Saliva flow rates and clinical characteristics of patients with burning mouth syndrome: A case-control study

Burning mouth syndrome (BMS) is a chronic pain condition that most commonly affects postmenopausal women older than 50 years of age. Xerostomia is a common complaint among BMS patients. However, previous studies showed inconsistent findings regarding saliva flow rate reduction. This study examined saliva flow rates, degree of mucosal hydration, xerostomia, and clinical characteristics in BMS patients compared with healthy controls. Unstimulated whole saliva (USWS) was collected through passive drooling; residual mucosal saliva (RMS) was collected using filter paper strips. Stimulated whole saliva (SWS) was collected while chewing on gum base. Oral exam and self-report data were collected. A total of 50 women (22 BMS cases and 28 healthy controls) aged 50 years or older were included in the analysis of this study. Mean age was 62 years for cases and 56 years for controls (P=0.05). Compared with controls, cases had significantly lower USWS flow rates (P<0.001) and had a higher prevalence of xerostomia (P=0.001), gastrointestinal disease (P<0.001), and vaginal dryness (P=0.01). These data show that oral and vaginal dryness are common among BMS patients. Further studies are needed to investigate potential pathophysiological mechanisms related to the quality of saliva and mucosal barrier status among these patients.

Abstract P1-10-07: Phase 3 comparison of APF530 versus ondansetron, each in a guideline-recommended 3-drug regimen for prevention of chemotherapy-induced nausea and vomiting due to anthracycline + cyclophosphamide (AC)–based highly emetogenic chemotherapy (HEC) regimens: A post hoc subgroup analysis of the MAGIC trial

Background:Managing delayed chemotherapy-induced nausea and vomiting (CINV) associated with HEC is an unmet need. AC-based HEC is often administered to breast cancer patients (pts), a mostly female, high-CINV-risk population. APF530, an extended-release formulation of granisetron, demonstrated superior complete response (CR; no emesis [vomiting, retching] + no rescue medication use) in delayed-phase (&gt;24-120 h) CINV with HEC (ASCO criteria) vs ondansetron (Ond) (65% vs 57%, P=0.014), each combined with a neurokinin-1 antagonist and dexamethasone (Dex) (NCT02106494). This post hoc analysis evaluated efficacy and safety of APF530 in pts receiving AC-based therapy.

Methods: In this randomized, double-blind, multicenter trial, pts scheduled to receive single-day HEC were stratified by cisplatin ≥50 mg/m2 yes/no and randomized 1:1 to APF530 500 mg SC (granisetron 10 mg) or Ond 0.15 mg/kg IV. Pts received concomitant Dex 12 mg IV and fosaprepitant 150 mg IV on day 1 and oral Dex on days 2-4. The primary end point was CR in the delayed phase. Secondary and other end points included CR in acute (0-24 h) and overall (0-120 h) phases, and complete control (CC; CR and no more than mild nausea) and total response (TR; CR and no nausea) in acute, delayed, and overall phases. Rates were compared using 95% confidence intervals (CIs) for treatment differences; post hoc analysis was not powered to detect treatment differences in the AC subgroup. Safety assessments included adverse events (AEs), injection-site reactions (ISRs), laboratory parameters, and vital signs.

Results: A total of 589/902 pts (65%) in the modified intent-to-treat population received AC-based HEC (APF530 291, Ond 298). Baseline demographics were balanced between treatment arms. The majority of pts in the AC subgroup were female (APF530 99%, Ond 98%). Delayed-phase CR was higher with APF530 vs Ond, approaching statistical significance (APF530 64%, Ond 56%; P=0.062) in the AC subgroup, similar to the benefit seen in the larger study. No appreciable benefit of APF530 vs Ond was observed in the acute phase, and trends favorable to APF530 were observed in the overall phase (Table). APF530 was well tolerated. Most AEs were ISRs, generally mild or moderate, and resolved by end of study.

Phase, n (%)APF530OndansetronTreatment DifferenceN=291N=298(95% CI), %Complete responseDelayed185 (64)167 (56)8 (-0.4, 15.4)Overall163 (56)153 (51)5 (-3.4, 12.7)Acute205 (70)204 (69)1 (-5.4, 9.4)Complete controlDelayed171 (59)156 (52)7 (-1.6, 14.4)Overall149 (51)143 (48)3 (-4.9, 11.3 )Acute193 (66)191 (64)2 (-5.5, 9.9)Total responseDelayed119 (41)107 (36)5 (-2.9, 12.8)Overall100 (34)94 (32)2 (-4.8, 10.4)Acute164 (56)173 (58)-2 (-9.7, 6.3)

Conclusions: APF530 demonstrated an apparent clinical benefit in delayed-phase CR in pts receiving AC-based HEC, concordant with the statistically significant benefit seen in the overall study population. Prevention of CINV in this patient population continues to be a treatment challenge and further investigation is needed.

Citation Format: Schnadig I, Agajanian R, Dakhil S, Taylor C, Wilks S, Cooper W, Mosier M, Payne Y, Klepper M, Vacirca J. Phase 3 comparison of APF530 versus ondansetron, each in a guideline-recommended 3-drug regimen for prevention of chemotherapy-induced nausea and vomiting due to anthracycline + cyclophosphamide (AC)–based highly emetogenic chemotherapy (HEC) regimens: A post hoc subgroup analysis of the MAGIC trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-07.

P1-18-01: Z-ACT1: Zometa Combined with Standard Therapy in Patients with Metastatic Breast Cancer Further Decreases the Proportion of Patients with CTC Counts of 5 or above

Introduction: Zoledronic acid (ZOL) has been shown to reduce the risk of recurrence and residual tumor size in the adjuvant/neoadjuvant setting in patients with early/intermediate-stage breast cancer (BC). In addition, ZOL combined with neoadjuvant chemotherapy reduced numbers of disseminated-tumor cells in the bone marrow compared with chemotherapy alone. However, the activity of ZOL on disseminated- or circulating-tumor cells (CTCs) in patients with metastatic breast cancer (MBC) is not well defined. Cristofanilli M, et al (J Clin Oncol. 2005; 23: 1420–30) reported that CTCs in MBC are an independent predictor of overall survival (OS) and progressionfree survival (PFS). Accordingly, this study is evaluating the potential anticancer benefit of adding ZOL to standard therapy in patients with newly diagnosed MBC as assessed by the change in CTC count from baseline to 3–5 weeks.

Methods: Eligible patients had HER2−negative MBC, newly diagnosed or at first relapse after adjuvant therapy with or without bone metastases. In this open-label 3-arm study, patients without bone metastases were randomized to standard therapy + ZOL every 3–4 weeks for the first 6 months (Arm A) or standard therapy + ZOL during month 6–12 after standard therapy initiation (Arm B). All patients with bone metastases received ZOL every 3–4 weeks (Arm C). The primary endpoint is PFS. Secondary endpoints include the proportion of patients with CTCs ≥5 or &lt;5 per 7.5 mL of peripheral blood 3–5 weeks after standard therapy initiation. Data were compared with historical controls (patients with MBC receiving first-line standard treatment alone; Cristofanilli M, et al. 2005). CTCs were quantified using CellSearch™.

Results: In Z-ACT1, 29 previously untreated MBC patients with bone metastases were enrolled in Arm C, all of whom had ≥1 CTC at study entry (range, 1–117). 53% received hormonal therapy alone, 42% chemotherapy alone, and 5% received various combinations. In patients receiving standard therapy + ZOL, the percentage of patients with CTC ≥5 decreased from 55% to 25% at 3–5 weeks. At baseline, the median uNTX level was 46.5 (n = 10) in patients with &lt; 5 CTCs and 57 in patients with ≥5 CTC (n = 13). At 3–5 weeks, the median decrease from baseline in uNTX was 74% (n = 10) in the &lt; 5 CTC group and 25% (n = 5) in the ≥5 CTC group. At 3–5 weeks, the median uNTX levels in the &lt;5 and ≥5 CTC groups were 12 and 22 nmol bce/mmol, respectively. This study has now been modified to a 2-arm study (standard therapy +/− ZOL) in MBC patients with no bone metastases. CTC, uNTX, and PFS data will be presented from this new head-to-head analysis. Changes in CTCs out to 6 months and correlation with uNTX and PFS in this original bone metastasis cohort will also be presented.

Conclusions: This preliminary analysis suggests that the addition of ZOL to standard therapy in women with bone metastases from MBC results in a further decrease in CTC numbers at 3–5 weeks after initiation of therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-18-01.

Zoledronic Acid for Treatment of Osteopenia and Osteoporosis in Women with Primary Breast Cancer (BC) Undergoing Adjuvant Aromatase Inhibitor (AI) Therapy

Background: Postmenopausal women with significant osteopenia/osteoporosis are at increased risk of fracture, a risk that is exacerbated by the use of Aromatase Inhibitors (AIs). Bisphosphonates may be used for these patients because there is no known interaction with estrogen and/or progesterone receptors (ER, PR). This study evaluated the concurrent use of zoledronic acid in patients with significant osteopenia or osteoporosis who received initial adjuvant letrozole therapy for primary BC, to determine if further bone mineral density (BMD) loss could be prevented.Methods: Postmenopausal women with Stage I-IIIa, ER and/or PR + BC, no evidence of metastatic disease, and a BMD T-score &lt; -2.0 were treated with daily letrozole 2.5 mg/d, vitamin D 400 international units/d, calcium 500 mg twice daily, and 4 mg I.V. zoledronic acid every 6 months (for 5 years). The BMD was measured at baseline and at one year. Kruskall-Wallis p-value methodology was used as the method of statistical analysis. Since this was a single-arm study, the analysis plan was primarily descriptive. The primary endpoint was the mean change in lumbar spine (LS) BMD at 1 year.Results: 60 patients were enrolled; 46 completed 1 year of treatment. Mean patient age was 67 years, with 44% having taken prior tamoxifen. At 1 year (see figure 1), LS BMD increased 2.66% (p=0.01), femoral neck (FN) BMD increased 4.81% (p=0.01), and any measured endpoint (within the LS or FN) increased 4.55% (p=0.0052). 7% of patients experienced a fracture vs.13% with a pre-existing history of fracture before enrollment. No patients had disease recurrence during year 1. Toxicity was minimal with arthralgia as the most common complaint. There were no reports of osteonecrosis of the jaw.Conclusion: Zoledronic acid prevents additional bone loss in postmenopausal women with significant osteopenia or osteoporosis initiating letrozole. Treatment with zoledronic acid was associated with an improvement in BMD.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2103.

Cardiac Safety of Lapatinib Given Concurrently with Paclitaxel and Trastuzumab as Part of Adjuvant Therapy for Patients with HER2+ Breast Cancer: Pilot Data from the Mayo Clinic Cancer Research Consortium Trial RC0639

Background: Despite the impressive results of the trastuzumab adjuvant therapy trials, 15% of patients (pts) with HER2 overexpressing or amplified breast cancer developed tumor relapse at 4 years. Lapatinib is a reversible tyrosine kinase inhibitor against ErbB1 and ErbB2. The current study was developed to assess the cardiac safety and feasibility of adding lapatinib to paclitaxel and trastuzumab following doxorubicin and cyclophosphamide as part of adjuvant therapy.Methods: A single-arm phase II study of doxorubicin (A, 60 mg/m2 day 1) and cyclophosphamide (C, 600 mg/m2 day 1) [q2w or q3w for 4 cycles]; followed by PTL: paclitaxel (P, 80 mg/m2 weekly), trastuzumab (T, 4 mg/kg loading dose then 2 mg/kg weekly), and lapatinib (L, 1000 mg PO daily which was later amended to 750 mg) [total of 12 weeks of treatment]; followed by T (6 mg/kg day 1, every 3 weeks) and L (1000 mg PO daily) [total of 40 weeks of treatment] was conducted. The primary endpoint was severe symptomatic congestive heart failure (CHF: New York Heart Association Class III or IV with a drop in left ventricular ejection fraction [LVEF] of at least 10 percentage points to below 50% confirmed by cardiologist) with secondary endpoints of cardiac death and grade 3+ cardiac adverse events (AEs).Results: From April 2007 to October 2008, 109 evaluable pts were enrolled and initiated study treatment. Median age was 51 (range 28-72). Median follow-up is 10.2 months. No pts experienced CHF or cardiac death while on active treatment. One pt had CHF and 1 pt died due to myocardial infarction (MI) after they went off study treatment. The pt with CHF refused further treatment after completing 2 cycles of PTL and had CHF 1.8 months post PTL discontinuation with LVEF of 45% and dyspnea on exertion. The pt with MI went off study treatment due to non-cardiac AEs after completing 2 cycles of PTL and died 2.9 months post PTL discontinuation. Mean LVEF at baseline was 63.6% (N=109, SD=5.7); end of AC was 63.3% (N=104, SD=6.4); end of PTL was 59.9% (N=89, SD=8.3); and cycle 12 was 59.7% (N=66, SD=7.1). Grade 3+ non-hematologic AEs with incidence &gt;5% include diarrhea (N=42, 39% & included both 1000mg & later amended 750mg dosing), fatigue (N=15, 14%), nausea (N=7, 6%), vomiting (N=7, 6%), acne (N=6, 6%), and hypokalemia (N=6, 6%). Pre-treatment cardiac marker data (troponin-T, troponin-I, brain natriuretic peptide, creatine kinase MB isoenzyme) will also be presented.Conclusions: Preliminary data suggest that the inclusion of L does not add to the cardiac profile of T. Data from ALTTO and long-term follow data are needed to confirm the cardiac safety of this regimen. Cardiac marker data are being analyzed in the context of changes in LVEF. We gratefully acknowledge support from the Breast Cancer Research Foundation and GlaxoSmthKline for this study.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3086.

Paclitaxel-Related Peripheral Neuropathy Associated with Improved Outcome of Patients with Early Stage HER2+ Breast Cancer Who Did Not Receive Trastuzumab in the N9831 Clinical Trial

Background: Microtubules are crucial for spindle formation during mitosis and for cellular proliferation. The antineoplastic effect of paclitaxel is mainly related to its ability to bind the beta subunit of tubulin, thus preventing tubulin chain depolarization and inducing apoptosis. Tubulins are expressed in human peripheral nerves and the binding of paclitaxel to tubulin may lead to neuropathy. Peripheral neuropathy is a common dose limiting toxicity of paclitaxel. We hypothesized that the occurrence of peripheral neuropathy may correlate with outcome (disease-free survival; DFS).Methods: This analysis sought to describe incidence of peripheral neuropathy following paclitaxel and its association to outcome (DFS) in patients who received paclitaxel (weekly x 12) in the adjuvant HER2+ intergroup trial N9831. Only eligible pts who initiated paclitaxel and did not have peripheral neuropathy at initiation of paclitaxel that were randomized to arms A (955 pts; chemotherapy alone) and C (889 pts; chemotherapy plus concurrent trastuzumab) of N9831 were included. Cox regression analysis stratified by ER/PR status and nodal status was used to compare DFS within arm between patients with and without peripheral neuropathy.Results: Out of 1844 eligible pts, 379 developed neuropathy (20.5%). For pts in arm A, those who developed neuropathy had better DFS than pts who did not (3 yr DFS: 86.2% vs 81.8%; HR 0.65; p=0.01), despite lower doses of paclitaxel in the pts with neuropathy. Grade of neuropathy did not appear to impact DFS. No statistical difference was noted for pts treated in the trastuzumab-containing arm (3 yr DFS: 92.8% vs 91.1% for pts with neuropathy vs not; HR 0.79; p=0.34). There were no differences in paclitaxel dose intensity between arms A and C.Conclusion: Patients with early stage HER2+ breast cancer who received adjuvant paclitaxel-containing chemotherapy in arm A and developed peripheral neuropathy had a better DFS than pts who did not develop neuropathy. This effect was possibly abrogated by the use of trastuzumab in Arm C. This side effect may represent effective bindings of paclitaxel to the target tubulin, lack of point mutations in tubulin at the paclitaxel binding site and/or lack of selective overexpression of β-III tubulin. This is a hypothesis generating study and additional analysis needs to be conducted from other large taxane-based trials.Partial support from Genentech and the Breast Cancer Research Foundation

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2100.

K-Ras mutation (mut), EGFR-related, and exploratory markers as response predictors of cetuximab in first-line advanced NSCLC: Retrospective analyses of the BMS099 trial

8021

Background: This phase III study investigated cetuximab (C) plus taxane/carboplatin (TC) in 1st-line advanced NSCLC. Progression-free survival (PFS) was not significantly different with the addition of C to TC; response rate (RR) was significantly higher; median overall survival (OS) was longer, with a difference (not statistically significant) similar in magnitude to the significant OS improvement from FLEX (cisplat/vinorelb±C). Potential patient-selection markers were analyzed, including mut in K-Ras, EGFR mut and gene copy number (GCN), EGFR protein expression, and gene expression profiles. Methods: Chemonaïve patients (pts) with stage IIIB/IV NSCLC (any histology or EGFR expression status) were randomized to TC±C. K-Ras gene exon 2, and EGFR exons 18–21 were sequenced bidirectionally using formalin-fixed paraffin embedded tissue-derived genomic DNA. EGFR GCN was measured by fluorescence in situ hybridization (FISH) and EGFR protein expression by immunohistochemistry (IHC). Exploratory expression profiling studies using Affymetrix GeneChip are ongoing. Analyses were blinded to clinical outcome. The relationships between biomarker status and efficacy were assessed with log-rank tests per study arm for treatment-specific effects, and across the total evaluable population. Results: Samples from 225/676 randomized pts were available; 35/202 (17%) had K-Ras mut, 17/167 (10%) had EGFR mut, 54/104 (52%) were EGFR FISH+, 131/148 (89%) were EGFR IHC+. There were no significant treatment-specific correlations between any biomarker assessed and PFS, OS or RR, except superior OS with TC for the EGFR FISH+ group (P=0.03). With all pts combined, OS was longer in the EGFR mut subset vs wt (P=0.09); PFS was longer in EGFR IHC- pts vs IHC+ (P=0.048). Results from gene expression profiling studies, including EGFR ligands, will be presented. Conclusions: There was no significant correlation between patient response to C and any molecular marker evaluated to date (K-RAS mut, EGFR mut, EGFR IHC, EGFR FISH), exploratory analyses are ongoing. Additional predictive-marker studies are needed to optimize cetuximab therapeutic use in NSCLC.

[Table: see text]

A preliminary report of a phase II trial of single-agent vinflunine as second-line treatment of advanced non-small cell lung cancer

18156

Background: In preclinical and early clinical trials, single-agent vinflunine (a novel microtubule inhibitor) has shown activity in a variety of tumors, including non-small cell lung cancer (NSCLC). The purpose of this phase II, single-arm study is to evaluate the safety and efficacy of vinflunine administration every 3 weeks to patients with advanced NSCLC who have progressed after prior treatment with a platinum-based doublet. The primary endpoint is 1-year survival rate. This report presents preliminary safety information demonstrating the safety and tolerability of this combination. Methods: Patients = 18 years with confirmed advanced NSCLC (stage IIIB with malignant pleural effusions or stage IV) that have progressed after receiving a platinum-based doublet as first-line therapy, received vinflunine (320 mg/m2) as a 20-minute IV infusion on Day 1 of each 21-day cycle. Results: At the time of analysis, 36 patients (of a planned total of 75) have received study treatment. Patient characteristics include: gender male/female, 24/12; median age 68.5 years (range 42–86); ECOG performance status 0/1, 10/26; and race Caucasian/Black, 34/2. The median number of cycles administered was 2 (range 1–9). Fourteen patients are still on study. The most common toxicities (NCI CTC version 2), regardless of causality, were Grade 3 fatigue (14.3%), asthenia (8.6%), neutropenia (8.6%), constipation (5.7%), cough (5.7%), dehydration (5.7%), vomiting (5.7%), dyspnea (5.7%), and ileus (5.7%). Grade 4 toxicities were neutropenia (22.9%) and change in mental status (5.7%). There were 5 deaths (2 from progressive disease, 1 from respiratory distress, 1 from coronary artery disease, and 1 case of sepsis possibly related to study drug). Conclusions: These preliminary results suggest that vinflunine has a manageable safety profile when used as a single agent for second-line treatment of patients with advanced NSCLC. Supported by Bristol-Myers Squibb.

[Table: see text]

A pilot, multi-dose, placebo-controlled evaluation of american ginseng (panax quinquefolius) to improve cancer-related fatigue: NCCTG trial N03CA

9001

Background: Fatigue is one of the most common symptoms in people diagnosed with cancer. Ginseng is a popular herb for treatment of this. It has been termed an “adaptogen”, felt to be able to restore balance to the body; its potential anti-fatigue efficacy is supported by animal data. The purpose of this pilot trial was to evaluate three doses of American Ginseng versus placebo for cancer-related fatigue. Methods: Patients with a life expectancy = 6 months and a history of cancer-related fatigue who had been experiencing fatigue = 1 month were eligible. Exclusion criteria included prior use of ginseng, chronic systemic steroids and brain malignancies. Other etiologies for fatigue, such as pain, were also excluded. Participants were randomized to receive, in a double blind manner, placebo, 750 mg/d, 1,000 mg/d or 2,000 mg/d of American Ginseng in BID dosing for 8 weeks. Endpoints included The Brief Fatigue Inventory (BFI), the Vitality Subscale of the SF-36 and several numeric analogue questions of perceived benefit; endpoints were measured at baseline, 4 weeks and 8 weeks. Area under the curve (AUC) and change from baseline were calculated. Results: Two hundred eighty two patients (69–72 per arm) were enrolled from 10/21/2005 to 07/05/2006. Available 8-week data are provided in the table below; higher numbers are better. There were no statistically significant differences in any grade of toxicity between active and placebo arms, and an equivalent number of patients discontinued the study due to adverse events in each arm. Conclusion: This randomized pilot trial provided data to suggest that American Ginseng doses of 1000–2000 mg/d may be effective for alleviating cancer related fatigue. Therefore, further study of American Ginseng in cancer survivors appears warranted.

No significant financial relationships to disclose.

[Table: see text]

Phase III study of immediate versus delayed docetaxel after induction therapy with gemcitabine plus carboplatin in advanced non-small cell lung cancer: Updated report with survival

LBA7516

Background: Gemcitabine (G) plus carboplatin (C) therapy is active in patients with advanced non-small-cell lung cancer (NSCLC). For nonprogressing patients, optimal timing of second-line therapy with a non-cross-resistant agent is unclear. This Phase III, randomized trial assessed the efficacy and safety of docetaxel (D) administered either immediately after GC induction therapy or upon disease progression (PD). Methods: Patients having either Stage IIIB with pleural effusion or Stage IV NSCLC were enrolled. Prior chemotherapy for NSCLC was not permitted. For GC induction, G 1000 mg/m2 was administered on Days 1, 8 followed by C AUC 5 on Day 1. After four 21-day cycles, nonprogressors were randomized to either the immediate D group (D 75 mg/m2 administered on Day 1 every 21 days, for a maximum of 6 cycles) or the delayed D group (patients given best supportive care after randomization and the same D regimen after first evidence of PD) treatment arms. Primary endpoint was overall survival (OS). Additional analyses included response rates, toxicity and progression-free survival (PFS). Results: Results are summarized in the table below. OS was not statistically different (p=0.071) between the two D arms. However, 31 patients (20.1%) in the delayed D arm and 38 patients (24.8%) in the immediate D arm were censored for OS analysis. PFS analysis (from randomization to first evidence of PD or death) showed a statistically significant (p=<0.0001) improvement in the immediate D arm. D given to NSCLS patients immediately after GC induction did not increase toxicity. Conclusions: Comparison of PFS for each D arm suggests a possible clinical benefit for immediate D therapy. However, even though OS trended in favor of immediate D therapy, the OS result did not reach statistical significance. The implications of these results will be discussed.

[Table: see text] [Table: see text]

Randomized phase II trial of gemcitabine plus weekly versus three-weekly paclitaxel in previously untreated advanced non-small-cell lung cancer

INTRODUCTION

Gemcitabine and paclitaxel (Taxol) each provides an efficacious non-platinum option for the treatment of advanced non-small-cell lung cancer (NSCLC), but the optimal dosage and schedule of the two agents used in combination are not well defined.

METHODS

Previously untreated patients with advanced NSCLC were randomized to receive gemcitabine-paclitaxel on a traditional three-weekly schedule (Arm A) or a novel weekly schedule (Arm B) as follows-Arm A (three-weekly): gemcitabine 1000 mg/m2 infused>30 min on days 1 and 8 and paclitaxel 200 mg/m2 infused>3 h on day 1 of a 21-day cycle or Arm B (weekly): gemcitabine 1000 mg/m2 infused>30 min and paclitaxel 100 mg/m2 infused>1 h, both administered on days 1 and 8 of a 21-day cycle.

RESULTS

One hundred patients received at least one dose of treatment. The weekly schedule, Arm B, was more efficacious and less hematologically toxic than Arm A. Confirmed complete and partial response rates were 28.2% and 26.8%, respectively. Median survival was 10.3 months on Arm B and 7.9 months on Arm A (log-rank P=0.10); 1- and 2-year survival rates also favor Arm B: 42.0% versus 34.0% and 18.0% versus 6.0%. Progression-free survival was 5.8 versus 4.8 months, again favoring Arm B (log-rank P=0.06). There was a two-fold lower frequency of grade 3/4 hematologic events with Arm B as follows: neutropenia (16% versus 30%), thrombocytopenia (4% versus 8%), and anemia (2% versus 6%). One patient (2%) in each treatment group developed febrile neutropenia.

CONCLUSION

In this trial, both schedules were efficacious and tolerable, although the weekly schedule resulted in improved survival and lower hematologic toxicity compared with a three-weekly schedule. The weekly schedule of gemcitabine-paclitaxel indicates an improved therapeutic index.

Cetuximab + FOLFOX6 as first line therapy for metastatic colorectal cancer (An International Oncology Network study, I-03–002)

3557

Background: Cetuximab, an IgG1 monoclonal antibody targeting the EGFR, is currently approved for second line treatment of metastatic colorectal cancer (CRC). This phase II trial was designed to evaluate the safety and efficacy of cetuximab combined with FOLFOX6 as first line therapy in this patient population. Promising results have been reported at ESMO in a similar small pilot study. Methods: Eligibility: Age ≥ 18, locally advanced or metastatic CRC, no prior therapy for advanced disease, EGFR expression positive or undetectable. Regimen: Cetuximab 400 mg/M2 (2 hour infusion) day 1; 250 mg/M2 day 8 (and 250 mg/M2 for all subsequent doses); and modified FOLFOX 6 (2 hour infusion); and 5FU bolus 400 mg/M2 day 1 followed by 5FU-CI 2400 mg/M2 over 46 hours (days 1 and 2). Cycles were repeated every 14 days. Results: 82 patients were enrolled in the study. The median number of treatment cycles administered was 8. (range 1–28) At the time of this report, 23 patients are still on study. Reasons for discontinuation of therapy included: Toxicity (14 patients), disease progression (20), investigator /patient decision (11), planned therapy completed (3). Five patients (6%) died on study. Causes of death included: PD (2 patients), acute MI (1), respiratory failure secondary to pneumonia (1), sudden death of unknown cause (1). The most frequently observed toxicity was neutropenia. Grade 3/4 toxicities are listed in the table below. At this early analysis time point, 32 of 60 patients evaluable for response have documented CR/PR (3 CR, 29 PR, overall response rate of 53%). A pre-meeting update is planned for presentation purposes. Conclusion: These findings suggest that the combination of cetuximab with FOLFOX6 is safe and active in first line treatment of patients with metastatic CRC. Updated efficacy and safety data will be presented.

[Table: see text]

No significant financial relationships to disclose.

Phase II trial of single-agent weekly docetaxel in hormone-refractory, symptomatic, metastatic carcinoma of the prostate

The purpose of this study was to assess the efficacy of weekly administration of docetaxel as a single agent in patients with hormone-refractory, symptomatic, metastatic prostate cancer with respect to symptom palliation, tumor response, time to progression, and survival. Sixty men with progressive metastatic prostate cancer that had progressed on at least one hormonal regimen were enrolled in this multicenter phase II study. Twenty-one percent of patients had received prior palliative radiotherapy, and 25% had received prior chemotherapy for hormone-refractory disease. Patients were scheduled to receive three 8-week cycles of docetaxel (36 mg/m(2) on days 1, 8, 15, 22, 29, and 36) with 2-week intervals between cycles. The docetaxel dose could be decreased in the event of toxicity, but no dose escalation was permitted. A > or =50% decrease in serum prostate-specific antigen (PSA) levels from baseline with stabilization or improvement of performance status lasting 2 months or longer occurred in 24 (41%) patients, of whom 16 (27%) had a > or =80% decrease for 2 months or more. The median time to progression for all patients was 5.1 months (range, 0.9 to 18.2 months). The estimated median time to progression for patients who had and those who did not have a > or =50% reduction in serum PSA level with stable or improved performance status was 6.65 and 4.3 months, respectively. The median overall survival was 9.4 months (range, 1.6 to 18.2 months). Treatment toxicity was considered acceptable. Single-agent docetaxel at 36 mg/m(2) weekly was associated with a PSA response rate of 41%, increased time to progression and survival, and minimal myelosuppression in patients with hormone-refractory metastatic prostate cancer.

TPDC-FuHu chemotherapy for the treatment of recurrent metastatic brain tumors

PURPOSE

To evaluate a combination of thioguanine, procarbazine, dibromodulcitol, CCNU (CCNU), fluorouracil, and hydroxyurea (TPDC-FuHu), designed to improve the efficacy of CCNU, in the treatment of recurrent metastatic brain tumors.

PATIENTS AND METHODS

One hundred fifteen patients with progressive or recurrent metastatic brain tumors that failed to respond to surgery and/or radiation therapy were enrolled onto a multicenter prospective study between 1989 and 1995. Patients received TPDC-FuHu in a repeated cycle every 6 weeks until recurrence or until they completed six courses.

RESULTS

Ninety-seven patients were assessable at the end of the study. Forty-eight had lung cancer (39 non-small-cell [NSCLC] and nine small-cell [SCLC]), 28 had breast cancer, nine had melanoma, and 12 had adenocarcinoma of different origins (three colon, two kidney, one bladder, one stomach, and five of unknown origin). The response and stable disease (SD) rate (overall response rate) was 52%, 66%, 60%, and 22% in patients with NSCLC, SCLC, breast cancer, and melanoma, respectively. Median time to progression (MTP) was 12, 26, 12, and 6 weeks, respectively, for the four groups. Side effects were mild to moderate in the majority of patients. Severe myelosuppression (grade 4) occurred in only 11% of the patients.

CONCLUSION

TPDC-FuHu chemotherapy is an active treatment against recurrent brain metastases from breast cancer and SCLC, and to a lesser extent from NSCLC. This regimen is well tolerated and has acceptable toxicity.

Phase II clinical trial of didemnin B in previously treated small cell lung cancer

Didemnin B (NSC 325319), a cyclic depsipeptide isolated from a Carribean sea tunicate, exhibited potent antitumor activity in preclinical studies. After determining the maximum tolerated dose in our previous phase I/II trial, we conducted a phase II study of this drug in patients with previously treated small cell lung cancer; the starting dose was 6.3 mg/m2 intravenously over 30 min every 28 days. The major side effects were in the neuromuscular system and included severe muscle weakness, myopathy and/or myotonia by electromyography, and elevation of creatine phosphokinase and aldolase levels. We also observed modest increases in bilirubin and alkaline phosphatase levels. There were minimal hematologic toxic effects. No response was observed among 15 evaluable patients, leading us to conclude that didemnin B was toxic but inactive in patients with previously treated small cell lung cancer at the stated dose and schedule. A review of the literature revealed no significant antitumor activity in cancers of the colon, breast, ovaries, cervix, or lung (non-small cell) or in renal cell carcinoma. Further clinical trials for didemnin B may not be warranted at the stated dose and schedule.

Totally implanted system for intravenous chemotherapy in patients with cancer

A totally implanted system for improved central venous access has been investigated in 20 patients with cancer (six with solid tumors, four with leukemia, and 10 with lymphomas) who were treated with aggressive chemotherapy regimens and who lacked peripheral venous sites. The system is implanted using local anesthesia and consists of a subcutaneous injection port connected to a Silastic catheter threaded through the subclavian vein into the superior vena cava. Injections and continuous infusions (for up to three weeks) of virtually all classes of antineoplastic agents, antibiotics, blood components, and intravenous solutions were administered through the system. The system was filled with heparinized saline and not otherwise flushed between uses. The system has remained functional for periods exceeding 450 days (mean 235 days). There was no significant local irritation and no system became infected. None of 18 large-bore catheters (0.63 mm lumen) became occluded (seven to 300 days), whereas five of six small-bore catheters (0.38 mm lumen) became occluded (90 to 420 days). Three of the occluded systems were replaced. Acceptance has been excellent, and patients have had no impediment to normal activities. This system appears to be an alternate means of safe and reliable central venous access with improved convenience and cosmetic acceptability.

Improved regional selectivity of hepatic arterial BCNU with degradable microspheres

Starch microspheres 40 micrometers in diameter, which are rapidly degraded by serum amylase, have been administered through hepatic arterial catheters to five patients with primary and metastatic liver cancer to determine whether (1) arterial blood flow through the liver could be temporarily blocked, and (2) such occlusion at the level of the arteriolar capillary bed would enhance regional uptake and catabolism and decrease systemic exposure to simultaneously administered hepatic arterial bischlorethylnitrosourea (BCNU). It was possible with 10 ml of microspheres (9 X 10(6) microspheres/ml) injected into the hepatic artery to transiently (for 15-30 minutes) reduce hepatic flow by 80-100% in the five patients. When BCNU (50 mg/m2 in one minute) was given with microspheres there was a 30-90% reduction in systemic nitrosourea exposure and in peak levels. No myelosuppression was noted and hepatic toxicity consisted of acute pain due to BCNU and 1.5-2.0 fold transient enzyme elevations. One patient with cholangiocarcinoma showed a partial response lasting three months; three patients had stable disease and one patient with colon carcinoma had progressive disease. Thus, this pilot study suggests that concurrent intra-arterial microspheres and BCNU may have the potential to improve selective regional drug effect with marked diminution in systemic toxicity.

Totally implanted drug delivery system for hepatic arterial chemotherapy

A totally implanted drug delivery system for hepatic arterial chemotherapy was evaluated in 13 patients with metastatic (11 colon and one carcinoid) or primary (one hepatoma) cancer of the liver. During laparotomy, a Silastic catheter was positioned in the hepatic artery for infusion to the entire liver arterial vasculature as ascertained by low-flow radionuclide angiography with 99Tc-macroaggregated albumin. The catheter was connected to a subcutaneously implanted model 400 Infusaid pump (Metal Bellows Corp, Sharon, MA). Each pump had a 50-ml volume and a set rate (3--6 ml/day) and required refill every 8--16 days. A side port bypassed the pumping mechanism and allowed direct catheter injection for nuclide angiography, for bolus drug administration, or for clearing of a blocked catheter. Pump refills and side port injections were performed by percutaneous injection. The 13 patients in this ongoing study received a median of 6 months (range, 4.5--17) of continuous hepatic arterial infusion. The pump performed reliably with stable (+/- 10%) flow rates and only one malfunction in 2800 cumulative days of use. Flow distribution determined by low-flow radionuclide angiography did not change in 12 patients. Patient acceptance was excellent, with the ability to participate fully in normal daily activities. Eleven patients showed partial hepatic tumor regressions documented by physical examination and nuclide liver scans. All patients were treated with 5-fluorodeoxyuridine. Two patients failed 5-fluorodeoxyuridine therapy and subsequently responded briefly to dichloromethotrexate. This implanted system should facilitate future investigation of regional chemotherapy using these and other agents.

Implanted system for intraventricular drug infusion in central nervous system tumors

We have developed a totally implanted drug delivery system capable of maintaining constant cerebrospinal fluid (CSF) drug levels through continuous intraventricular infusion in outpatients. This system was used to infuse methotrexate (MTX) intraventricularly in seven patients with incurable CNS malignancies. One patient with meningeal diffuse histiocytic lymphoma, five patients with grade III--IV astrocytomas, and one patient with melanoma metastatic to the brain were treated with this system for 4--40+ weeks. The system consists of an Infusaid pump (Metal Bellows Corp, Sharon, MA), implanted subcutaneously in the infraclavicular fossa, which delivers a drug-containing solution at a set rate (3--5 mg/day) through a subcutaneous silastic catheter to a Rickham ventriculostomy reservoir and into a lateral ventricle. System placement and maintenance were readily tolerated. Constant MTX infusion at rates of 0.5--10 mg/day generated corresponding constant CSF drug levels in the range of 2--30 microM. Simultaneous serum MTX levels were undetectable (less than 0.01 microM), indicative of a 200- to 3000-fold selective regional concentration advantage for this approach. CNS toxic effects included transient meningism and fever (four patients), transverse myelitis (one), and the development of a diffuse hypodensity of the white matter on computerized tomographic scan which was not associated with any neurologic deficit (two). The usual systemic toxic effects (myelosuppression and mucositis) of MTX were not seen. The patient with meningeal lymphoma has had a complete remission of meningeal disease continuing past 10 months. Computerized tomography showed that three of the five high-grade astrocytomas had 25% size reductions in tumors lasting 2--6 months. This system may provide a means for improved treatment of meningeal tumor although its role in the treatment of intraparenchymal brain tumors is less clear. Of greater consequence, however, is the demonstrated ability of this system to maintain a controlled CSF drug level which should prove useful in many areas of therapeutic research.