Abstracts to Watch in Lung Cancer for ASCO 2008 (Part 2)

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May 26, 2008 - 5:55 pm email to a friend printer friendly view / write comments

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Dr. West

   Let’s round out the discussion of additional abstracts that will be worthy of further discussion based on their implications for clinical practice.  Here are another five to add to the five I introduced in the last post.

6)  Molecular signatures to predict which patients benefit from adjuvant chemo (abstract here):  Using tissue from 133 patients enrolled on the JBR.10 trial of adjuvant cisplatin/navelbine vs. observation (New England Journal of Medicine abstract here), investigators from NCI-Canada were able to identify a 15-gene signature (pattern) that can discriminate between high risk patients, who received a very striking benefit from adjuvant chemo, and low risk patients, who received a significant detrimental effect from chemo.  This is very encouraging, but whether this will end up being more useful and widely adopted than any of several other gene signature concepts or even just ERCC1 (described in a prior post) is not clear.

7)  Randomized trial of carbo/alimta vs. carbo/etoposide in SCLC (abstract not yet available): we haven’t seen much evidence of activity for alimta in SCLC thus far, but this trial will likely clarify whether it offers a benefit compared to our current standard of platinum/etoposide.   It would be nice to have something new: now that it appears irinotecan isn’t a real improvement in the US (abstract here), unlike the more favorable experience in Japan, we’re left with a standard that goes back several decades without our ability to improve on it.   A phase II trial with cisplatin or carboplatin combined with alimta (abstract here) looked OK, if not especially encouraging, compared to our typical results with a platinum and etoposide.

Customized treatment with tarceva for patients with EGFR activating mutations (abstract here): This study by the Spanish Lung Cancer Group screened over 2000 patients and found 307 with EGFR mutations, who all received tarceva at the standard 150 mg per day.  The majority were women, never-smokers, and had an adenocarcinoma, begging the question of how much molecular testing really adds.  In addition, while results were very favorable, with a median survival of 2 years and 73% of patients responding.  I think it’s interesting that the patients who had received prior chemo did just as well (actually better, with a hazard ratio below 1, consistent with a slightly better survival), and that 27% of patients didn’t respond.  For someone like me, who is inclined to give tarceva to someone as a second or third line therapy anyway, these results beg the question of why to bother to do molecular testing?  It’s no guarantee of great results, and the people who get it after chemo don’t seem to suffer for waiting.  But more later – the abstract only reported on about half of the enrolled patients, and I expect that the investigators will have more information at the conference.

9) Carbo/alimta with/without erbitux, combined with concurrent chest radiation for locally advanced NSCLC (abstract here): It’s a randomized phase II trial by the cancer cooperative group CALGB, being presented by my friend Ramiswamy Govindan at Washington University in St. Louis.  With only 106 eligible patients randomized to chemo/RT vs. chemo/erbitux/RT, it won’t generate any new treatment standards, but we’ll learn more about how safe and feasible this approach really was.  Since I and many other oncologists regularly use cisplatin/etoposide as our chemo backbone, it would be helpful to know if there’s a less toxic and/or more effective chemotherapy to give with concurrent chest radiation.  However, the list of chemo drugs that can be given at full dose with radiation at the same time is pretty limited.  Carboplatin and alimta is a more current regimen, but is it promising enough to move into larger trials?  We’ll need to really see the data to get a better sense of whether the side effects were really manageable or whether these combinations will need to be re-tooled before being considered a chemo regimen worth incorporating as a regimen for future trials in locally advanced NSCLC.

10) Is SCLC with a malignant pleural effusion limited or extensive? (abstract here):  I’ve mentioned in a general review of SCLC (prior post here) that a pleural effusion is a “no man’s land” of staging that is sometimes considered limited disease, and other times considered extensive disease.  This has potentially significant implications, because it speaks to whether this is a curable situation: so is it?  This Japanese abstract provides a retrospective review of 56 patients from a single center with SCLC who received chemo for a cycle, then assessment of whether the effusion resolved.  If it did, most received radiation with their subsequent chemo, and compared with the patients who also had resolution of their effusions but didn’t receive radiation, they had a better long-term survival.  It’s not a large study, but it shows me that 1) it’s possible to have long-term survival after presenting with a pleural effusion in SCLC, and 2) the likelihood of long-term survival appears to be improved in patients who undergo radiation in addition to chemo, so it should probably fit into the LD-SCLC camp.

    I’ll cover these topics in greater detail once more data become available at the meeting, but these are some of what I’d consider to be highlights in the lung cancer sessions.

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