Gemcitabine, ifosfamide and paclitaxel in advanced/metastatic non-small cell lung cancer patients: a phase II study

Although platinum-based two-drug combinations represent the elective therapeutic approach for advanced/metastatic NSCLC, there is still interest in exploring the efficacy and tolerability of platinum-free combinations including third generation agents in selected NSCLC population. Based on the satisfying activity of gemcitabine (G), ifosfamide (I) and paclitaxel (T) as single agents in NSCLC, we have designed a phase II study to explore an alternative approach to platinum-containing regimens using a combination of these three drugs. To investigate the activity/toxicity of T 175 mg/m2 on day 1, I 3 g/m2 on day 1 (with Mesna uroprotection) and G 1,000 mg/m2 on day 1-8, every 3 weeks in the treatment of advanced/metastatic NSCLC, 46 patients (38 male, 8 female) with NSCLC were enrolled: mean age 58 (range 33-70); Stage IIIB/IV=15/31; ECOG PS 0-1/2=31/15;

HISTOLOGY

adenocarcinoma=20, squamous=14, large cell=3, NSCLC=8, adenosquamous=1. A total of 221 cycles have been administered (median number 4.8 for patients). In intent-to-treat analysis, partial response was achieved in 17 patients (36.95%), stable disease and progressive disease was detected in 16 (34.78%) and 10 (21.73%) patients, respectively. Time to progression was 30.9 weeks; median survival time was 42.7 weeks; the survival rates at 12 and 18 months were 34.79 and 15.21%, respectively. No toxic deaths occurred. No patients experienced grade 4 neutropenia and thrombocytopenia. Neutropenia grade 3 occurred in 10 patients (21.7%); Anemia grade 3 in 1 (2.1%); Thrombocytopenia grade 2 in two patients (4.3%) and grade 3 in one (2.1%). Peripheral neuropathy grade 1 occurred in ten (21.7%) and grade 2 in two patients (4.3%). Additional non-haematological toxicities were mild nausea, emesis and fatigue. GIT is well tolerated and active regimen in both advanced and metastatic NSCLC. These data suggest future investigations for GIT schedule as a possible alternative to platinum-based regimens in selected advanced/metastatic NSCLC patients where survival, tolerability and quality of life are the primary goals.

Two consecutive phase 1–2 studies of cisplatin (P)-based 1st-line chemotherapy (CT) in elderly patients (pts) with advanced non-small cell lung cancer (NSCLC). The MILES-2P studies

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Background: P-based CT needs prospective testing in elderly pts with advanced NSCLC. In two consecutive studies, with equal design, feasible dose of P combined with gemcitabine (PG) or vinorelbine (PV) were identified and toxicity and activity were described. Methods: Advanced (stage IV or IIIb with supraclavear nodes or pleural effusion) NSCLC pts, aged >70 years, PS 0–1, were eligible. P was given on day (d) 1, starting dose-finding at 50 mg/m2 (level 0), with G (fixed dose: 1000 mg/m2 dd 1&8) or V (fixed dose: 25 mg/m2 dd 1&8); at each level <2 unacceptable toxicities in cycle 1–3 (UT) out of 6 evaluable pts were needed to escalate; CT was given every 3 weeks, up to 6 cycles. A two-stage flexible optimal design was applied at the feasible dose. With rate of pts without UT as endpoint, type I and II error =0.10, p0=0.70, p1=0.85, ≥47 pts without UT out of 60 enrolled were required at the final stage. NCI-CTC for toxicity and RECIST for response coding were used. Results: From June 2002 to November 2004, 159 pts were enrolled (38 in dose-finding and 121 in phase 2); 45% of them were aged ≥75. P was feasible at 60 mg/m2 (level +1) with G, and 40 mg/m2 (level -1) with V. With PG (n=60): 50 (83%) pts without UT; response rate (RR): 43%, 95% exact CI: 31–57; median progression-free (PFS) and overall survival (OAS): 25 and 44 wks, respectively. Toxicity (≥5% of pts): g3 anemia (5%), RBC transfusion (8%), g3–4 platelets (10%), g2–3 cardiac (10%), g2 renal (7%). With PV (n=61): 50 (82%) pts without UT, 2 toxic deaths (1 with febrile neutropenia [FN] and 1 with cardiac toxicity); RR 36%, 95% exact CI: 24–49; median PFS and OAS: 21 and 33 wks, respectively. Toxicity (≥5% of pts): g3 anemia (5%), RBC transfusion (8%), FN (5%), g≥2 neurologic (5%). Conclusions: The combination of cisplatin and gemcitabine (with P 60 mg/m2) is safe, active, and deserves comparison vs single-agent chemotherapy in elderly pts with advanced NSCLC.

No significant financial relationships to disclose.

A randomised clinical trial of two docetaxel regimens (weekly vs 3 week) in the second-line treatment of non-small-cell lung cancer. The DISTAL 01 study

Docetaxel (75 mg m(-2) 3-weekly) is standard second-line treatment in advanced non-small-cell lung cancer (NSCLC) with significant toxicity. To verify whether a weekly schedule (33.3 mg m(-2) for 6 weeks) improved quality of life (QoL), a phase III study was performed with 220 advanced NSCLC patients, < or =75 years, ECOG PS < or =2. QoL was assessed by EORTC questionnaires and the Daily Diary Card (DDC). No difference was found in global QoL scores at 3 weeks. Pain, cough and hair loss significantly favoured the weekly schedule, while diarrhoea was worse. DDC analysis showed that loss of appetite and overall condition were significantly worse in the 3-week arm in the first week, while nausea and loss of appetite were more severe in the weekly arm in the third week. Response rate and survival were similar, hazard ratio of death in the weekly arm being 1.04 (95% CI 0.77-1.39). A 3-weekly docetaxel was more toxic for leukopenia, neutropenia, febrile neutropenia and hair loss; any grade 3-4 haematologic toxicity was significantly more frequent in the standard arm (25 vs 6%). The weekly schedule could be preferred for patients candidate to receive docetaxel as second-line treatment for advanced NSCLC, because of some QoL advantages, lower toxicity and no evidence of strikingly different effect on survival.

Supportive care in patients with advanced non-small-cell lung cancer

The present study describes supportive care (SC) in patients with advanced non-small-cell lung cancer (NSCLC), evaluating whether it is affected by concomitant chemotherapy, patient's performance status (PS) and age. Data of patients enrolled in three randomised trials of first-line chemotherapy, conducted between 1996 and 2001, were pooled. The analysis was limited to the first three cycles of treatment. Supportive care data were available for 1185 out of 1312 (90%) enrolled patients. Gastrointestinal drugs (45.7%), corticosteroids (33.4%) and analgesics (23.8%) were the most frequently observed categories. The mean number of drugs per patient was 2.43; 538 patients (45.4%) assumed three or more supportive drugs. Vinorelbine does not produce substantial variations in the SC pattern, while cisplatin-based treatment requires an overall higher number of supportive drugs, with higher use of antiemetics (41 vs 27%) and antianaemics (10 vs 4%). Patients with worse PS are more exposed to corticosteroids (42 vs 30%). Elderly patients require drugs against concomitant diseases significantly more than adults (20 vs 7%) and are less frequently exposed to antiemetics (12 vs 27%). In conclusion, polypharmacotherapy is a relevant issue in patients with advanced NSCLC. Chemotherapy does not remarkably affect the pattern of SC, except for some drugs against side effects. Elderly patients assume more drugs for concomitant diseases and receive less antiemetics than adults.