Cisplatin + irinotecan versus cisplatin + etoposide in extensive stage small cell lung cancer (E-SCLC): Final “common arm”: Comparative outcomes analysis of JCOG 9511 and SWOG 0124

8027

Background: S0124 was a large North American phase III trial (n=651) that failed to confirm a survival benefit for cisplatin/irinotecan over cisplatin/etoposide in patients with E-SCLC, contrary to the results of J9511, a phase III trial exclusively in Japanese patients (n=154). As S0124 and J9511 protocols used identical treatment regimens and similar eligibility criteria, we compared demographics, toxicity, and outcomes using patient-level data and a “common arm” analysis to explore potential reasons for the divergent results. Methods: In both trials, patients with documented E-SCLC and adequate end-organ function were randomized to receive either cisplatin 60 mg/m2 day 1 + irinotecan 60 mg/m2 days 1, 8, & 15 Q 4 weeks or cisplatin 80 mg/m2 day 1 + etoposide 100 mg/m2 days 1–3 Q 3 weeks. Demographics and outcomes data were compared among 805 patients enrolled in J9511 and S0124 receiving identical treatment using a logistic model adjusted for age, sex, and performance status. Results: Of 671 patients in S0124, 651 were eligible. Patient characteristics (J9511 & S0124, respectively): Mean age - 61 & 62 years; Male sex - 132 (86%) & 370 (57%), p<0.001; Performance status 0 - 19 (12%) & 211 (32%), p<0.001. Efficacy and toxicity comparisons are summarized below. Conclusions: Significant differences in patient demographics, toxicity, and efficacy exist between J9511 and S0124 populations. These results, relevant in the current era of clinical trials globalization, warrant 1) consideration of differential patient characteristics and outcomes amongst populations receiving identical therapy; 2) utilization of the “common arm” model in prospective trials; and 3) inclusion of pharmacogenomic correlates in cancer trials where ethnic/racial differences in drug disposition are expected.

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SWOG S0509: A phase II study of novel oral antiangiogenic agent AZD2171 (NSC-732208) in malignant pleural mesothelioma

7511

Background: Preclinical studies suggest the autocrine growth loop involving VEGF and its receptors is a relevant therapeutic target for malignant pleural mesothelioma (MPM). We evaluated AZD2171, a potent tyrosine kinase inhibitor (TKI) of VEGFR1/2 in MPM. Methods: MPM patients (pts) after platinum-based chemotherapy, with PS 0–2, measurable disease and adequate organ function were treated with oral daily dosing of AZD2171 45 mg. Study endpoints were response rate, progression free survival (PFS), overall survival (OS), frequency/severity of toxicities, and correlation of clinical outcomes with tumor and serum biomarkers. Results: 54 pts were registered between November 2005 and April 2008; 45 pts are eligible for response and 46 for toxicity analysis. Median age was 66.8 yrs; M/F: 37/9. Tumor response by RECIST was seen in 4/45 (9%) of pts; of these responders, 2 pts with bulky disease had 56% and 91% tumor shrinkage, respectively. 15/45 (33%) had SD; 21/45 (47%) had PD; 1/45 (2%) had early death. Thirty-five pts have died. For 46 pts, median PFS is estimated at 3 months; median OS is estimated at 10 months. For 46 pts, frequent grade 1–3 toxicities included anorexia (30%), diarrhea (63%), fatigue (60%), hypertension (67%), and proteinuria (28%). There were 8 grade 4 events: Cognitive disturbance, colitis, confusion, ileal perforation, hypertension, hyponatremia, hypotension, and renal failure. Conclusions: AZD2171 has antitumor activity in MPM, with a DCR (CR/PR/SD) of 42% by RECIST, which has limitations in measuring response in pleural tumors. Notably, 2 pt tumors were exquisitely sensitive to this drug. Toxicities were consistent with those of the anti-angiogenic TKI class of drugs. Studies correlating outcome measures with tumor hypoxia- and angiogenesis-related gene expression and circulating endothelial cells are underway. Based on these data, we are proceeding in SWOG with a study of pemetrexed/cisplatin ± AZD2171 (S0905). This investigation was supported in part by the following PHS Cooperative Agreement grant numbers awarded by the National Cancer Institute, DHHS: CA32102, CA38926, CA14028, CA46441, CA105409, CA13612, CA45808, CA20319, CA86780, CA35090, CA67663, CA46282, CA42777, CA76448, CA04919, CA35176, CA63848, CA27057, CA16385.

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A phase II randomized selection trial evaluating concurrent chemotherapy plus cetuximab or chemotherapy followed by cetuximab in patients with advanced non-small cell lung cancer (NSCLC): Final report of SWOG 0342

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Background: Randomized clinical trials have failed to show a survival benefit for small molecule epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors plus chemotherapy in unselected patients with metastatic NSCLC. In contrast, pilot trials of EGFR targeted antibodies plus chemotherapy have suggested enhanced anti-tumor activity. This randomized phase II selection trial was designed to select a cetuximab-chemotherapy regimen for future evaluation in a phase III setting. Methods: Untreated patients (pts) with advanced stage NSCLC were randomized to receive paclitaxel (P) 225 mg/m2 and carboplatin (Cb) AUC=6 every 3 weeks plus concurrent cetuximab (C) 400 mg/m2 loading dose followed by 250 mg/m2, weekly for 4 cycles followed by maintenance C or sequential PCb for 4 cycles followed by C. Treatment was continued until disease progression. Eligible patients were required to have stage IIIB (pleural effusion) or IV (without brain metastases) disease, a performance status of 0–1 and adequate organ function. The primary endpoint was overall survival. The regimen with superior median survival would be considered for further evaluation provided it met a 10-month minimum. Given a true hazard ratio of 1.3, the probability of correctly choosing the superior arm would be > 90%. Results: From July 2004 to June 2005, 242 eligible pts were enrolled onto the study, Final results are described below: Conclusions: Both regimens met efficacy criterion for continued evaluation though the concurrent regimen of PCb + C, had numerically higher survival, and was chosen for further study. Some toxicities were significantly increased with concurrent therapy. A phase II trial of PCb + Cetuximab + Bevacizumab is ongoing (SWOG 0536) in anticipation of a phase III trial. Molecular correlative studies of the EGFR signaling pathway including EGFR IHC, FISH and mutation analysis are underway.

No significant financial relationships to disclose.

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Erlotinib as initial therapy in patients with advanced non-small cell lung cancer (NSCLC) and a performance status (PS) of 2: A SWOG phase II trial (S0341)

7536

Background: Patients (pts) with advanced NSCLC and PS 2 have an inferior survival compared with good PS pts. Single agent and combination chemotherapy have been used with modest success with toxicity often limiting treatment. Targeted agents such as the EGFR tyrosine kinase inhibitor erlotinib (E) offer an alternative which may confer comparable benefit with better tolerance. This phase II trial of E in unselected chemotherapy-naive pts with advanced NSCLC and PS 2 was performed to obtain preliminary data regarding efficacy and EGFR biology in this pt population, and to set the stage for a subsequent randomized trial of E vs.chemotherapy, in pts selected for EGFR expression. Methods: Eligibility: stage IIIB (pleural effusion)/IV NSCLC; measurable disease; PS 2; no prior chemotherapy/biologic treatment for NSCLC. Treatment: E 150 mg orally daily. Molecular correlative studies:EGFR protein expression (IHC), gene copy (FISH), mutation analysis. Results: Pts: 82; 73 eligible; 72 fully evaluable; age (median) 74.4; M/F 47%/53%; current/former smoker 91%; stage IIIB/V 12%/88%; adenoca 54%. Treatment was well tolerated. Five pts (7%) had a grade 4 toxicity (fatigue 3 pts; dyspnea 2 pts). Most common grade 3 toxicities: fatigue 9 pts (13%); rash 7 pts (10%); diarrhea 5 pts (7%); anorexia 5 pts (7%). There was 1 possible treatment related death due to pneumonitis. One complete (1%) and 5 (7%) partial responses were noted. Stable disease was seen in 25 pts (35%) for an overall disease control rate (DCR) of 43% (31 pts). Progression free survival: 2.1 months (95% CI 1.5 –3.1); Median survival: 5.0 months (95 % CI 3.5 –7.3). One year survival: 22% (95% CI 12 –32%). Analysis of molecular correlates is ongoing. Conclusions: Single agent erlotinib is a well tolerated treatment for chemotherapy- naive patients with advanced NSCLC and PS 2 with an overall DCR of 43% and median survival of 5 months. These efficacy results are comparable to the outcome seen in SWOG trial S0027 in PS 2 pts employing sequential vinorelbine and docetaxel. We hypothesize that pt selection by an EGFR biomarker strategy will improve results with E, and that E will be superior to chemotherapy in this selected population.This trial design is under development within SWOG at present.

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S9900: Surgery alone or surgery plus induction (ind) paclitaxel/carboplatin (PC) chemotherapy in early stage non-small cell lung cancer (NSCLC): Follow-up on a phase III trial

7520

Background: Small randomized and non-randomized studies suggest induction chemotherapy may improve survival in early stage NSCLC. The primary objective of this study was to determine if induction PC could improve survival over surgery alone. Preliminary results of this trial were reported at ASCO 2005 (J Clin Oncol, ASCO Proc 23(16S) 2005:7012). Median time for patients alive at last contact is now 46 months (mos). Methods: Consenting patients with clinical stage T2N0, T1–2N1 and T3N0–1 NSCLC (excluding superior sulcus tumors) were stratified by clinical stage (IB/IIA vs. IIB/IIIA) and randomized to induction PC (P:225 mg/m2 over 3 hours, C:AUC=6) on day 1, every 3 weeks × 3 or surgery alone. Eligible patients had a performance status 0–1, age =18 years (yrs), predicted post- resection FEV1 =1.0L. Surgery was at least a lobectomy and mediastinal nodal sampling. The primary endpoint was a 33% increase in overall survival over expected 2.7 yrs median for surgery. Planned sample size was 600 patients, 81% power, 1-sided test, 0.025 significance. Results: S9900 closed 07/04 when adjuvant chemotherapy became standard. 354 patients had accrued; 174-surgery alone, 180- induction PC; 19 were ineligible. Median age 65 yrs, 66% male, 70% IB/IIA, 30% IIB/IIIA. Major radiographic response to induction PC was 41%. Treatment-related deaths: 3 during induction PC, 11 within 30 days of surgery (7-induction PC arm, 4-control). Progression-free survival (PFS), overall (OS) survival rates and hazard ratios (HR) are shown. Conclusions: PFS and OS continue to trend in favor of induction PC with HR similar to those observed in adjuvant trials, supporting the role of chemotherapy in operable NSCLC. Randomized trials comparing induction to adjuvant chemotherapy are warranted. Supported by SWOG CA30102.

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Updated analysis of SWOG 0023: A randomized phase III trial of gefitinib versus placebo maintenance after definitive chemoradiation followed by docetaxel in patients with locally advanced stage III non-small cell lung cancer

7513

Background: Early clinical studies with gefitinib (G) showed promising efficacy and mild toxicity in patients (pts) with advanced NSCLC. Thus, G was an ideal agent to evaluate in a maintenance setting in stage III disease following definitive treatment. Methods: Untreated pts with stage III NSCLC, a PS of 0–1 and adequate organ function were eligible. Patients received the SWOG 9504 core regimen (cisplatin 50 mg/m2, d1 & 8 plus etoposide 50 mg/m2 day 1–5, every 28 days for 2 cycles with concurrent thoracic radiation, 1.8–2 Gy fractions/day, total dose 61 Gy, followed by 3 cycles of docetaxel 75 mg/m2). Non- progressing pts were randomized to G 250 mg per day or placebo (P) until disease progression, intolerable toxicity or 5 years. The planned sample size was 672, to confer power of 0.89 to detect a 33% increase over the expected median survival of 21 months (one-sided 0.025 level logrank test). Randomization was stratified by stage and histology. Results: Enrollment began in July 2001. An unplanned interim analysis prompted by outside data was conducted in April 2005 and the alternative hypothesis of improved survival was rejected at the 0.0015 level for 243 randomized patients. The study closed and preliminary results were reported (ASCO 2005). Now with a median follow up of 27 months, median survival for the G arm (n=118) was 23 months and was 35 months for the P arm (n=125) (two sided p=0.013). Overall survival for the 571eligible patients was 19 months. ≥ Grade 3 toxicities in the G arm were rash (7%), diarrhea (7%) and pneumonitis (3%). Conclusion: In this unselected population G did not improve survival. Decreased survival was due to cancer not G toxicity. Three year survival estimates will be presented. Molecular studies of the EGFR pathway are underway and will be correlated with outcomes.

No significant financial relationships to disclose.

Combination of EGFR gene copy number and protein expression predicts outcome for advanced non-small-cell lung cancer patients treated with gefitinib

BACKGROUND

Biological markers for optimal selection of patient to epidermal growth factor receptor (EGFR)-targeted therapies are not established in advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

EGFR/HER2 gene copy number by FISH, EGFR protein and pAKT expression by immunohistochemistry (IHC) and EGFR and KRAS mutations were tested in 204 gefitinib-treated NSCLC patients.

RESULTS

Increased EGFR and HER2 gene copy number (FISH+), EGFR protein overexpression (IHC+), EGFR mutations and pAKT overexpression were all associated with significantly higher response rates (33%, 29%, 22%, 39% and 20% respectively). EGFR FISH+ (32%) and IHC+ (61%) correlated with improved survival, while EGFR mutations (27%), KRAS mutations (26%) and pAKT expression (69%) did not. In multivariate survival analysis EGFR FISH and IHC were independent predictive markers. EGFR FISH+/IHC+ patients (23%) had a median survival of 21 months versus 6 months for double-negative patients (30%).

CONCLUSION

Combination of EGFR FISH and IHC is effective predictor for benefit from gefitinib. Patients with double-negative results are unlikely to benefit in western NSCLC populations.

Elevated osteopontin (OPN) plasma levels are highly prognostic in advanced non-small cell lung cancer (NSCLC): Analysis of SWOG S0003

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Background: OPN is a secreted glycoprotein with a diverse array of functions, including induction of uPA & increased cell migration. OPN has been shown to be elevated in a number of tumor types, & its downregulation reduces tumorigenicity & metastasis in tumor models. High levels have also been associated with tumor hypoxia/angiogenesis, as are vascular endothelial growth factor (VEGF) & plasminogen activator inhibitor (PAI-1). We hypothesized that secreted levels of these biomarkers would correlate with clinical outcome after treatment. Methods: Plasma concentrations of OPN, VEGF & PAI-1 were measured by ELISA in 160 NSCLC patients enrolled on the Southwest Oncology Group (SWOG) trial S0003 (paclitaxel/carboplatin ± the hypoxic cytotoxin tirapazamine). Post-treatment plasma samples were available in 56 patients. Results: Baseline OPN plasma levels correlated significantly with patient overall survival (OS). High interpatient variability was observed, with levels ranging from undetectable to 2560 ng/ml, (median: 606.5 ng/ml). When dichotomized, median OS was 11 months for patients below median OPN levels & 7 months for those above (p = 0.004). Survival decreases with increasing OPN concentration. Furthermore, OPN levels correlated with response rate (RR) (median responders: 497; median non-responders: 698 ng/ml. Wilcoxon rank-sum p = 0.03). No association between baseline levels of either VEGF or PAI-1 with RR or OS was observed. However, plasma levels of both PAI-1 & VEGF were significantly inter-related & trended together (p < 0.0001), & both decreased significantly after treatment (p = 0.0004 & 0.04, respectively). Median decrease: OPN: 17%, PAI: 44%, VEGF: 42%. No significant differences were observed between study arms, suggesting that OPN is prognostic in NSCLC, but not predictive for response to tirapazamine. Conclusions: 1) There is a great need for development of tumor biomarkers which can be serially assessed pre- & post-therapy. 2) High OPN plasma levels were significantly associated with reduced RR & OS for patients on this trial. OPN is a strong candidate for inclusion in a panel of prognostic (& perhaps predictive) markers for NSCLC. Supported by the Hope Foundation & R01-CA107228.

No significant financial relationships to disclose.

Advanced bronchioloalveolar carcinoma: a phase II trial of paclitaxel by 96-hour infusion (SWOG 9714): a Southwest Oncology Group study

BACKGROUND

There are no published prospective trials of chemotherapy for advanced bronchioloalveolar carcinoma (BAC), a subtype of non-small-cell lung cancer for which there is no current standard therapy. This phase II study assesses the efficacy and toxicity of 96-h paclitaxel in chemotherapy-naive patients with advanced BAC.

PATIENTS AND METHODS

Patients with histologically confirmed stage IIIB (with pleural effusion) or stage IV BAC were eligible. Treatment consisted of paclitaxel 35 mg/m2/24 h continuously infused over 96 h (days 1-4) every 21 days for up to six courses.

RESULTS

A total of 58 eligible patients were enrolled. The objective response rate was 14% (all partial responses, 9% confirmed); 40% of patients demonstrated stable disease. The median progression-free and overall survivals were 5 and 12 months, respectively. Grade 3 or greater toxicities included neutropenia/granulocytopenia (43%), febrile neutropenia (12%), infection (22%), and stomatitis/pharyngitis (10%); there were five treatment-related deaths.

CONCLUSIONS

S9714 represents the first prospective multi-institutional cooperative group trial focusing on treatment outcomes in BAC. Studies targeting this population are feasible, and while first-line paclitaxel administered as a prolonged infusion is active in this setting, toxicities limits the utility of this regimen. S9714 serves as a historical control for BAC patients against which future therapeutic approaches can be compared.

Ultrasonography for cervical length measurement: agreement between transvaginal and translabial techniques

OBJECTIVE

To assess agreement between transvaginal and translabial ultrasonography for measuring cervical length in the second and third trimesters.

METHODS

Eighty-four obstetric patients at 14-40 weeks' gestation were enrolled. Three images of the cervix were obtained by translabial (3.5-MHz curvilinear transducer) and transvaginal (6.5-MHz endovaginal probe) ultrasonography. The mean cervical length obtained by using each method was used for data analysis. The McNemar chi(2) test was used to assess the difference between techniques in their ability to obtain a measurement. The paired t-test was used to evaluate the differences between the measurements. The mean difference and SD for the differences were used to calculate the limits of agreement. An acceptable difference was defined as less than 0.5 cm.

RESULTS

Cervical length measurements were obtained in 84 patients (100%) by using the transvaginal technique and in 80 patients (95%) by using the translabial technique (P =.1). Eighty patients had both transvaginal and translabial measurements for comparison. The mean difference in cervical length was 0.37 cm (P <.001; 95% confidence interval [CI] 0. 21, 0.52). The upper and lower limits of agreement were 1.75 cm (95% CI 1.48, 2.02) and -1.01 cm (95% CI -0.74, -1.28), respectively. The differences between the two measurements were within these limits 95% of the time. These limits of agreement were greater than the acceptable difference of 0.5 cm.

CONCLUSION

Transvaginal and translabial techniques should not be used interchangeably for clinical assessment of cervical length because agreement between the methods is not within an acceptable range.

Substituting proxy ratings for patient ratings in cancer clinical trials: an analysis based on a Southwest Oncology Group trial in patients with brain metastases

In studies of the effect of cancer treatment in the advanced disease setting, researchers have attempted to avoid missing data for quality of life (QOL) assessments by either substituting proxy for patient assessments from the outset or by interspersing proxy measures when patients are unable to respond. Although poor agreement between patient and proxy assessments has been amply demonstrated in the literature, interest in using proxy measures persists. Completion of the Spitzer QL-Index by a small sample of patients with brain metastases and family member proxies provided data for evaluating the ability to substitute proxy for patient QOL assessments. These data cannot address treatment efficacy due to the modest sample size. Rather, the analyses serve to alert researchers to the important distinction (in a clinical trial setting) between agreement and the use of the proxy as a surrogate. We present several methods for evaluating the accuracy of proxy measures and for identifying other sources of error and bias that may vary with time or with treatment arm. Lin's concordance correlation coefficient suggests that proxies are generally a poor substitute for capturing a patient's perspective of his/her QOL. A longitudinal analysis suggests that the use of proxy rather than patient responses could lead to different conclusions concerning radiation therapy's effect on QOL.