement of the quality of patient care and safety, practice standardization, decrease in the risk of therapy ordering errors. The main drawbacks are inhibition of patient-physician interaction and visit time extension. Conclusions: According to our pilot experience, G2-clin successfully satisfied requirements of procedures standardization and allowed distribution of accurate data to all operators. Moreover it has been useful in monitoring outcomes of care, effectiveness, efficiency, adherence to clinical practice guidelines, resources and costs.

No significant financial relationships to disclose.

Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited indications

BACKGROUND

Bone scanning (BS), liver ultrasonography (LUS) and chest radiography (CXR) are commonly used in patients with newly diagnosed breast cancer as part of baseline staging. However, in the absence of symptomatic disease, the usefulness of this routine diagnostic work-up is not evidence-based.

METHODS

We selected the study sample from 516 consecutive patients with newly diagnosed invasive breast cancer. For each diagnostic test (BS, LUS, CXR), we analyzed the prevalence defined as the number of patients with diagnosis of metastatic disease after an imaging technique divided by the total number of patients tested. In addition, sensitivity and specificity were calculated. Initial suspicion was confirmed by other independent tests (bone X-ray, computerized tomography scan, magnetic resonance imaging) in order to identify "true" positive diagnoses.

RESULTS

At baseline, BS was carried out in 412 patients, LUS in 412 patients and CXR in 428 patients. Thirty-three patients were correctly diagnosed by the initial staging investigations as having metastatic disease (true positive cases). BS detected skeletal metastases in 6.31% of patients, LUS detected liver metastases in 0.72% of patients and CXR detected lung metastases in 0.93% of patients. Before imaging tests, all patients with either LUS or CXR evidence of metastases were previously classified as having stage III disease. On the other hand, only 26.9% of bone metastases were detected in patients with stage III. Accordingly, the detection rate in stage III patients was 14%, 5.6% and 7.2%, respectively for BS, LUS and CXR.

CONCLUSIONS

These findings indicate that a complete diagnostic work-up to detect metastases is unnecessary in the majority of patients with newly diagnosed breast cancer, whereas it may be indicated for specific patient categories such as those with stage III disease.