Analyzing the effect of physician assignment in the survival of patients with advanced non-small-cell lung cancer

Background

Non-small-cell lung cancer (nsclc) is the most common cause of cancer deaths worldwide, with a 5-year survival of 17%. The low survival rate observed in patients with nsclc is primarily attributable to advanced stage of disease at diagnosis, with more than 50% of cases being stage iv at presentation. For patients with advanced disease, palliative systemic therapy can improve overall survival (os); however, a recent review at our institution of more than 500 consecutive cases of advanced nsclc demonstrated that only 55% of the patients received palliative systemic therapy. What is unknown to date is whether that observed low rate of systemic therapy in our previous study is uniform across oncologists.

Methods

With ethics approval, we performed a retrospective analysis of newly diagnosed patients with stage iv nsclc seen as outpatients at our institution between 2009 and 2012 by 4 different oncologists. Demographics, treatment, and survival data were collected and compared for the 4 oncologists.

Results

The 4 oncologists saw 528 patients overall, with D seeing 115; L, 158; R, 137; and M, 118. Significant variation was observed in the proportion receiving 1 line or more of chemotherapy: D, 60%; L, 65%; R, 43%; and M, 52%. Physician assignment was not associated with a difference in median os, with D's cohort having a median os of 6.8 months; L, 8.4 months; R, 7.0 months; and M, 7.0 months.

Conclusions

Practice size and proportion of patients treated varied between oncologists, but those differences did not translate into significantly different survival outcomes for patients.

Canadian consensus: oligoprogressive, pseudoprogressive, and oligometastatic non-small-cell lung cancer

Background

Little evidence has been generated for how best to manage patients with non-small-cell lung cancer (nsclc) presenting with rarer clinical scenarios, including oligometastases, oligoprogression, and pseudoprogression. In each of those scenarios, oncologists have to consider how best to balance efficacy with quality of life, while maximizing the duration of each line of therapy and ensuring that patients are still eligible for later options, including clinical trial enrolment.

Methods

An expert panel was convened to define the clinical questions. Using case-based presentations, consensus practice recommendations for each clinical scenario were generated through focused, evidence-based discussions.

Results

Treatment strategies and best-practice or consensus recommendations are presented, with areas of consensus and areas of uncertainty identified.

Conclusions

In each situation, treatment has to be tailored to suit the individual patient, but with the intent of extending and maximizing the use of each line of treatment, while keeping treatment options in reserve for later lines of therapy. Patient participation in clinical trials examining these issues should be encouraged.

Increased compliance with tumor treating fields therapy is prognostic for improved survival in the treatment of glioblastoma: a subgroup analysis of the EF-14 phase III trial

BACKGROUND

Tumor treating fields (TTFields) is a non-invasive, antimitotic therapy. In the EF-14 phase 3 trial in newly diagnosed glioblastoma, TTFields plus temozolomide (TTFields/TMZ) improved progression free (PFS) and overall survival (OS) versus TMZ alone. Previous data indicate a ≥ 75% daily compliance improves outcomes. We analyzed compliance data from TTFields/TMZ patients in the EF-14 study to correlate TTFields compliance with PFS and OS and identify potential lower boundary for compliance with improved clinical outcomes.

METHODS

Compliance was assessed by usage data from the NovoTTF-100A device and calculated as percentage per month of TTFields delivery. TTFields/TMZ patients were segregated into subgroups by percent monthly compliance. A Cox proportional hazard model controlled for sex, extent of resection, MGMT methylation status, age, region, and performance status was used to investigate the effect of compliance on PFS and OS.

RESULTS

A threshold value of 50% compliance with TTFields/TMZ improved PFS (HR 0.70, 95% CI 0.47-1.05) and OS (HR 0.67, 95% CI 0.45-0.99) versus TMZ alone with improved outcome as compliance increased. At compliance > 90%, median survival was 24.9 months (28.7 months from diagnosis) and 5-year survival rate was 29.3%. Compliance was independent of gender, extent of resection, MGMT methylation status, age, region and performance status (HR 0.78; p = 0.031; OS at compliance ≥ 75% vs. < 75%).

CONCLUSION

A compliance threshold of 50% with TTFields/TMZ correlated with significantly improved OS and PFS versus TMZ alone. Patients with compliance > 90% showed extended median and 5-year survival rates. Increased compliance with TTFields therapy is independently prognostic for improved survival in glioblastoma.

Are clinical trial eligibility criteria an accurate reflection of a real-world population of advanced non-small-cell lung cancer patients?

Background

Advanced non-small-cell lung cancer (nsclc) represents a major health issue globally. Systemic treatment decisions are informed by clinical trials, which, over years, have improved the survival of patients with advanced nsclc. The applicability of clinical trial results to the broad lung cancer population is unclear because strict eligibility criteria in trials generally select for optimal patients.

Methods

We performed a retrospective chart review of all consecutive patients with advanced nsclc seen in outpatient consultation at our academic institution between September 2009 and September 2012, collecting data about patient demographics and cancer characteristics, treatment, and survival from hospital and pharmacy records. Two sets of arbitrary trial eligibility criteria were applied to the cohort. Scenario A stipulated Eastern Cooperative Oncology Group performance status (ecog ps) 0-1, no brain metastasis, creatinine less than 120 μmol/L, and no second malignancy. Less-strict scenario B stipulated ecog ps 0-2 and creatinine less than 120 μmol/L. We then used the two scenarios to analyze treatment and survival of patients by trial eligibility status.

Results

The 528 included patients had a median age of 67 years, with 55% being men and 58% having adenocarcinoma. Of those 528 patients, 291 received at least 1 line of palliative systemic therapy. Using the scenario A eligibility criteria, 73% were trial-ineligible. However, 46% of "ineligible" patients actually received therapy and experienced survival similar to that of the "eligible" treated patients (10.2 months vs. 11.6 months, p = 0.10). Using the scenario B criteria, only 35% were ineligible, but again, the survival of treated patients was similar in the ineligible and eligible groups (10.1 months vs. 10.9 months, p = 0.57).

Conclusions

Current trial eligibility criteria are often strict and limit the enrolment of patients in clinical trials. Our results suggest that, depending on the chosen drug, its toxicities and tolerability, eligibility criteria could be carefully reviewed and relaxed.

Algorithm for the treatment of advanced or metastatic squamous non-small-cell lung cancer: an evidence-based overview

The treatment of squamous non-small-cell lung cancer (nsclc) is evolving. In the past, the backbone of treatment was chemotherapy, with very few other options available. Fortunately, that situation is changing, especially with a better understanding of tumour biology. Various strategies have been tried to improve patient outcomes. The most notable advance must be immunotherapy, which has revolutionized the treatment paradigm for lung cancer in patients without a driver mutation. Immunotherapy is now the treatment of choice in patients who have progressed after chemotherapy and is replacing chemotherapy as upfront therapy in a selected population. Other strategies have also been tried, such as the addition of targeted therapy to chemotherapy. Targeted agents include ramucirumab, an inhibitor of vascular endothelial growth factor receptor 2, and necitumumab, a monoclonal antibody against epithelial growth factor receptor. Recently, advances in molecular profiling have also been applied to tumours of squamous histology, in which multiple genetic alterations, including mutations and amplifications, have been described. Research is actively seeking targetable mutations and testing various therapies in the hopes of further improving prognosis for patients with squamous nsclc. Here, we review the various advances in the treatment of squamous nsclc and present a proposed treatment algorithm based on current evidence.

Chemotherapy in recurrent advanced non-small-cell lung cancer after adjuvant chemotherapy

INTRODUCTION

Despite adjuvant systemic therapy in patients with completely resected non-small-cell lung cancer (nsclc), many will subsequently relapse. We investigated treatment choices at relapse and assessed the effect of palliative platinum doublet systemic therapy in this population.

METHODS

With research ethics board approval, we performed a retrospective chart review of all patients with resected nsclc who received adjuvant systemic therapy from January 2002 until December 2008 at our institution. The primary outcome was the response rate to first-line palliative systemic therapy among patients who relapsed.

RESULTS

We identified 176 patients who received adjuvant platinum doublet systemic therapy (82% received cisplatin-vinorelbine). In the 85 patients who relapsed (48%), median time to relapse was 18.5 months (95% confidence interval: 15 months to 21.3 months). Palliative systemic therapy was given in 43 patients. Of those 43 patients, 25 (58%) were re-challenged with platinum doublet systemic therapy, with a response rate of 29% compared with 18% in 18 patients who received other systemic therapy (p = 0.48). We observed a trend toward an increased clinical benefit rate (complete response + partial response + stable disease) in patients who were treated with a platinum doublet (67% vs. 41%, p = 0.12). Median overall survival (os) from relapse was 15.3 months in patients receiving palliative systemic therapy and 7.8 months in those receiving best supportive care alone. Compared with patients treated with non-platinum regimens, the platinum-treated group experienced longer survival after relapse (18.4 months vs. 9.7 months, p = 0.041).

CONCLUSIONS

In patients previously treated with adjuvant systemic therapy, re-treatment with platinum doublet chemotherapy upon relapse is feasible. Moreover, compared with patients receiving other first-line systemic therapy, patients receiving platinum doublets experienced higher response rates and significantly longer survival.

Metaphors and malignancy: making sense of cancer

The classic description of a metaphor is that it is a linguistic construction of the format A is B.[...]

Adjuvant hormonal therapy (AHT) in women with early stage breast cancer (BC)

11053

Background: The ASCO technology assessment on adjuvant use of AI states that optimal AHT for a postmenopausal woman with HR-positive BC should now include an AI. We assessed uptake and patterns of AHT use in early stage HR-positive BC at a regional cancer center. Methods: A retrospective review of patients diagnosed with HR-positive early stage BC from January 2004 to December 2005 treated at our center was performed. Data included patient demographics, dates of diagnosis, treatment, last follow-up, AHT choices considered, patient compliance, and treatment toxicity. Patient risks for disease recurrence and mortality were estimated using adjuvantonline. Factors predicting a preference for AI use were identified using univariable and multivariable analysis. Results: 900 patients were identified for the stated period of time with HR-positive early stage BC. 340 patients have been evaluated. Median age was 59 years. Menopausal status was post-/ pre- in 267/73 patients. Stage was I/IIA/IIB in 202/95/43 patients. 267 patients were lymph node (LN) negative. ER, PR and Her2/neu status were positive/negative/unknown in 332/7/1, 292/46/2 and 11/69/260 patients. Initial AHT choice was tamoxifen/anastrozole/letrozole/exemastane/none in 196/79/9/2/54 patients. Of those started upfront on tamoxifen, plan to switch to an AI was stated in 41%. Statistically significant factors associated with any adjuvant AI use included disease stage, menopausal status as well as individual physician preferences. In further analysis, patients’ compliance and toxicity will be reported. Correlation of recurrence risk, as determined through adjuvantonline, with upfront selection of an AI has also been performed. Conclusion: Guidelines have stated the use of an AI (upfront, sequential or extended) should be considered in HR-positive early stage BC. Results from this study provide further insights on the uptake of such therapy as well as factors (disease related, patient and physician preferences) influencing adjuvant treatment decision-making. A prospective trial assessing treatment decision regarding AHT is also in progress. (This study is sponsored by the Canadian Breast Cancer Foundation)

No significant financial relationships to disclose.

A phase II trial of motexafin gadolinium (MGd) in advanced non-small cell lung cancer (NSCLC) patients who had failed platinum-based chemotherapy: Preliminary results of stage 1

18001

Background: Motexafin gadolinium (MGd) is a tumor-selective antineoplastic agent that disrupts redox dependent pathways by targeting oxidative stress-related proteins such as thioredoxin reductase (TRX). TRX often is overexpressed in NSCLC and is associated with a poor prognosis. Inhibition of TRX reverses tumor phenotype in lung carcinoma cells in vitro and in vivo. This randomized 2-stage phase II trial investigated tumor response and survival with 2 regimens of single agent MGd for the 2nd line treatment of advanced NSCLC. Methods: Patients with locally advanced or metastatic NSCLC ± brain metastases, ECOG PS 0–1, who had received one prior platinum-based chemotherapy regimen ± kinase inhibitor were randomized to intravenous MGd (10 mg/kg/week - Group A) or MGd (15 mg/kg/q 3 weeks - Group B) given in 21 day cycles. The sample size was 30 per arm in stage 1, and 24 per arm in stage 2. Response was evaluated by RECIST every 6 weeks. Results: 51 evaluable patients, median age of 62 years (range 41–85), with locally advanced (14%) or metastatic (86%) adenocarcinoma (47%), squamous cell carcinoma (14%), large cell carcinoma (10%), bronchoalveolar carcinoma (2%) or other NSCLC (27%) were randomized to group A (N=22) or group B (N=29). 37% had not responded to first line chemotherapy. MGd treatment was well tolerated, with 1–12 cycles (median 2, mean 3) administered. The most common grade 3+ adverse events were hypophosphatemia (15.7%), fatigue (13.7%), dyspnea (9.8%), hypoxia (7.8%), and finger blisters (5.9%). 48 patients were evaluable for response, with a confirmed response rate of 4.2% (2 PR). Median time to progression was 7 weeks in each group, with 26% and 15% free from progression at 4 and 6 months, respectively. Median survival of 51 evaluable patients was 10.2 months (95% CI: 6.7 months - not reached), 9.2 months for group A and not reached at > 1 year for group B. Conclusions: MGd appears active as a single agent for second line treatment of NSCLC patients with advanced or metastatic NSCLC who have failed prior platinum-based chemotherapy, with a modest response rate and promising survival. The trial has met the criteria for continuation into stage 2 for each treatment group.

No significant financial relationships to disclose.

Actions of Short-Term Fasting on Human Skeletal Muscle Myogenic and Atrogenic Gene Expression

BACKGROUND

Skeletal muscle mass is governed by multiple IGF-1-sensitive positive regulators of muscle-specific protein synthesis (myogenic regulatory factors which includes myoD, myogenin and Myf5) and negative regulators, including the atrogenic proteins myostatin, atrogin-1 and muscle ring finger 1 (MuRF-1). The coordinated control of these myogenic and atrogenic factors in human skeletal muscle following short-term fasting is currently unknown.

METHOD

Healthy adults (n = 6, age 27.6 years) undertook a 40-hour fast. Skeletal muscle biopsy (vastus lateralis) and venous blood samples were taken 3, 15 and 40 h into the fast after an initial standard high-carbohydrate meal. Gene expression of the myogenic regulator factors (myoD, myogenin and Myf5) and the atrogenic factors (myostatin, atrogin-1 and MuRF-1) were determined by real-time PCR analysis. Plasma myostatin and IGF-1 were determined by ELISA.

RESULTS

There were no significant alterations in either the positive or negative regulators of muscle mass at either 15 or 40 h, when compared to gene expression measured 3 h after a meal. Similarly, plasma myostatin and IGF-1 were also unaltered at these times.

CONCLUSIONS

Unlike previous observations in catabolic and cachexic diseased states, short-term fasting (40 h) fails to elicit marked alteration of the genes regulating both muscle-specific protein synthesis or atrophy. Greater periods of fasting may be required to initiate coordinated inhibition of myogenic and atrogenic gene expression.

An analysis of adjuvant temozolomide plus radiotherapy vs radiotherapy alone in a single academic institution

1575

Background: The NCIC CE.3/EORTC 22981/26981 was open during the time period of August 2000 to March 2002. When the study closed, there existed a gap in care that did not address the ongoing management of patients (pts) with glioblastoma multiforme (GBM) that had been surgically excised. As a result of this gap, it was decided that the adjuvant use of temozolomide (TMZ) was to become the standard of care at our centre due to its lack of perceived toxicities and early evidence for its activity. Methods: An analysis was performed of all pts with GBM that were seen at the centre from 1998 to the summer of 2005. In total, 240 pts were identified across multiple medical and radiation oncologists. 75 pts were treated with radiotherapy (RAD) alone post surgery, 86 pts were treated with RAD + TMZ post surgery, 18 pts only had surgery and the remaining pts were unresectable. Average age was 59.7 years for pts treated only with RAD, and 54.6 years for those treated with TMZ + RAD (p = 0.028). 59% of pts treated with RAD were male, while 62% treated with RAD + TMZ were male. Median follow-up was 11.3 months for RAD and 15.7 months for TMZ + RAD (p = 0.0001816). Preliminary survival analysis demonstrates a 56% reduction in the risk of death for pts treated with TMZ + RAD when compared to RAD (log rank p = 9.6 × 10−6). Median survival was 12.7 months for pts treated with RAD and 27 months for pts treated with TMZ + RAD (see table ). A further analysis including recursive partitioning analysis (RPA) and duration of therapy post RAD will be attempted to confirm the similarities between the two groups. Conclusion: Adjuvant TMZ + RAD has increased overall survival by 14.3 months in our institution. Further analysis is necessary to determine the impact on duration of therapy of TMZ.

[Table: see text]

[Table: see text]

Risk factors for stroke after coronary artery bypass

To determine the prevalence of stroke after coronary artery bypass grafting and to evaluate risk factors, we reviewed the records of 1000 patients undergoing coronary bypass within a 1-year time period. Demographic and perioperative data were evaluated by chi 2 analysis. A history of diabetes, evidence of mural thrombus, positive oculopneumoplethysmography findings, increased age, aortic calcification, and postoperative arrhythmias all correlated with increased risk of permanent neurologic deficit for the patient undergoing coronary bypass. Risk factors were analyzed with stepwise logistic regression. A history of diabetes, presence of mural thrombi, and aortic calcification carried a higher probability that the patient would have a permanent neurologic deficit.

Triazene metabolism. VI. 3-Azidomethyl-3-alkyl-1-aryltriazenes, a new class of anti-tumour triazene with potential pro-drug applications

The synthesis of a new series of 3-azidomethyl-3-methyl-1-aryltriazenes is described. 3-Acetoxymethyl-3-methyl-1-aryltriazenes react with a large molar excess of sodium azide in aqueous acetone to afford the 3-azidomethyltriazenes in high yield. The rate of formation of the azidomethyltriazene increasing azide concentration, suggesting either an SN2 mechanism or a significant ionic strength effect on an SN1 reaction. In the absence of azide ion, the acetoxymethyltriazene undergoes a slow hydrolysis to give a bis-anilinomethane, which presumably arises via hydrolysis of the triazene to the aniline followed by condensation with formaldehyde released during the hydrolysis. The azidomethyltriazenes undergo facile hydrolysis in aqueous buffer solution with identical kinetic parameters to those of the hydrolysis of hydroxymethyltriazenes, suggesting that the azides may be good pro-drugs for the cytotoxic monomethyltriazene, the hydrolysis product derived from the hydroxymethyltriazene. Indeed, the azidomethyltriazenes have comparable anti-tumour activity against the P388 and PC6 tumours to other triazenes in this series. Furthermore, the azidomethyltriazenes display selective toxicity towards a human tumour cell line (the BE cell line) which is deficient in the repair of O6-methylguanine lesions, suggesting that these triazenes are capable of generating the monomethyltriazene without the need for metabolic activation.

Mapping of the pneumococcus chromosome: differences between recipient strains varying in hex property and the location of the opt-r2 gene

Transformation studies in pneumococcus had shown that loci determining the resistance to erythromycin and streptomycin were unlinked when strain Cl3 was recipient but linked when strain SIII-I was recipient. This phenomenon also applies to other pairs of markers studied in these two recipients, no matter whether the transforming DNA was derived from strain Cl3 or strain SIII-I. Other differences between the two recipient strains were also revealed. Whereas competent cultures of strain Cl3 were composed of all competent cells, which was in agreement with previous reports of pneumococcal cultures, strain SIII-I normally gave a maximum average of 28% competent cells. Strain SIII-I was unstable, since on repeated sub-culturing the competence peak profile changed and the value of ‘fcq’ increased. These properties were reflected in the twohex−strains 401 and R6x which were found to be similar to the ‘altered SIII-I’ strain. The results from the linkage studies have been applied to the chromosome map and have placed theopt-r2gene in thestr-r41-containing chromosome arm.

Twenty-one years' experience with ruptured abdominal aortic aneurysms

The surgical experience with 107 ruptured abdominal aortic aneurysms at this hospital during the years 1953 to 1975 has been reviewed. The operative mortality rate during the first ten years of this study was 86 per cent, but since 1966, it has fallen to 40 per cent. These improved mortality statistics are related primarily to improved techniques for controlling operative blood loss and minimizing the time of aortic cross clamping. The use of an intra-aortic balloon has been useful in this regard. Twenty-four additional patients died from ruptured aneurysms without undergoing operation, all before 1966. Only seven had a correct diagnosis prior to death, and these seven serve to emphasize the importance of being alert to the diagnosis of ruptured aneurysm which often masquerades as urologic or orthopedic problems because of the frequent symptoms of back, abdominal, flank or groin pain. Since the operative mortality rate for elective resection of the aneurysm has been less than 1 per cent at this institution during the last eight years, we believe we are justified in encouraging prompt resection of aneurysms on an elective basis to eliminate the high mortality rate that still accompanies rupture of the aneurysm.