Phase III study of irinotecan/5FU/LV (FOLFIRI) or oxaliplatin/5FU/LV (FOLFOX) ± cetuximab for patients (pts) with untreated metastatic adenocarcinoma of the colon or rectum (MCRC): CALGB 80203 preliminary results

3509

Background: FOLFIRI or FOLFOX are 1st-line treatments (Rx) for MCRC. Cetuximab is an IgG1 Mab that targets the epidermal growth factor receptor (EGFR) and is approved as monotherapy or in combination with irinotecan in irinotecan-refractory, EGFR + pts with MCRC. CALGB 80203 randomized untreated MCRC pts to FOLFOX or FOLFIRI ± cetuximab (independent of EGFR status.) Methods: Pts with performance status 0–1 with tumor blocks available for EGFR analysis received either irinotecan 180 mg/m2 over 1.5 hours (h) or oxaliplatin 85 mg/m2 over 2h combined with LV 400 mg/m2 over 2h and 5FU 400 mg/m2 bolus, then 46–48h CI 5FU 2400 mg/m2 q o w. Cetuximab dose: 400 mg/m2 loading dose, then 250 mg/m2 qw. Rx continued until progression or toxicity; subsequent Rx was not mandated although information was collected on such rx. Accrual goal was 2200 pts with intended 1° endpt of overall survival (OS). 80203 closed administratively in 1/05 (due to slow accrual) with 238 pts accrued. 2° endpts of response rate (RR), progression free survival (PFS), duration of R and toxicity are now able to be analyzed. Results: Accrual: FOLFIRI (A) - 61; FOLFIRI + cetuximab (B) - 59: FOLFOX (C) - 60; FOLFOX + cetuximab (D) - 58; approx median follow-up (f/u) is 12 months. RR (CR + PR, not all yet confirmed): A - 34%; B - 42%; C - 32%; D - 55%. RR was similar in the FOLFIRI or FOLFOX arms (A+B v. C+D; 38% v. 43%, p=0.44; chi-square) while C225 containing arms (B+D) v. non-C225 arms (A+C) had a superior RR (49% v. 33%; p=0.014, chi-square) It is too early to tell if there are differences in PFS, duration of response or OS. No significant differences in gr III diarrhea or any gr IV toxicities were seen. Conclusions: These results suggest that FOLFIRI and FOLFOX are similar in efficacy for pts with untreated MCRC and that adding cetuximab to either in1st-line Rx appears to increase response rates. PFS and duration of response do not appear different at this analysis. Further f/u and an analysis of prospective companion correlative studies may help to further clarify these results.

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A double-blind placebo-controlled randomized phase III trial of 5-fluorouracil and leucovorin, plus or minus trimetrexate, in previously untreated patients with advanced colorectal cancer

BACKGROUND

Trimetrexate (TMTX) biochemically modulates 5-fluorouracil (5-FU) and leucovorin (LCV). Two phase II trials demonstrated promising activity for TMTX/5-FU/LCV in patients with untreated advanced colorectal cancer (ACC). This trial was designed to demonstrate the safety and efficacy of TMTX/5-FU/LCV as first-line treatment in ACC.

PATIENTS AND METHODS

Eligible patients with ACC were randomized in double-blind fashion to receive placebo or TMTX (110 mg/m2) intravenously (i.v.) followed 24 h later by i.v. LCV 200 mg/m2, and 5-FU 500 mg/m2 plus oral LCV rescue. Both schedules were given weekly for 6 weeks every 8 weeks. Patients were evaluated for progression-free survival (PFS), overall survival (OS), tumor response, quality of life (QoL) and toxicity.

RESULTS

A total of 382 eligible patients were randomized. Significant toxicities were noted more frequently with TMTX/5-FU/LCV. Diarrhea was the most common grade 3 or 4 side-effect (41% and 28% on the TMTX and placebo arms, respectively). QoL scores and response rates did not differ between treatment arms. PFS was 5.3 months and 4.4 months in the TMTX and placebo arms, respectively (P = 0.77; Wilcoxon). OS was 15.8 months and 16.8 months, respectively (P = 0.73; Wilcoxon).

CONCLUSIONS

The addition of TMTX to a weekly regimen of 5-FU/LCV worsened grade 3 or 4 diarrhea. The inclusion of TMTX did not yield any significant improvements in response rate, PFS or OS.

An investigational new drug treatment program for patients with gemcitabine: results for over 3000 patients with pancreatic carcinoma

BACKGROUND

An Investigational New Drug (IND) treatment program allows patients access to a drug that has shown activity against a serious or life-threatening disease prior to full Food and Drug Administration (FDA) review and approval. This treatment IND program, in which patients with locally advanced or metastatic pancreatic carcinoma were treated with gemcitabine, began in 1995.

METHODS

Eligibility criteria were < or =1 prior chemotherapy regimen; a Karnofsky performance status (KPS) of > or =50; and adequate bone marrow, liver, and renal function. Gemcitabine was given at a dose of 1000 mg/m2 weekly x 7 followed by a week of rest, then weekly x 3 every 4 weeks thereafter. In this program, disease-related symptom improvement (DRSI) was defined retrospectively as 1) improvement in pain (on a 7-point scale) and/or analgesic class (e.g., morphine improving to codeine) and/or KPS (> or =20 points), or 2) stability of these three parameters with a 7% increase in weight from baseline.

RESULTS

A total of 3023 patients enrolled. At baseline, 80% of them had Stage IV disease, and 84% had a baseline KPS > or = 70. The median age was 65 years, and 56% of the patients were male. The cumulative DRSI response rate after the fourth cycle was 18.4%. Of 982 patients with tumor response data, there were 14 with complete response and 104 with partial response, for an overall response rate of 12.0% (95% confidence interval [CI], 10.0-14.0%). For 2380 patients with survival data, the median survival was 4.8 months (95% CI, 4.5-5.1 months) and the 12-month survival was 15%. Gemcitabine was well tolerated; only 4.6% of discontinuations were due to adverse events.

CONCLUSIONS

Notable disease-related symptom improvement and survival were seen with gemcitabine in this large, compassionate-use setting, and these findings were in agreement with those of earlier registration trials.

Concomitant 5-FU, hydroxyurea and cisplatin with external beam radiation therapy for locally advanced pancreatic cancer

The aim of the study was to determine the efficacy and toxicity of alternate week concurrent 5-fluorouracil, hydroxyurea, and cisplatin with radiotherapy for locally advanced pancreatic adenocarcinoma. Patients received 5-fluorouracil, hydroxyurea and cisplatin with radiotherapy on an alternate week basis. Chemoradiotherapy was given day 1-5, and no therapy given day 6-14 for each 14 day cycle. Chemotherapy doses were as follows: hydroxyurea 1 mg every 12 h starting day 0, 5-fluorouracil 800 mg/m(2)/day for 5 days starting day 1, and cisplatin 20 mg/m(2) daily for 5 days every other cycle. A radiation dose of 6000 cGy was prescribed. Acute toxicities were monitored and therapy modified for hematologic toxicity. Nine patients enrolled, however eight were evaluable; one patient expired prior to therapy. The median radiation dose delivered was 5540 cGy. Sixty-three percent required a chemotherapy dose reduction. Fifty percent achieved local control by radiographic imaging after completion of therapy. Median survival was 12 months. Acute toxicity included: 38% grade 2-3 nausea, 37% grade 2-3 vomiting, 63% grade 2-3 mucositis, 63% grade 2-3 neutropenia, and 88% grade 3-4 thrombocytopenia. Other sequelae included hand-foot syndrome, deep venous thrombosis, hearing loss, seizures, and anorexia. Patients achieved the same median survival as compared to other reported studies of radiation therapy with single agent 5-fluorouracil. We do not recommend this protocol due to the significant toxicity. Future studies to incorporate conformal radiation therapy with more active, less toxic chemotherapeutic agents should be investigated.

Phase III randomized study to compare interferon alfa-2a in combination with fluorouracil versus fluorouracil alone in patients with advanced colorectal cancer

PURPOSE

To compare the efficacy and toxicity profiles of a combination of fluorouracil (5-FU) and recombinant human interferon alfa-2a ([IFN alpha 2a] Roferon-A; Hoffmann-LaRoche, Basel, Switzerland) versus 5-FU alone in the treatment of advanced colorectal cancer (ACC).

PATIENTS AND METHODS

A total of 245 previously untreated ACC patients were randomized to receive either IFN alpha 2a (9 million IU) subcutaneously (SC) three times weekly with 5-FU (750 mg/m2/d) by continuous intravenous (CIV) infusion on days 1 to 5 and then, after a 1-week hiatus, as a weekly IV bolus at the same dose (IFN/ 5-FU), or 5-FU alone at the same dose schedule (5-FU).

RESULTS

There were no significant differences between IFN/5-FU and 5-FU alone in the overall response rate (24% v 17%, P = .2), duration of response (median, 6.4 v 8.1 months), time to response (plateau at 3 months), time to progressive disease ([PD] median, 4.8 v 4.9 months), or survival duration (median, 13.9 v 13.2 months). Toxicity profiles were not statistically different except for constitutional symptoms, which were more frequent and more severe with IFN/5-FU. More patients interrupted treatment for adverse events (AEs) with IFN/ 5-FU (34%) than with 5-FU alone (21%) (P = .03). The number of deaths (mostly unrelated to drug treatment) during the study (8%) was similar with both regimens.

CONCLUSION

The combination IFN/5-FU produced a response rate, response duration, and survival duration similar to that of 5-FU alone. The addition of IFN to 5-FU in the doses and schedules used in this study did not provide any further benefit over 5-FU alone and cannot be recommended for patients with metastatic ACC. This study confirms the value of large prospective randomized clinical trials to determine the clinical value of regimens that emerge from smaller single-center phase II studies.

Phase-I trial of Thiotepa, granulocyte-macrophage colony-stimulating factor and prednisone or pentoxifylline in patients with refractory solid tumors

In a phase I trial, 13 patients with refractory solid tumors received thiotepa, granulocyte-macrophage colony-stimulating factor (GM-CSF), and either prednisone or pentoxifylline (PTX) on alternate cycles. The prednisone and PTX were administered in an attempt to ameliorate toxicity related to GM-CSF. Of the first six patients treated at a thiotepa dose of 60 mg/m(2), five experienced grade 3 or 4 thrombocytopenia and four grade 2 or greater leukopenia. One of these patients died secondary to E. coli sepsis. Seven patients received a thiotepa dose of 50 mg/m(2), with one experiencing grade 3 thrombocytopenia and another grade 3 leukopenia. The latter patient died secondary to presumed sepsis. The five remaining patients at the 50 mg/m(2) dose did not experience greater than grade 1 hematologic toxicity. Serum tumor necrosis factor levels were not increased by GM-CSF. Patients in this trial were not evaluable for amelioration of GM-CSF toxicity as too few received a second cycle of treatment. We conclude that thiotepa doses greater than 50 mg/m(2) are not tolerated due to severe thrombocytopenia which is not diminished by the administration of GM-CSF.

Vascular events in patients receiving high-dose infusional 5-fluorouracil-based chemotherapy: the University of Chicago experience

In a retrospective review, 22 of a total of 244 patients (9%) patients with head and neck or gastrointestinal cancer who were treated with infusional 5-fluorouracil (5-FU)-based chemotherapy regimens experienced thrombotic vascular events. These events occurred concurrently with treatment or several months following the completion of therapy and consisted mainly of cardiac arrhythmias, myocardial infarction, sudden death, and thromboembolism. The temporal relationship of these vascular events to the time of treatment suggests that infusional 5-FU may have been the underlying cause.

Platinum-based combination chemotherapy in advanced non-small cell lung cancer: a randomized phase II trial of the Cancer and Leukemia Group B

The Cancer and Leukemia Group B (CALGB) utilized a randomized phase II trial design to evaluate two cisplatin-based combinations, cisplatin-cytarabine (ara-C) and cisplatin-vinblastine, in 151 patients with advanced non-small cell lung cancer. Patients entered on study had not received prior chemotherapy. Platinum doses were equivalent in the two treatment programs. The total response rate (complete response, partial response, regression of evaluable disease) for the cisplatin-vinblastine group was 22% (16/73). Failure-free survival at six months for this group was 41%, survival at six months was 63%. The cisplatin-ara-C group had a total response rate of 9% (7/78) with a failure-free survival at six months of 14% and a six-month survival of 47%. Severe or life-threatening toxicity was seen in 73% of cisplatin-vinblastine cases and 59% of cisplatin-ara-C patients. Neither regimen is active enough to warrant designation as "standard therapy" for patients with M1 disease.

Toxic effects of cis-dichlorodiammineplatinum(II) in man

Administration of cis-dichlorodiammineplatinum(II) may be associated with a number of serious side effects, including nephrotoxicity, gastroeintestinal side effects (nausea, vomiting, and diarrhea), myelosuppression, and occasional transient elevations in liver function tests. In addition, ototoxicity (tinnitus and hearing loss), anaphylactic reactions, peripheral neuropathies, and hypomagnesemia with resulting tetany may also be encountered. The toxic potential of this new agent necessitates careful clinical monitoring during treatment.

Chemotherapy for testicular cancer: current status of the National Cancer Institute Combined Modality Trial

Twenty-five previously untreated patients with advanced testicular carcinoma were treated with a five-drug combination chemotherapy program containing cis-dichlorodiammineplatinum(II). This drug regimen was used as part of a trial testing the efficacy of cytoreductive surgery (15 patients) and in ten additional patients not eligible for the combined modality study. Eleven of 25 (44%) patients had a complete response and 11 of 25 (44%) patients had a partial response. Nine of 11 (82%) patients with minimal tumor burden upon initiation of chemotherapy had a complete response. With a median followup of 12+ months, none have relapsed. Complete remissions in patients with very advanced bulky disease were rare (two of 14 [14%] patients) and of short duration, with both patients relapsing. In addition to the usual hematologic toxicity, 14 of 25 (56%) patients developed hypomagnesemia and five of 25 (20%) patients developed systemic reactions to cis-dichlorodiammineplatinum(II) which prevented further drug administration.