1 / 50

טיפול כימי משלים בחולים עם שאת הריאה אחרי כריתה

טיפול כימי משלים בחולים עם שאת הריאה אחרי כריתה. מיה גוטפריד מנהלת היחידה לגידולי ריאה מרכז רפואי מאיר. Problems with Surgery and Adjuvant Chemotherapy. Adjuvant Chemotherapy Low compliance: 60% to 70% Need to Identify the best chemotherapy combination Surgery

amalie
Download Presentation

טיפול כימי משלים בחולים עם שאת הריאה אחרי כריתה

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. טיפול כימי משלים בחולים עם שאת הריאה אחרי כריתה מיה גוטפריד מנהלת היחידה לגידולי ריאה מרכז רפואי מאיר

  2. Problems with Surgery andAdjuvant Chemotherapy Adjuvant Chemotherapy • Low compliance: 60% to 70% • Need to Identify the best chemotherapy combination Surgery • High risk of local relapse despite radical resection • Growth factors released during and after surgery may stimulate residual cancer cells • Putative risk of seeding of cancer cells during surgery Can the use of neoadjuvant chemotherapy solve some of these problems?

  3. 5-year survival rates in NSCLC following surgical resection alone Mountain CF, et al. Chest 1997;111:1718–23

  4. The prognostic importance of disease stage in lung cancer Mountain CF. Semin Surg Oncol 2000;18:106–15 Mountain CF. Chest 1997;111:1710–17

  5. Types of surgery • Lung-sparing anatomic resection (sleeve lobectomy) preferred over pneumonectomy, if anatomically appropriate • Lobectomy or pneumonectomy, if physiologically feasible • Limited resection, if physiologically compromised • Definitive radiotherapy, if determined medically inoperable Depending on extent and type of comorbidity, patients with stage I or II tumours are generally considered candidates for surgery

  6. Rationale for adjuvant/neo-adjuvant chemotherapy in early-stage NSCLC

  7. Disease recurrence post-surgery • Majority of post-surgical relapses are due to distant metastases; <25% of first recurrences are in regional sites alone • Micrometastatic cancer cells are often present in the bone marrow of patients with NSCLC • may be a significant predictor of early recurrence • further evaluation of this method may be useful in identifying patients with NSCLC who are most likely to benefit from adjuvant chemotherapy Ohgami A, et al. Ann Thorac Surg 1997;64:363–7

  8. Meta-analysis of the effect of chemotherapy (NSCLC Collaborative Group) • Effect of chemotherapy on survival in patients with NSCLC • data from 52 randomised clinical trials (9,387 patients) • Results: • surgery ± chemotherapy: HR=0.87; 13% reduction in risk of death • radiotherapy ± chemotherapy: HR=0.87; 13% reduction in risk of death • supportive care ± chemotherapy: HR=0.73; 27% reduction in risk of death • Conclusion: chemotherapy may be beneficial NSCLC Collaborative Group, BMJ 1995;311:899–909

  9. 100 90 80 70 60 50 40 30 20 10 0 Percentage survival Surgery plus chemotherapy Surgery 0 6 12 18 24 30 36 42 48 54 0 5 10 15 20 60 Surgery plus chemotherapy better Surgery (control)better Survival months Meta-analysis of the effect of chemotherapy (NSCLC Collaborative Group) NSCLC Collaborative Group, BMJ 1995;311:899–909

  10. Post-operative chemotherapy in patients with early-stage NSCLC • Meta-analysis1 • Pre-IALT: INT 0116, BLT, ALPI • IALT • Post-IALT: NCIC-ECOG, CALGB, ANITA • UFT trials 1 NSCLC Collaborative Group, BMJ 1995;311:899–909

  11. Adjuvant chemotherapy: early trials failed to show a benefit – Adjuvant Lung Project Italy (ALPI) • Mitomycin C, vindesine plus cisplatin (MVP) in 1,209 patients with resected stage I, II and IIIA NSCLC • Failed to confirm effectiveness of adjuvant MVP (no difference in OS [p=0.589] or PFS [p=0.128]) 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 HR=0.96 (0.81, 1.13); p=0.589 Overall survival Events Total MVP 279 548 Control 289 540 0 1 2 3 4 5 Years from randomisation Scagliotti GV, et al. JNCI 2003;95:1453–61

  12. IALT (International Adjuvant Lung Trial) • n=1,867 patients (1995–2000) • Stage I, II and IIIA • Treatment: surgery ± platin chemotherapy. RT optional • Results: • 5-year survival rates: 45% vs 40% • HR 0.86 (95% CI: 0.76, 0.98; p<0.03) • 69% completed chemotherapy • 73.8% received ≥240mg CDDP • ‘Problems’ • original sample size >3,000 patients The IALT Collaborative Group, N Engl J Med 2004;350:351–60

  13. Hazard ratios (95% CI) for death in pre-specified subgroups of patients in the chemotherapy group versus patients in the control group The IALT Collaborative Group, N Engl J Med 2004;350:351–60

  14. 775 181 932 450 308 624 At risk 935 602 432 286 164 774 Overall Survival Chemotherapy Control Years

  15. HR= 0.72 [0.59-0.89]p=0.003 Control Chemotherapy Years 737 171 932 424 291 583 At risk 935 556 401 265 150 719 Incidence of local relapse

  16. HR= 0.84 [0.72-0.98]p=0.03 Control Chemotherapy Years 702 165 932 412 285 568 At risk 935 538 388 262 154 695 Incidence of metastasis

  17. HR= 1.07 [0.82-1.39]p=0.61 Control Chemotherapy Years 702 165 932 412 285 568 At risk 538 388 262 154 935 695 Incidence of brain metastasis as first metastasis

  18. INTERACTION WITH COVARIATES No significant interaction with any covariate PopulationTreatment Gender Cisplatin dose per cycle Age Total cisplatin dose WHO PS Combined drug Type of surgery Planned RT Stage N status Histology

  19. Adjuvant therapy with vinorelbine/cisplatin: JBR-10 trial • 482 patients with completely resected stage IB or II NSCLC • Overall and 5-year survival were significantly improved by chemotherapy Winton T, et al. N Engl J Med 2005;352:2589–97

  20. 100 80 e g a 60 t n e c r 40 e P 20 0 0.0 2.0 4.0 6.0 8.0 10.0 239 182 94 47 13 0 243 193 121 51 10 0 Observation Vinorelbine Log-Rank test for equality of groups: p=0.0164 Wilcoxon test for equality of groups: p=0.0100 Survival rate at 5 years for Observation: 54% - % C.I. ( 48%, 61%) Survival rate at 5 years for Vinorelbine: 69% - % C.I. ( 62%, 75%) JBR.10 - Overall Survival P = 0.012 69% 54% Years Time (years)

  21. 1.0 CALGB 9633OVERALL SURVIVAL 0.8 0.6 Probability 0.4 ----- Chemotherapy ----- Observation p=0.028 0.2 0.0 0 20 40 60 80 Survival Time (Months)

  22. UFT JAPANESE META-ANALYSIS Surgery  UFT in rescted NSCLC 2003 patients UFT Control • UFT : 250 mg/m² daily x 2 years • 84% adenoca, 95% stage I • Overall benefit : HR 0.74 (p=0.001) • 5-year survival, 81.8% vs 76.5% • 7-year survival, 77.2% vs 69.5% ASCO 2004 Abs 7002

  23. ANITA • 35% Stage I, 30% stage II, 35% stage IIIa • 59% squamous cell carcinoma • 37% pneumonectomies • Median Survival: 65.8 Mo vs 43.7 Mo • HR: 0.79 (0.66-0.95) ; p= 0.01 • 5-year survival: 51% vs 43% • Benefit restricted to Stages II and III

  24. 1.00 0.75 Survival Distribution Function 0.50 Obs 0.25 NVB + CDDP 0 0 20 40 60 80 100 120 months Overall Survival - Stage I (pT2N0)

  25. 1.00 0.75 Survival Distribution Function 0.50 Obs 0.25 NVB + CDDP 0 0 20 40 60 80 100 120 months Overall Survival - Stage II (pT 1-2, N1)

  26. 1.00 0.75 0.50 Survival Distribution Function Obs 0.25 NVB + CDDP 0 0 20 40 60 80 100 120 months Overall Survival - Stage III A (pT1-2 N2, pT3 N0-3)

  27. Are these results consistent ? Trial N HR (95%CI) p Benefit IALT 1,867 0.86 (0.76 – 0.98) 0.03 4% ALPI 1,076 0.94 (0.79 – 1.12) 0.6 3% NCI – C 482 0.70 (?) 0.012 15% CALGB 344 0.62 (0.41 – 0.95) 0.028 12% ANITA 840 0.79 (0.66-0.95) 0.01 8% UFT overview 2,003 0.77 (0.63 – 0.94) 0.001 5%

  28. Randomized Adjuvant Chemotherapy Trials Establish Role of Platinum-Based Regimens

  29. 1,000,000 new lung cancers yearly 80% NSCLC 33% resectable NSCLC 75% candidates to adjuvant chemotherapy 180,000 patients candidates to adjuvant chemotherapy 4.5% increase in survival 7,000 deaths could be avoided

  30. 1,000,000 new lung cancers yearly 80% NSCLC 33% resectable NSCLC 75% candidates to adjuvant chemotherapy 180,000 patients candidates to adjuvant chemotherapy 14% increase in survival 25,200 deaths could be avoided

  31. Adjuvant CMF in breast cancer 100 5-year survival (%) Status Node -ve: 3–4 80 Node +ve: 2–7 60 Probability of survival 40 CMF 20 Control 0 0 5 10 15 20 Years after mastectomy Bonadonna G, et al. N Engl J Med 1995;332:901–6

  32. Adjuvant chemotherapy for NSCLC: summary • Cisplatin-based adjuvant CT improves survival in patients with completely resected NSCLC • This finding is consistent with the benefit achieved with adjuvant CT for other cancers • Questions remaining • regimen of choice? • subsets of patients benefiting (stage, age, PS...)? • For individual patients, the potential benefits of adjuvant CT must be balanced against the risk and the preference of physicians and patients

  33. The future . . . • Neo-adjuvant strategies • Search for molecular markers (prognostic,predictive) • Potential of new targeted agents: lower toxicity and increased efficacy

More Related