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PubMed2005

Perspectives on salvage therapy for non-small-cell lung cancer.

Platinum-based chemotherapy offers a modest survival advantage over best supportive care in chemotherapy-naive patients with a good performance status and advanced/metastatic non-small-cell lung cancer (NSCLC). Despite the survival benefit associated with first-line chemotherapy, the majority of patients will experience relapse or disease progression. In clinicalpractice, an increasing number of patients maintain a good performance status after first-line treatment and are eligible for further treatments. Docetaxel (Taxotere) at 75 mg/m2 given once every 3 weeks has been the standard of care for second-line chemotherapy since the year 2000. Pemetrexed (Alimta) is a novel multitargeted antifolate agent with single-agent activity in first- and second-line treatment of NSCLC. A large phase 111 study comparing docetaxel to pemetrexed in second-line therapy demonstrated that pemetrexed is equally active and less toxic than docetaxel. Based on these results, pemetrexed is a reasonable second-line chemotherapy option for patients with recurrent, advanced NSCLC. Progress made in the field of molecular biology has led to the identification of drugs active against specific cellular targets. Gefitinib (Iressa) and erlotinib (Tarceva) are both orally active tyrosine kinase inhibitors of the epidermal growth factor receptor. Phase II and III trials have demonstrated that these agents are active particularly in a subgroup of patients with specific biologic characteristics. Both drugs have been approved for the treatment of pretreated NSCLC. Other drugs, such as cetuximab (Erbitux) and bevacizumab (Avastin) have shown promising activity in NSCLC and are currently being tested in clinical trials.

Aged↗

PubMed2003

Second-line chemotherapy for non-small cell lung cancer.

Several agents have been evaluated for the second-line treatment of patients with non-small cell lung cancer. The TAX 317 trial found that patients treated with docetaxel (Taxotere) 75 mg/m2 had significantly longer survival than those treated with best supportive care alone. In addition, symptom control was better for patients who received chemotherapy. The TAX 320 trial found that treatment with docetaxel 75 or 100 mg/m2 resulted in significantly higher response rates than treatment with vinorelbine (Navelbine) or ifosfamide (Mitoxana), and the 1-year survival rate was also significantly better for patients treated with docetaxel 75 mg/m2. A large randomized trial compared pemetrexed (LY-231514 or Alimta) 500 mg/m2 with docetaxel 75 mg/m2. Response and survival rates were similar in the two treatment arms, however, the toxicity profile of pemetrexed was superior to that of docetaxel with significantly less Grade 3/4 neutropenia and febrile neutropenia. Fewer patients in the pemetrexed arm required hospitalization. Topotecan (Hycamtin) 2.3 mg/m2/day orally for 5 days has been compared with docetaxel 75 mg/m2 in a large 800-patient study. The results of this trial are awaited. Gemcitabine (Gemzar) and irinotecan (Campto) have been evaluated both as single agents and in combination with each other and study results do not suggest that either of these drugs is superior to docetaxel or pemetrexed. The vinca alkaloid vinorelbine has proved to be inferior to docetaxel in a randomized trial. The epidermal growth factor receptor inhibitors gefitinib (ZD1839, Iressa) and erlotinib (CP-358774, OSI 774, Tarceva) have been evaluated in Phase II trials in the second- and third-line setting. Both drugs have demonstrated interesting response rates ranging from 10 to almost 20%. The results of placebo-controlled randomized trials of this family of drugs are awaited. In summary, several studies have now found a definite role for the second-line treatment of patients with non-small cell lung cancer.

Antineoplastic Agents↗

PubMed2005

The evolution of cancer research and drug discovery at Lilly Research Laboratories.

This review highlights the discovery and development of chemotherapy at Eli Lilly & Company over the past 30 years from the Vinca alkaloids-vincristine, vinblastine, and vindesine-to targeted therapy. During the late 1970s, Lilly began an exploration of new synthetic compounds based on solid tumor screening models. Several novel antimetabolites with the potential to treat solid tumors were identified. Two such agents, gemcitabine and pemetrexed, underwent clinical development and are now among Lilly's portfolio of approved anticancer drugs. Gemcitabine, a pyrimidine nucleoside that has a profound effect on DNA synthesis, has been approved for the treatment of pancreatic, non-small cell lung, bladder, and most recently, breast, and ovarian cancer. Pemetrexed, a novel antifolate with potent cytotoxic effects, is distinguished from other antifolates by virtue of its ability to inhibit multiple folate-dependent enzymes. Pemetrexed, given in combination with cisplatin, has been recently approved for the treatment of malignant pleural mesothelioma and as second-line treatment for non-small cell lung cancer. Spurred by advances in the understanding of cancer as a disease process, Lilly's anticancer drug program began to transition to a more "targeted" approach during the 1990s. These efforts have recently culminated in the identification and development of enzastaurin, a PKCbeta inhibitor with potent anti-angiogenic properties. Enzastaurin has shown promising single-agent activity in patients with relapsed diffuse large B-cell lymphoma and recurrent glioblastoma multiforme, and is an excellent candidate for combination with cytotoxic agents.

Antineoplastic Agents↗

PubMed2005

Advances in the treatment of second-line non-small-cell lung cancer.

Treatment with third-generation chemotherapy agents improves survival and quality of life of patients with non-small-cell lung cancer (NSCLC). Despite these favorable outcomes, most patients receiving front-line therapy experience disease progression. The availability of many new novel agents with activity in NSCLC has prompted investigators to explore second-line chemotherapy options. For many years, docetaxel was the only approved agent for the second-line treatment of NSCLC. More recently, the multi-targeted antifolate pemetrexed has demonstrated activity in patients previously treated with chemotherapy with locally advanced or metastatic NSCLC. The findings of a phase III trial comparing pemetrexed to docetaxel led to the regulatory approval of pemetrexed as monotherapy for the second-line treatment of NSCLC. Several other novel therapies, including molecular targeting agents such as erlotinib, are under development in clinical trials in patients with NSCLC. One of these trials has subsequently led to the approval of erlotinib as second- or third-line therapy in advanced NSCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2005

Seeking new options for the treatment of small-cell lung cancer.

The current prognosis for patients with extensive stage (ES) small-cell lung cancer (SCLC) remains poor, even though considerable improvements have been made in treatments for limited stage (LS) SCLC over the past several decades. Pemetrexed is an antimetabolite with an innovative mechanism of action. It demonstrates activity both as a single-agent and in combination regimens in patients with non-small-cell lung cancer (NSCLC) or malignant pleural mesothelioma. With an excellent antitumor activity, favorable tolerability profile, ease of administration and convenient schedule in NSCLC patients, pemetrexed is currently being investigated in a phase II trial for the first-line treatment of ES SCLC. Observations from this trial will help to define the future role of pemetrexed in SCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2004

The role of alpha-folate receptor-mediated transport in the antitumor activity of antifolate drugs.

PURPOSE: Raltitrexed, pemetrexed, lometrexol, and ZD9331 are antifolate drugs transported into cells via the ubiquitously expressed reduced-folate carrier. They display also high affinity for the alpha-folate receptor (alpha-FR), a low capacity folate transporter that is highly overexpressed in some epithelial tumors. The role of alpha-FR in the activity of the antifolates has been evaluated in two alpha-FR-overexpressing cell lines grown in a physiological concentration of folate (20 nM R,S-Leucovorin). EXPERIMENTAL DESIGN AND RESULTS: A431-FBP cells (transfected with the alpha-FR) were 3-5-fold more sensitive to the antifolates than A431 cells. KB cells (constitutive alpha-FR overexpression) were less sensitive to the drugs when coexposed to 1 microM folic acid to competitively inhibit binding to the alpha-FR. Raltitrexed, pemetrexed, and lometrexol are polyglutamated in cells leading to drug retention, e.g., the raltitrexed 4- and 24-h IC(50)s in A431 cells were approximately 0.6 and 0.008 microM, respectively, compared with 0.003 microM for 72-h continuous exposure. A431-FBP cells were approximately 3-fold more sensitive to raltitrexed and pemetrexed at all exposure times. ZD9331 is not polyglutamated, and the 4- and 24-h IC(50)s in A431 cells were >100 and approximately 100 microM, respectively, reducing to 2 and 0.1 microM, respectively, in A431-FBP cells. The ZD9331 4- and 24-h IC(50)s in KB cells were 20 and 1 microM, respectively, and reversible by coaddition of 1 microM folic acid. An in situ thymidylate synthase assay demonstrated continued thymidylate synthase inhibition after ZD9331-treated A431-FBP and KB, but not A431, cells were placed in drug-free medium for 16 h. A model is proposed in which the antifolates accumulate in the alpha-FR/endosomal apparatus, leading to slow release into the cytoplasm. In particular, this leads to cellular retention of the nonpolyglutamatable ZD9331. CONCLUSIONS: Antifolate drugs, particularly ZD9331, have the potential for increased efficacy in tumors that highly overexpress the alpha-FR.

Antimetabolites, Antineoplastic↗

PubMed2004

Current chemotherapeutic treatment of malignant pleural mesothelioma.

Malignant pleural mesothelioma is an aggressive malignancy which is almost always fatal; median survival is usually < 1 year. Most patients present with symptoms including pain, dyspnoea, pleural effusions and chest wall masses. Until recently, there has been no effective treatment which can improve symptoms and prolong survival. This article reviews recent developments in the treatment of mesothelioma, particularly advances in drug therapy and the use of the current most active drug combination: pemetrexed and cisplatin. Pemetrexed is a novel antifolate drug with multiple enzyme targets. The combination of pemetrexed and cisplatin demonstrated a survival advantage over cisplatin alone in patients with pleural mesothelioma, and can give symptomatic benefits. This combination has become the standard of care in mesothelioma treatment.

Antineoplastic Agents↗

PubMed2006

Second- and third-line treatments in non-small cell lung cancer.

Slow but steady progress has been made in the treatment of advanced non-small cell lung cancer. For first-line therapy, multiple chemotherapy combination therapies can extend survival and improve quality of life. And recently, for the first time ever, a noncytotoxic agent, the antivascular endothelial growth factor antibody bevacizumab, has been shown to improve survival when added to chemotherapy. Striking improvements have also been made in second-line treatment. In August 2004, only one agent was US Food and Drug Administration (FDA) approved in this setting, docetaxel, but by the beginning of 2005, two more were available, pemetrexed and erlotinib. All three of these drugs can significantly benefit patients, with 1-year survival in excess of 30%. Choosing between the three agents can be challenging, and this review focuses on the toxicity differences and predictors of response that can help guide this decision. Docetaxel and pemetrexed, both traditional intravenous cytotoxins, are excellent options for patients who have shown some response to first-line chemotherapy, but at this time, no other means exist to determine likelihood of response. When choosing between the two, pemetrexed causes significantly less neutropenia than does docetaxel, at least on the standard every-3-week regimen. With erlotinib, an oral epidermal growth factor receptor (EGFR) inhibitor, there are factors that can predict for response, including little or no smoking history, and adenocarcinoma histology. Therefore, patients who fit these characteristics are good candidates for second-line erlotinib. However, the relationship between response to erlotinib and improved survival remains unclear, and several laboratory analyses that may help further, such as evaluation of EGFR gene copy number, are still under development. Although erlotinib is the only FDA-approved option currently available for third-line therapy, many patients with good performance status may benefit from third-line therapy and beyond. In addition to the approved second-line options, other single-agent chemotherapies to consider for treatment beyond second-line are gemcitabine, irinotecan, and oral topotecan. Many new drugs, including bevacizumab, ZD6474 (AstraZeneca, Wilmington, DE), sorafenib, cetuximab, paclitaxel poliglumex, epothilones, and others, alone or in combination with traditional agents, are currently undergoing investigation and hold great promise.

Antineoplastic Agents↗

PubMed2005

Computer modelling of antifolate inhibition of folate metabolism using hybrid functional petri nets.

Antifolates are used in the treatment of various human malignancies and exert their cytotoxic activity by inhibiting folate-dependent enzymes resulting in disruption of DNA synthesis and cell death. Here we devised a computerized hybrid functional petri nets (HFPN) modelling of folate metabolism under physiological and antifolate inhibitory conditions. This HFPN modelling proved valid as a good agreement was found between the simulated steady-state concentrations of various reduced folates and those published for cell extracts; consistently, the simulation derived total folate pool size (11.3 microM) was identical to that published for cell extracts. In silico experiments were conducted to characterize the inhibitory profile of four distinct antifolates including methotrexate (MTX), tomudex, and LY309887, which inhibit dihydrofolate reductase (DHFR), thymidylate synthase (TS) and glycineamide ribonucleotide transformylase (GARTFase), respectively, as well as pemetrexed which has the capacity to inhibit all three enzymes. In order to assess the inhibitory activity of antifolates on purines and pyrimidines, the biosynthesis rates of IMP (20.53 microM/min) and dTMP (23.8 microM/min) were first simulated. Whereas the biochemical inhibitory profile of MTX was characterized by increased dihydrofolate and decreased tetrahydrofolate (THF) concentrations, the remaining antifolates did not decrease THF levels. Furthermore, MTX was 766- and 10-fold more potent in decreasing the production rates of IMP and dTMP, respectively, than pemetrexed. LY309887 indirectly decreased the rate of dTMP production by reducing the levels of 5-CH2-THF, a folate cofactor for TS. Surprisingly, pemetrexed failed to inhibit DHFR even at high concentrations. This HFPN-based simulation offers an inexpensive, user-friendly, rapid and reliable means of pre-clinical evaluation of the inhibitory profiles of antifolates.

Antimetabolites, Antineoplastic↗

PubMed2005

[Treatment of the unresectable non small cell lung carcinoma].

In recent years, treatment of the locally advanced unresectable Non Small Cell Lung Cancer (NSCLC) has evolved from the radiotherapy alone to sequential therapy settings with induction chemotherapy followed by radiotherapy. During recent years, concomitant chemoradiotherapy has become the standard treatment for these patients. The addition of chemotherapy during the course of radiotherapy provides better locoregional control of the disease by killing the radioresistant cells, inhibition of the reparation processes in the sublethally damaged cells and accumulation of the cells in the G2/M phase, when the cells are sensitive to radiation. It also reduces the spread of the micrometastases. Administration of cisplatin-based regimens appears to be the most effective. Acute pneumonias can be effectively suppressed by amifostine administration. Locally advanced inoperable NSCLC can be cured by chemoradiotherapy in more than 10% of patients. Fractionation radiotherapy does not yield prolonged survival. Currently the other clinical studies investigating the effects of hyperfractionation, 3D conformal radiotherapy and IMRT (intense modified radiotherapy) are being conducted. Also the role of various radiosensitizing agents is currently under clinical evaluation. The results of a study, comparing various doublet combinations of taxanes and gemcitabine with cisplatin or carboplatin demonstrate, that as for the efficacy, the standard doublet regimens reached a certain plateau and that they prolong the survival in comparison with the standard regimens used before 1990. The only statistically significant difference in the efficacy among the individual treatment arms is the significantly longer time to the progressive disease in the arm treated by gemcitabine and cisplatin. Studies with triplet regimens show that the addition of the third cytotoxic agent might increase the overall response rate with the increase of toxicity and only a very small survival benefit. The replacement of the platinum derivate by some of the new cytotoxic agents does not appear to yield lower efficacy and also shows a more favorable toxicity profile; it is, however, significantly more expensive. Overall differences among the cytostatic combinations based on cisplatin in comparison with combinations based on carboplatin are not very distinct. Nevertheless, the combination of cisplatin with third generation cytotoxic agents is recommendable as it is more effective for patients with advanced NSCLC without renal impairment and with adequate bone marrow reserve. A high percentage of patients with NSCLC are older that 70 and this percentage will increase further. Earlier, chemotherapy was not used for these patients with the explanation that elderly people are usually polymorbid and the function of their organs which metabolize the cytostatics is reduced. However, a survival benefit in elderly patients treated by cytotoxic monotherapy was proven in comparison with the best supportive care. Other studies, however, found significant differences neither in toxicity nor in survival in comparison with younger patients, when using the same treatment regimens. Platinum doublets, based namely on carboplatin, are useful for patients older than 70, who are in good clinical condition. In the second-line therapy of NSCLC pemetrexed demonstrates identical efficacy as docetaxel, which is considered as a standard monotherapy in the second-line treatment of NSCLC. Moreover, pemetrexed is associated with less toxicity. These data show that in future, pemetrexed may become the standard treatment for second-line therapy of NSCLC. In patients with stage IIIB/IV of NSCLC, the addition of biological treatment to standard doublet cytostatic combination does not bring any survival benefit. In future, more detailed attention should be paid to selection of the patients for this treatment modality. When comparing survival time by meta-analysis, significantly longer survival time of the patients treated with gemcitabine combination was found in comparison with other treatment. Similarly, the progression-free survival is significantly longer in the patients treated with gemcitabine containing regimen. This data has proven good clinical efficacy of gemcitabine in the first-line therapy of advanced NSCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2026

Osimertinib With or Without Chemotherapy in Advanced Non-Small Cell Lung Cancer With EGFR and Concurrent TP53 Mutations: A Randomized Clinical Trial.

IMPORTANCE: Combination therapy has emerged as a promising therapeutic approach for patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC). However, its clinical benefit-risk profile remains a focus of ongoing debate. Identifying patients most likely to derive benefit from such regimens remains an unmet clinical need. OBJECTIVE: To prospectively compare the efficacy and safety of first-line osimertinib plus chemotherapy with osimertinib monotherapy for patients with EGFR-mutated advanced NSCLC harboring concurrent TP53 mutations. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, randomized, open-label, phase 3 study conducted at 17 sites in China. Between March 25, 2021, and July 11, 2024, a total of 294 eligible patients with treatment-naive, stage IV or recurrent nonsquamous NSCLC harboring concurrent TP53 and EGFR-sensitizing mutations were enrolled. INTERVENTIONS: Patients were randomized (1:1) to receive osimertinib plus chemotherapy (pemetrexed and carboplatin every 3 weeks for 4 cycles, followed by maintenance therapy of osimertinib plus pemetrexed; n = 146) or osimertinib monotherapy (n = 148). MAIN OUTCOMES AND MEASURES: The primary end point was investigator-assessed progression-free survival. Secondary end points included overall survival, response, safety, and quality of life. RESULTS: Among 294 enrolled patients, the median age was 57 years (range, 26-79 years), and 159 (54.1%) were female. The data cutoff date was November 11, 2025. At a median follow-up of 25.1 months for the osimertinib-chemotherapy group and 26.1 months for the osimertinib monotherapy group, median progression-free survival was significantly longer with osimertinib plus chemotherapy than with osimertinib monotherapy (34.0 vs 15.6 months; difference, 18.4 months [95% CI, 9.9-22.3]; hazard ratio, 0.44 [95% CI, 0.32-0.60]; P < .001). This benefit was consistent across prespecified subgroups, including those with brain metastases and L858R mutations. The overall survival data remained immature (30.6% maturity); however, a trend toward overall survival benefit with combination therapy was observed. The incidence of grade 3 or higher treatment-related adverse events was higher in the combination group, with no new safety signal identified. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, osimertinib plus chemotherapy significantly increased progression-free survival among patients with EGFR-mutated advanced NSCLC harboring concurrent TP53 mutations. These findings provided a clinical rationale for individualized combination strategies in the management of patients with EGFR-mutated NSCLC. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04695925.

Adult↗

PubMed2006

Systemic chemotherapy in the management of malignant peritoneal mesothelioma.

AIM: To review available evidence on the efficacy of chemotherapy in malignant mesothelioma of any origin. METHODS: All original research and review papers related to the role of systemic chemotherapy in the treatment of malignant mesothelioma, published from 1966 through February 2005, were identified through a MEDLINE search of the literature using the following search terms: "mesothelioma", "peritoneal", "chemotherapy", "antifolates", "cancer therapy". This search was supplemented by a manual search of the Proceedings of the Annual Meetings of the American Association for Cancer Research, American Society of Clinical Oncology, and the American Association for Cancer Research (AACR)-European Organization for Research and Treatment of Cancer (EORTC)-National Cancer Institute (NCI) Symposium on New Anticancer Drugs. RESULTS: Pemetrexed in combination with cisplatin is the first treatment regimen that demonstrates a survival improvement in patients with unresectable malignant pleural mesothelioma. Data from uncontrolled studies suggest similar antineoplastic efficacy in patients with mesothelioma of peritoneal origin. Preliminary results also suggest a possible survival advantage for a combination of cisplatin and raltitrexed as compared to cisplatin alone. Other cytotoxic agents that have shown to be active in this setting include vinorelbine and gemcitabine, either alone or combined with platinum compounds. CONCLUSION: The pemetrexed-cisplatin combination has become the new standard of care for patients with unresectable malignant mesothelioma. Future strategies shall incorporate these novel agents into multimodality approaches at earlier stages of the disease. Given the low incidence of this disease, encouraging physicians to refer these patients to specialized centers and patients to participate in clinical trials is of utmost importance.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2025

Clinicopathologic and genomic analyses of SMARCA4-mutated non-small cell lung carcinoma implicate the needs for tailored treatment strategies.

BACKGROUND: The clinicopathologic and therapeutic significance of SMARCA4 mutation in non-small cell lung carcinoma (NSCLC) remains unclear. METHODS: We retrieved 575 NSCLC cases from the clinical target sequencing cohort (N = 2157) to compare the clinicopathologic characteristics of groups subclassified based on the presence of truncated or non-truncated SMARCA4 mutations (SMARCA4-truncated, SMARCA4-non-truncated, and SMARCA4-wild type [WT]). The differences in gene expression profiles between these groups were evaluated using the TCGA-LUAD dataset. RESULTS: Fifty (2.3%) SMARCA4-truncated and 63 (2.9%) SMARCA4-non-truncated NSCLCs were identified. The majority of SMARCA4-truncated NSCLCs were present in male smokers (94.0%) and pathologically diagnosed as adenocarcinoma (76.0%). The SMARCA4-truncated group showed rare targetable driver alterations with a higher tumor mutation burden than the SMARCA4-WT group. Gene expression profile analysis revealed that cancer/testis antigen (CTA) expression was enriched in the SMARCA4-truncated group, with up to 57% of the cases displaying immunoreactivities for MAGEA4, CT45A, and/or PRAME. The SMARCA4-non-truncated group showed heterogeneous clinicopathologic, genomic, and immunohistochemical features that fell between SMARCA4-truncated and WT groups. Both SMARCA4-truncated and non-truncated groups showed significantly poor prognosis with pemetrexed-platinum chemotherapy, yet there was no significant difference in survival following immune checkpoint inhibitor monotherapy. CONCLUSION: SMARCA4-truncated NSCLC represents a variant of driver-negative NSCLC, mainly occurring in male smokers with poorly differentiated adenocarcinoma histology. In contrast, SMARCA4-non-truncated NSCLC indicates a heterogeneous subpopulation, exhibiting intermediate characteristics between the SMARCA4-truncated and SMARCA4-WT groups. While showing poor response to pemetrexed-platinum chemotherapy, increased CTA expression could be a novel therapeutic target in SMARCA4-mutated NSCLCs.

Humans↗

PubMed2025

Real-world frontline treatments in patients with advanced non-small-cell lung cancer harboring epidermal growth factor receptor exon 20 insertions and adjusted comparisons versus amivantamab plus chemotherapy from the PAPILLON study.

INTRODUCTION: In PAPILLON, frontline amivantamab + carboplatin + pemetrexed (ACP) demonstrated superior efficacy over carboplatin + pemetrexed in patients with advanced or metastatic non-small-cell lung cancer (aNSCLC) harboring mutations in epidermal growth factor receptor (EGFR) exon 20 insertions (exon20ins). Real-world (RW) treatment patterns and comparative effectiveness of ACP versus RW treatments are unknown. MATERIALS AND METHODS: The present study (NECTAR) retrospectively analyzed frontline treatments prescribed 2012-2023 for patients with aNSCLC and confirmed EGFR exon20ins from English (ENG-NCRD), French (FR-ESME), and US (US-COTA and US-ConcertAI) datasets. Overall survival (OS), time to next treatment (TTNT), and progression-free survival (PFS) were assessed in RW pooled and individual treatment classes and in indirect treatment comparisons (ITC) between ACP from PAPILLON and RW treatments using Cox proportional hazards model adjusted for prognostic factors. RESULTS: NECTAR assessed 208 RW patients: ENG-NCRD, n = 23; FR-ESME, n = 91; US-COTA, n = 39, and US-ConcertAI, n = 55. Common frontline treatment classes were platinum-based chemotherapy (33.7 %), platinum + immunotherapy (23.1 %), EGFR tyrosine kinase inhibitors (TKIs) alone (15.4 %), platinum + VEGF inhibitors (VEGFi) (11.1 %), and immunotherapy alone (7.7 %). Compared with platinum-based chemotherapy, none of the evaluated treatment classes demonstrated improved OS, TTNT, and PFS. Exceptions were platinum + VEGFi in TTNT and PFS and platinum + immunotherapy in TTNT. In ITCs, ACP significantly improved OS over pooled RW treatments (HR = 0.48 [95 % CI, 0.32-0.71]; P < 0.001), platinum-based chemotherapy (HR = 0.48 [0.30-0.77]; P = 0.003), platinum + immunotherapy (HR = 0.41 [0.23-0.73]; P = 0.003), and EGFR TKI alone (HR = 0.48 [0.23-1.02]; P = 0.055). TTNT and PFS results were similar to OS. CONCLUSIONS: In patients with EGFR exon20ins aNSCLC, frontline ACP was superior to common RW treatments, highlighting the need for practice change.

Humans↗

PubMed2005

Standard therapy for the treatment of malignant pleural mesothelioma.

Almost all of the established cytotoxic agents have now been examined both as single-agents and in combination chemotherapy regimens as treatment approaches for malignant pleural mesothelioma (MPM). Until recently, only few agents have consistently produced objective response rates greater than 20%, and no agent has improved median survival beyond 10 months. The recent development of several new cytotoxic agents, such as the novel antimetabolite pemetrexed, has yielded encouraging results. In particular, pemetrexed produces response rates of up to 45%, and increases median survival to over 12 months when used in combination with cisplatin. This doublet-based chemotherapy regimen is now the standard therapy for the first-line treatment of MPM.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2002

The emerging role of antifolates in the treatment of malignant pleural mesothelioma.

Clinicians have long regarded malignant pleural mesothelioma as a chemoresistant neoplasm and as a result no standard chemotherapy regimen has emerged. Antifolates such as methotrexate are among the most active compounds in mesothelioma, albeit based only on phase II data. Recently two antifolate-based combinations with apparently higher efficacy than older regimens have emerged: the pemetrexed/cisplatin regimen and the raltitrexed/oxaliplatin regimen. In two phase I trials with pemetrexed combined with either cisplatin or carboplatin responses occurred in five of 11 and nine of 29 patients, respectively. In a phase I trial of raltitrexed/oxaliplatin, six of 17 patients (35%) with mesothelioma achieved a partial response. In a phase II trial of raltitrexed/oxaliplatin, 14 objective responses were confirmed in 72 patients (25%) with malignant pleural mesothelioma. Indeed, responses were seen in cisplatin-refractory patients. Based on the promising results from these combination trials, two large phase III studies have begun. The first study was a multicenter, multinational trial sponsored by Eli Lilly and Company, which randomized more than 430 patients with malignant pleural mesothelioma to cisplatin with or without pemetrexed. That trial completed enrollment in February 2001 and is the largest trial ever conducted in mesothelioma. The second trial is being conducted by the European Organization for the Research and Treatment of Cancer (EORTC) and compares cisplatin with or without raltitrexed with planned accrual of 240 patients. In both trials, survival is the main endpoint. These trials will help to define the role of these new antifolates in malignant pleural mesothelioma.

Antimetabolites, Antineoplastic↗

PubMed2002

Emerging insights into the biology and therapy of malignant mesothelioma.

Malignant mesothelioma is an aggressive malignancy that may be caused by environmental carcinogens (asbestos and erionite), viruses (SV40), and genetic predisposition. Pleural malignant mesotheliomas are far more common than the peritoneal variants. Diagnosis relies on radiographic studies as well as histology and molecular biologic analyses. The prognostic scoring systems of the Cancer and Leukemia Group B and the European Organization for Research and Treatment of Cancer are the most useful of those currently available. These systems rate performance status, age, histology, and hematologic parameters as the best prognostic factors for mesothelioma. Most patients with mesothelioma are not candidates for surgical or radiotherapy treatment, and cytotoxic agents are the only options. Historically, no classes or combinations of agents consistently yielded response rates over 20%. Recently, pemetrexed has been evaluated in phase I, II, and III clinical trials with promising results. The phase II trial showed an overall response rate of 14.1% with a 1-year survival rate of 47.8%. A phase III trial of cisplatin versus cisplatin and pemetrexed closed in February 2002 and a final analysis was presented in May 2002. Novel targeted agents are also being tested in clinical trials among mesothelioma patients and include drugs inhibiting the vascular endothelial growth factor and its receptor, the epidermal growth factor receptor, and platelet-derived growth factor receptor.

Antimetabolites, Antineoplastic↗

PubMed2004

Second-line chemotherapy in the treatment of advanced non-small cell lung cancer (NSCLC).

An increasing number of patients with advanced non-small cell lung cancer (NSCLC) progressing after front-line chemotherapy are still in good performance status and willing to receive further treatment. Several drugs have been tested in this setting of treatment, but the only agent registered world-wide for second-line chemotherapy of advanced NSCLC is docetaxel. This drug, at dose of 75 mg/m2 every three weeks, has been the standard of care as second-line chemotherapy since 2000, based on two trials that reported improved survival times and quality of life when comparing with best supportive care (TAX 317) and with ifosfamide or vinorelbine (TAX 320). Docetaxel, given at this dose and schedule, resulted in significant haematological toxicity, with many patients at risk for neutropenic fever. Pemetrexed is a novel multitargeted antifolate agent with single-agent activity in first- and second-line treatment of NSCLC. In a phase III study in 571 patients pemetrexed, comparing with docetaxel in second-line chemotherapy, demonstrated clinically equivalent therapeutic outcomes, but a more favourable haematological toxicity profile, with fewer episodes of neutropenia, neutropenic fever, and infections and less use of granulocyte colony-stimulating factor support. Others several agents have been evaluated for the second-line treatment of patients with non-small cell lung cancer, but no comparative phase III studies with docetaxel has been carried out. The epidermal growth factor receptor-tyrosine kinase inhibitors gefitinib (ZD1839, Iressa) and erlotinib (OSI 774, Tarceva) have been evaluated in the second- and third-line setting. Both drugs have demonstrated interesting response rates and toxicity profile and, in particular, erlotinib evidenced a survival advantage of 2 months respect placebo in recent phase III trial. Future developments are likely to value poli-chemotherapy or combination chemotherapy with EGFR tyrosine kinase inhibitors in second-line treatment of advanced NSCLC.

Carcinoma, Non-Small-Cell Lung↗