Mike Crowe_May 2009 Seminar Paper_Cisplatin v Carboplatin

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Mike Crowe, Pharm D Candidate

Ferris State UniversityCollege of Pharmacy

May 15, 2009

Objectives

At the conclusion of this seminar, the audience member will be able to successfully complete each of the following.

1/ One

Describe the histology, clinical presentation and diagnosis of non-small cell lung cancer (NSCLC).

2/ Two

Identify pharmacologic similarities and differences between cisplatin and carboplatin.

3/ Three

Select an appropriate treatment for a patient with advanced NSCLC based on patient characteristics.

Cisplatin v Carboplatin

Which platinum agent is more efficacious in advanced non-small cell lung cancer?


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Topic Review

Non-Small Cell Lung Cancer

I. Lung cancer is the most common malignancy in the world.1,2a. Estimated that over 215,000 new cases were diagnosed in 2008b. More than 160,000 deaths were associated with lung cancer that same yearc. The five-year survival rate for all types of lung cancer is only 15%.

II. Non-small cell lung cancer (NSCLC)a. Etiology1,2

Smoking is the leading cause of all lung cancers, being associated with 85% of the cases. Other causes include

o Environmental exposure to carcinogens (benzene, asbestos)o Genetic risk factors (elevated risk when occurring in first-degree relatives)o History of respiratory diseases such as tuberculosis and emphysema

b. Histology1 NSCLC makes up 80 to 85% of lung cancer cases. This encompasses squamous cell, adenocarcinoma and large cell lung cancers

o 60% adenocarcinomao 35% squamous cell (typically given a better prognosis)o 5% large cell

NSCLC has a slower growth rate and therefore better prognosis than SCLC.c. Presentation1

Very few patients (16%) present with localized disease. 37% will present with regional spread and 39% with distant metastasis. Cough, dyspnea, chest pain, sputum production, and hemoptysis are local signs. Signs of systemic involvement include anorexia, weight loss, and fatigue. Unfortunately, these signs and symptoms often overlap those of concurrent diseases. Many patients will not have obvious signs until the disease has reached advanced stages.

d. Diagnosis1 A multidisciplinary diagnostic evaluation is recommended for all suspect patients. Diagnostic tests for lung cancer include chest radiography as well as CT and PET scans. A thorough physical exam can help to identify signs of a tumor and metastases. A patient should also be assessed for

o Weight losso Smoking historyo Performance status (Appendix A)

e. Staging1 Staging is important for proper selection of therapy and determination of prognosis. Two-thirds of NSCLC presents in advanced stages (unresectable stage IIIB or stage IV).


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Current Recommended Treatment of Advanced NSCLC

III. Selection of treatment depends on the followinga. Stageb. Performance status (PS)c. Individual patient characteristics

Table 1. Select NCCN Recommendations for Systemic Treatment of Advanced or Metastatic Disease.

Advanced Diseaseo Stage, weight loss, PS, and gender predict survival.o Platinum-based chemotherapy improves survival, symptom control and quality of life (QOL).o New agent platinum combinations have generated a plateau in ORR, TTP, and median, 1-year and 2-year survival.o No specific platinum-based cytotoxic combination is clearly superior.o Unfit of any age (PS 3-4) do not benefit from cytotoxic treatment.

First-Line Therapyo Two-drug regimens are preferred.o Single agent therapy or platinum-based combinations are a reasonable alternative in PS 2 or elderly patients.o Cisplatin-based combinations have been proven superior to best supportive care in advanced, incurable disease.o Both platinum agents have been proven effective in combination with third-generation agents.o New agent/non-platinum combinations are acceptable alternatives if data shows activity and tolerable toxicity .

Recommendations are based on NCCN Clinical Practice Guidelines.2 Appendix Bcontains specific chemotherapy regimens used in A-NSCLC.

Third-generation agents include paclitaxel, docetaxel, vinorelbine and gemcitabine.

Abbreviations: PS, performance status; ORR, objective response rate; TTP, time to progression

Platinum Agent Comparison

IV. Commonalities of Cisplatin (Cs) and Carboplatin (Cb)a. Mechanism of Action3-5

Platinum agents are cell-cycle phase non-specific bifunctional alkylating agents. Intrastrand (and interstrand) cross-links form between DNA and the platinum agent. This cross-linking occurs between neighboring guanines and causes DNA distortion. DNA distortion leads to cellular damage as transcription and translation are impaired.

b. Mechanisms of Resistance3,6 Cellular drug accumulation (impaired influx or enhanced efflux) Inactivation of drug (glutathione, metallothioneins, other thiol-containing proteins) Enhancement of DNA repair

c. Dosage Adjustment4,5 Renal Impairment Hematologic Adjustment

d. Administration4,5 Monitor for extravasation during infusion. Avoid contact with aluminum-containing materials, which may yield a precipitate.


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Table 2. Differences between Cisplatin and Carboplatin.

Characteristic Cisplatin (Platinol) Carboplatin (Paraplatin)

Toxicity Profile3

[Black Box Warning]7,8

Nausea and EmesisCumulative Nephrotoxicity

Myelosuppression

Anemia

Ototoxicity

Peripheral Neuropathy

Anaphylaxis

Rarely > 100 mg/m2 q 3-4 wks

Myelosuppression

Thrombocytopenia

Anemia

Vomiting

Leukopenia

Neutropenia

Anaphylaxis

Administration7,8Pretreatment Hydration (1-2 L)

Maintain Hydration & UO > 24 hoursPretreatment Hydration Not Required

Dosing3 Based on mg/m2Calvert Formula

Dose (mg) = AUC x (CrCl + 25)

Contraindications4,5Myelosuppression

Baseline Renal or Hearing Impairment

Severe Myelosuppression

Significant Bleeding

Chemical Structures from Supko et al.9

Abbreviations: UO, urinary output; AUC, area under the curve; CrCl, estimated using the Cockcroft-Gault formula

Literature Review

Ardizzoni et al.Cisplatin- Versus Carboplatin-Based Chemotherapy in First-Line Treatment of A-NSCLC: An Individual Patient Data Meta-Analysis11

I. Primary ObjectiveTo compare efficacy of cisplatin and carboplatin in the first-line

chemotherapy treatment of advanced NSCLC with sufficient statistical power

II. Study Design. Individual Patient Data Meta-AnalysisIII. Trial Selection Criteria (n = 2,968 patients)

a. Patients must be randomly assigned to each treatment arm.b. Cisplatin and carboplatin were compared in first-line chemotherapy.c. Control and experimental groups could only differ by cisplatin and carboplatin components.d. Only patients with a diagnosis of NSCLC were included.

IV. Interventions of Included Trials (Table 1, Appendix C13,15,25-31)


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V. Main Outcome Measuresa. Primary Endpoint Overall Survival (OS)b. Secondary Endpoints.Overall Response Rate (ORR), Toxicity

VI. Statistical Analysisa. Intention-to-treat was applied.b. Summary hazard ratios (HR), odds ratios (OR) and 95% confidence intervals (CI) were used.c. Pvalues < 0.05 were considered statistically significant, except in subgroup analysis (< 0.10).

VII. Resultsa. Survival

i. Overall (Figure 1)1. Median Survival Cs 9.1 months vs. Cb 8.4 months2. 1-Year Survival..Cs 37% vs. Cb 34%3. Risk of Death in Cb.. HR 1.07 (95% CI 0.99 1.15, P= 0.100)

ii. Subgroup Analysis (Figure 2)1. Non-squamous histology favored survival in the cisplatin arm.2.

Use of third-generation agents favored survival in the cisplatin arm.3. No other subgroup analysis revealed a significant difference.

b. Responsei. Overall (Figure 3)

1. Response RateCs 30% vs. Cb 24%2. Risk of No Response CbOR 1.37 (95% CI 1.16 1.61, P< 0.001)

ii. Subgroup Analysis1. Non-Squam Response.. OR 1.58 (95% CI 1.27 1.97, P= 0.046)2. No other subgroup analysis revealed a significant difference.

Figure 1. Overall Survival of Carboplatin- versus Cisplatin-Based Chemotherapy.

From Ardizzoni et al.11 The test for heterogeneity was statistically significant for mortality comparison. The authors conducted a second test

of heterogeneity, omitting Jelic et al, and found this study to be the source of most heterogeneity (P = 0.418, I2 = 1%).


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Figure 2. Subgroup Analysis of Survival of Carboplatin- versus Cisplatin-Based Chemotherapy.

From Ardizzoni et al.11 Upon test for interaction subgroup analysis, only histology and chemotherapy regimen reached statistical significance

(P = 0.098 and 0.093, respectively). The hazard ratio for mortality in the squamous histology subgroup was 0.97 (95% CI 0.85 -1.10), whereas

in the non-squamous histology it was 1.12 (95% CI 1.01 1.23). In combination with second or third generation agents, the hazard ratios

were 0.94 (95% CI 0.80 1.11) and 1.11 (95% CI 1.01- 1.21), respectively. Third generation agents include paclitaxel, docetaxel, gemcitabine,

and vinorelbine.

Figure 3. Response Rate of Carboplatin- versus Cisplatin-Based Chemotherapy.

From Ardizzoni et al.11 Response rates were 30% for cisplatin and 24% for carboplatin. This corresponds to an odds ratio for non-response

(among those treated with carboplatin versus those treated with cisplatin) of 1.37 (95% CI 1.16 1.61, P < 0.001).


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Table 3. Rates (%) of Grade 3-4 Toxicities of Carboplatin- versus Cisplatin-Based Chemotherapy.

ToxicityCisplatin Frequency (%)

(n = 1,375)

Carboplatin Frequency (%)

(n = 1,365)OR (95% CI)

Leukopenia 33 32 0.96 (0.81 1.14)

Neutropenia 54 53 0.95 (0.80 1.12)

Anemia 12 13 1.10 (0.87 1.40)

Thrombocytopenia 6 12 2.27 (1.71 3.01)

Nausea & Vomiting 18 8 0.42 (0.33 0.53)

Neurotoxicity 12 11 0.96 (0.75 1.23)

Nephrotoxicity 1.5 0.5 0.37 (0.15 0.88)

Adapted from Ardizzoni et al.11 Statistically significant(P< 0.001); Statistically significant (P = 0.018)

VIII. Authors Conclusionscisplatin-based chemotherapy is slightly superior to carboplatin-based

chemotherapy in terms of response rate and, in certain subgroups, in prolongingsurvival without being associated with an increase in severe toxic effects.

IX. Reviewers Evaluation and Conclusiona. Cisplatin is associated with certain increased toxicities, contrary to the conclusion.b. Some of the trials included were questionable regarding selection of dose, agent, etc.c. Significant heterogeneity was found during survival analysis.d. Pvalue selected for subgroup analysis was set at < 0.10 for significance.e. A previous meta-analysis including 8 of the 9 trials concluded similar findings.10f. 80% of trial participants received a third-generation regimen.

Schiller et al.Comparison of Four Chemotherapy Regimens for Advanced Non-Small Cell Lung Cancer13

I. Primary Objectiveto compare overall survival in patients treated with cisplatin and gemcitabine,

cisplatin and docetaxel, carboplatin and paclitaxel, or cisplatin and paclitaxel.

II. Study Design. Phase III, Randomized, Multicenter Clinical Trial

III.

Participant Selection Criteria

a. Patients must have confirmed disease and have received no prior chemotherapy.b. Patients were required to have adequate renal, hematologic and hepatic function.c. Patients with stable brain metastases were eligible.


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IV. InterventionFigure 4. Stratification and Randomly Assigned Treatment Regimens.

Adapted from Schiller et al.13

V. Main Outcome Measuresa. Primary Endpoint... Overall Survival (OS)b. Secondary Endpoints Response Rate and Toxicity

VI. Statistical Analysisa. Time-to-Event Data.... Two-Sided, Log-Rank Test and the Kaplan-Meier Methodb. Response and Toxicity..Fischers Exact Test

VII. ResultsTable 4. Efficacy Results of Cisplatin-Containing Regimen Compared to Carboplatin-Containing Regimen.

Measured OutcomeCisplatin and Paclitaxel

(n = 288)

Carboplatin and Paclitaxel

(n = 290)

Median Survival (95% CI)mo 7.8 (7.0 8.9) 8.1 (7.0 9.5)

1-yr Survival (95% CI)% 31 (26-36) 34 (29 40)

2-yr Survival (95% CI)% 10 (5 12) 11 (7 14)

Median TTP (95% CI)mo 3.4 (2.8 3.9) 3.1 (2.8 3.9)

Overall Response Rate% 21 17

Withdrawal due to Progression% 53 44

Adapted from Schiller et al.13 No significant difference was found between cisplatin and carboplatin in terms of survival, TTP, or response.Statistically significant (P < 0.001); Abbreviations: CI, confidence interval; TTP, time to progression

Table 5. Rate (%) of Toxic Effects in Cisplatin- versus Carboplatin-Containing Regimens.

Toxicity

(Grade)

Cisplatin and Paclitaxel

(n = 300)


(n = 293)

Febrile Neutropenia (3, 4) 16 4

Anemia (3, 4) 13 10

Thrombocytopenia (3, 4) 6 10

Nausea (3) 25 9

Vomiting (3, 4) 24 8

Neuropathy (3) 5 10

Nephrotoxicity (3, 4, 5) 3 1

Sum of Toxicities (4, 5) 73 57

Adapted from Schiller et al.13 Statistically significant (P < 0.05)

Performance Status0 or 1 vs. 2

Weigh Loss< 5% vs. > 5%

Disease StageIIIB vs. IV or Recurrent

Brain MetastasesPresent vs. Absent

Cisplatin 75 mg/m2 d 2Paclitaxel 135 mg/m2 d 1

Repeat q 3 wks

(n = 303)

Cisplatin 100 mg/m2 d 1Gemcitabine 1000 mg/m2 d 1,8,15

Repeat q 4 wks

(n = 301)

Cisplatin 75 mg/m2 d 1Docetaxel 75 mg/m2d 1

Repeat q 3 wks

(n = 304)

Carboplatin AUC 6 d 1Paclitaxel 225 mg/m2 d 1

Repeat q 3 wks

(n = 299)


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VIII. Author ConclusionsNo significant difference in survival was observed among four commonly used regimens,

although the regimen of carboplatin and paclitaxel had a lower rate of toxic effects. On the basis of these

results, ECOG has chosen carboplatin and paclitaxel as its reference regimen for future studies.

IX. Reviewers Evaluation and Conclusiona. The paclitaxel dose in the carboplatin arm was 65% larger than that of the cisplatin arm.b. Paclitaxel was given as a 24-hour infusion with cisplatin and over 3 hours with carboplatin.c. The design was amended to only accept patients with a PS of 0 or 1 after 66 had enrolled.d. 94% of patients had a PS of 0 or 1; 87% were diagnosed with stage IV disease.e. A more recent study using identical paclitaxel doses concluded similar findings.14f. A study focusing on the direct comparison of platinum agents is needed.g. Ideally, the dose of the non-platinum agent (in this case, paclitaxel) would be identical.

Rosell et el.Phase III Randomized Trial Comparing Paclitaxel/Carboplatin with Paclitaxel/Cisplatin in A-NSCLC: A Cooperative Multinational Trial15

I. Primary Objectiveto assess whether response rate in patients receiving a paclitaxel/carboplatin

combination was similar to that in patients receiving a paclitaxel/cisplatin combination.

II. Study Design. Randomized, Multicenter, Multinational, Non-Inferiority TrialIII. Participant Selection Criteria

a. All patients must have confirmed stage IIIB or IV NSCLC and received no chemotherapy.b. Patients must have a performance status of< 2 and have a life expectancy of > 12 weeks.c. Adequate bone marrow, liver and renal function was also required.d. Any of the following diseases disqualified patients from entering the trial

i. History of malignancy in the past five yearsii. Symptomatic brain metastasesiii. Evidence of peripheral neuropathy

iv. Active infectionv. Cardiovascular disease

vi. Uncontrolled diabetes mellitusvii. Pregnancy, lactation or refusal to use adequate contraception

IV. InterventionFigure 5. Stratification and Randomly Assigned Treatment Regimens.

Adapted from Rosell et al.15

Performance Status0 or 1 vs. 2

Disease StageIIIB vs. IV or Recurrent

HistologySquamous vs. Non-Squamous

Cisplatin 80 mg/m2

Paclitaxel 200 mg/m2 over 3 hrsRepeat q 21 days , Max 6 Cycles

(n = 309)

Carboplatin AUC 6Paclitaxel 200 mg/m2 over 3 hrsRepeat q 21 days , Max 6 Cycles

(n = 309)


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V. Main Outcome Measuresa. Primary Endpoint Objective Response Rate (ORR)b. Secondary Endpoints.Survival, Toxicity

VI. Statistical Analysisa. Intention to treat was applied to survival data.b. Cox-proportional hazards regression was used for survival analysis.c. Non-inferiority could be concluded if the upper limit of the 90% CI was < 1.27 (Cs vs. Cb).d. Kaplan-Meier analysis was completed for each time-to-event variable.e. The Fischers Exact Test was used for comparing toxicity among each treatment arm.

VII. ResultsTable 6. Efficacy Results of Cisplatin-Containing Regimen Compared to Carboplatin-Containing Regimen.

Measured OutcomeCisplatin and Paclitaxel

(n = 284)


(n = 279)

ORR (95 % CI)% 28 (23 34) 25 (20 31)

Median Survival

mo 9.8 (8.3 11) 8.5 (7.4 9.6)1-yr Survival (95% CI)% 38 (33 44) 33 (27 38)

Median PFS (95% CI)mo 4.2 (3.3 4.4) 3 (2.7 3.9)

HR for Survival (Cs vs. Cb) 1.22 (90 % CI 1.06 1.40, P= 0.019)

From Rosell et al.15Statistically significant (P = 0.035)

Abbreviations: ORR, objective response rate; CI, confidence interval; PFS, progression free survival

Table 7. Rate (%) of Toxic Effects in Cisplatin- versus Carboplatin-Containing Regimens.

Toxicity of Any GradeCisplatin and Paclitaxel

(n = 302)


(n = 306)

Leukopenia 16 23

Anemia 95 94Thrombocytopenia 13 27

Nausea/Vomiting 70 49

Diarrhea 19 9

Peripheral Neuropathy 58 59

Nephrotoxicity 38 15

Adapted from Rosell et al.15Statistically significant difference (P < 0.05)

VIII. Author Conclusionsits [cisplatin/paclitaxel] use can be recommended in the treatment of patients with

advanced and metastatic NSCLC [based on longer median survival]. Carboplatin/paclitaxel represents

a viable alternative [based on response rate, safety profile, and ease of administration]

IX. Reviewers Evaluation and Conclusiona. The study was well-designed with regard to dosage selection for all three agents.b. Strengths of the study include consistency of patient characteristics and cycles administered.c. A few of the authors conclusions are questionable, both bias-related and statistically.d. Results must be applied cautiously as 71% were < 65 years old and 83% were PS 0 or 1.e. Cisplatin is not less efficacious than carboplatin when combined with paclitaxel.f. Intolerability of cisplatin would warrant use of carboplatin in combination with paclitaxel.


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Evidence-Based Recommendation

In regards to platinum-paclitaxel combinations Cisplatin-based regimens may be used as first-line treatment, barring contraindications. Carboplatin may be preferred in patients with poor PS. Carboplatin is the likely alternative in patients with contraindications to cisplatin.

Overall Cisplatin has shown to be more efficacious than carboplatin when an advantage exists. With 3rd generation agents, cisplatin may produce a survival and/or response advantage.


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References

1. McCune JS, Frieze DA. Chapter 132. Lung Cancer. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: APathophysiologic Approach, 7th Edition: http://0-www.accesspharmacy.com.libcat.ferris.edu/content.aspx?aID=3218960.

2. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: non-small cell lung cancer, v.2.2009[monograph on the internet]. NCCN; 2008 [cited 2009 Feb 2]. Available from: http://www.nccn.org/professionals/physician_gls.

3. Medina PJ, Fausel C. Chapter 130. Cancer Treatment and Chemotherapy. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, PoseyLM. Pharmacotherapy: A Pathophysiologic Approach, 7th Edition: http://0-www.accesspharmacy.com.libcat.ferris.edu/content.

4. Micromedex [database on the Internet]. Greenwood Village (CO):Thomson Micromedex; 1974-2009 [cited 2009 Apr 17]. CisplatinDrugPoint Summary; [multiple screens]. Available from: http://www.thomsonhc.com/hcs/librarian/

5. Micromedex [database on the Internet]. Greenwood Village (CO):Thomson Micromedex; 1974-2009 [cited 2009 Apr 17].Carboplatin DrugPoint Summary; [multiple screens]. Available from: http://www.thomsonhc.com/hcs/librarian/

6. Go RS, Adjei AA. Review of the comparative pharmacology and clinical activity of cisplatin and carboplatin. J Clin Oncol.Jan 1999;17(1):409-22.

7. Lexi-Comp, Inc. Drug information handbook for oncology. 7th ed. Solimando DA, editor. Hudson (OH): Lexi-Comps InformationManagement System; 2008. Cisplatin; p 224-31.

8. Lexi-Comp, Inc. Drug information handbook for oncology. 7th ed. Solimando DA, editor. Hudson (OH): Lexi-Comps InformationManagement System; 2008. Carboplatin; p 173-8.9. Supko JG et al. Chapter 51. Antineoplastic Agents. Brunton LL, Lazo JS, Parker KL: Goodman & Gilman's The Pharmacological Basis of

Therapeutics, 11th Edition: http://0-www.accesspharmacy.com.libcat.ferris.edu/content.aspx?aID=957513.

10.Hotta K, Matsuo K, Ueoka H, Kiura K, Tabata M, Tanimoto M. Meta-analysis of randomized clinical trials comparing cisplatin tocarboplatin in patients with advanced non-small-cell lung cancer. J Clin Oncol. 2004 Oct 1;22:3852-9.

11.Ardizzoni A, Boni L, Tiseo M, Fossella F, Schiller J, Paesmans M, et al. Cisplatin- versus carboplatin-based chemotherapy in first-linetreatment of advanced non-small-cell lung cancer: an individualized patient data meta-analysis. J Natl Cancer Inst. 2007;99:847-57.

12. Jiang J, Liang X, Zhou X, Huang R, Chu Z. A meta-analysis of randomized controlled trials comparing carboplatin-based to cisplatin-based chemotherapy in advanced non-small cell lung cancer. Lung Cancer. 2007 Mar 18;57:348-58.

13.Schiller JH, Harrington D, Belani CP, Langer C, Sandler A, Krook J, et al. Comparison of four chemotherapy regimens for advanced non-small cell lung cancer. N Engl J Med. 2002;346:92-8.

14.Chen YM, Perng RP, Tsai CM, Whang-Peng J. A phase II randomized study of paclitaxel plus carboplatin or cisplatin against chemo-nave inoperable non-small cell lung cancer in the elderly. J Thorac Oncol. 2006 Feb;1:141-5.

15.Rosell R, Gatzemeier U, Betticher DC, Keppler U, Macha HN, Pirker R, et al. Phase III randomized trial comparingpaclitaxel/carboplatin with paclitaxel/cisplatin in patients with advanced non-small cell lung cancer: a cooperative multinational

trial. Ann Oncol. 2002;13:1539-49.

16.Pfister DG, Johnson DH, Azzoli CG, et al. American Society of C linical Oncology treatment of unresectable nonsmall-cell lung cancerguideline: Update 2003. J Clin Oncol 2004;22:330353. [PMID: 14691125]

17.Lexi-Comp, Inc. Drug information handbook for oncology. 7th ed. Solimando DA, editor. Hudson (OH): Lexi-Comps InformationManagement System; 2008. Paclitaxel; p 858-64.

18.Micromedex [database on the Internet]. Greenwood Village (CO):Thomson Micromedex; 1974-2009 [cited 2009 Apr 17]. PaclitaxelDrugPoint Summary; [multiple screens]. Available from: http://www.thomsonhc.com/hcs/librarian/

19.Lexi-Comp, Inc. Drug information handbook for oncology. 7th ed. Solimando DA, editor. Hudson (OH): Lexi-Comps InformationManagement System; 2008. Docetaxel; p 342-8.

20.Micromedex [database on the Internet]. Greenwood Village (CO):Thomson Micromedex; 1974-2009 [cited 2009 Apr 17]. DocetaxelDrugPoint Summary; [multiple screens]. Available from: http://www.thomsonhc.com/hcs/librarian/

21.Lexi-Comp, Inc. Drug information handbook for oncology. 7th ed. Solimando DA, editor. Hudson (OH): Lexi-Comps InformationManagement System; 2008. Gemcitabine; p 499-504.


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22.Micromedex [database on the Internet]. Greenwood Village (CO):Thomson Micromedex; 1974-2009 [cited 2009 Apr 17].Gemcitabine DrugPoint Summary; [multiple screens]. Available from: http://www.thomsonhc.com/hcs/librarian/

23.Lexi-Comp, Inc. Drug information handbook for oncology. 7th ed. Solimando DA, editor. Hudson (OH): Lexi-Comps InformationManagement System; 2008. Vinorelbine; p 1107-11.

24.Micromedex [database on the Internet]. Greenwood Village (CO):Thomson Micromedex; 1974-2009 [cited 2009 Apr 17].Vinorelbine DrugPoint Summary; [multiple screens]. Available from: http://www.thomsonhc.com/hcs/librarian/

25.Klastersky J, Sculier J, Lacroix J, Dabouis G, Bureau G, Libert P, et al. A randomized study comparing cisplatin or carboplatin withetoposide in patients with advanced non-small cell lung cancer: European Organization for Research and Treatment of Cancer

protocol 07861. J Clin Oncol. 1990;8:1556-62.

26. Jelic S, Mitrovic L, Radosavljevic D, Elezar E, Babovic N, Kovcin V, et al. Survival advantage for carboplatin substituting cisplatin incombination with vindesine and mitomycin C for stage IIIB and IV squamous-cell bronchogenic carcinoma: a randomized phase III

study. Lung Cancer. 2001;34:1-13.

27.Zatloukal P, Petruzelka L, Zemanova M, Vitezslav K, Skrickova J, Pesek M et al. Gemcitabine plus cisplatin vs. gemcitabine pluscarboplatin in stage IIIb and IV non-small cell lung cancer: a phase III randomized trial. Lung Cancer. 2003 Apr 8;41:321-31.

28.Fossella F, Pereira JR, von Pawel J, Pluzanska A, Gorbounova V, Kaukel E, et al. Randomized, multinational, phase III study ofdocetaxel plus platinum combinations vs vinorelbine plus cisplatin for advanced non-small cell lung cancer. The TAX 326 Study

Group. J Clin Oncol. 2003;21:3016-24.

29.Mazzanti P, Massacesi C, Rocchi MBL, Mattioli R, Lippe P, Trivisonne R, et al. Randomized, multicenter, phase II study of gemcitabineplus cisplatin vs gemcitabine plus carboplatin in patients with advanced non-small-cell lung cancer. Lung Cancer. 2003;18:317-23.

30.Paccagnella A, Favaretto A, Oniga F, Barbieri F, Ceresoli G, Torri W, et al. Cisplatin versus carboplatin in combination with mitomycinand vinblastine in advanced non-small cell lung cancer. A multicenter, randomized phase III trial. Lung Cancer. 2004;43:83-91.

31.Bisset D, Nicolson M, Falk S, Dunlop D, Stares N, Loh E. Randomized phase II study of tirapazamine with either cisplatin orcarboplatin in advanced NSCLC. Proc Am Soc Clin Oncol. 2001;20:346a.

32.Colleoni M, Vicario G, Pancheri F, Sgarbossa G, Nelli P, Manente P. A randomized phase II trial of cisplatinum plus mitomycin C plusvinorelbine and carboplatin plus vinorelbine in advanced non-small cell lung cancer. Int J Oncol 1997;10:619-22.

33.Baldini E, Tibaldi C, Ardizzoni A, Salvati F, Antilli A, Portalone L, et al. Cisplatin-vindesine-mitomycin (MVP) vs cisplatin-ifosfamide-vinorelbine (PIN) vs carboplatin-vinorelbine (CaN) in patients with advanced non-small cell lung cancer (NSCLC: a FONICAP

randomized phase II study. Italian Lung Cancer Task Force (FONICAP). Br J Cancer. 1998;77:2367-70.

34.Kelly K, Crowley J, Bunn PA, Presant CA, Grevstad PK, Moinpour CM, et al. Randomized phase III trial of paclitaxel plus carboplatinversus vinorelbine plus cisplatin in the treatment of patients with advanced non-small-cell lung cancer: a Southwest Oncology Group

trial. J Clin Oncol. 2001;19:3210-8.

35.Scagliotti GV, De Marinis F, Rinaldi M, Crino L, Gridelli C, Ricci S, et al. Phase III randomized trial comparing three platinum-baseddoublets in advanced non-small-cell lung cancer. J Clin Oncol. 2002;20:4285-91.

36.Danson S, Middleton MR, OByrne KJ, Clemons M, Ranson M, Hassan J, et al. Phase III trial of gemcitabine and carboplatin versusmitomycin, ifosfamide, and cisplatin or mitomycin, vinblastine, and cisplatin in patients with advanced non-small cell lung

carcinoma. Cancer. 2003;98:542-53.

37.Belani CP, Lee JS, Socinski MA, Robert F, Waterhouse D, Rowland K, et al. Randomized phase III trial comparing cisplatin-etoposide tocarboplatin-paclitaxel in advanced or metastatic non-small cell lung cancer. Ann Oncol. 2005;16:1069-75.

38.Rudd RM, Gower NH, Spiro SG, Eisen TG, Harper PG, Littler JA, et al. Gemcitabine plus carboplatin versus mitomycin, ifosfamide, andcisplatin in patients with stage IIIB or IV non-small-cell lung cancer: a phase III randomized study of the London Lung Cancer Group. J

Clin Oncol. 2005;23:142-53.

39.Booton R, Lorigan P, Anderson H, Baka S, Ashcroft L, Nocolson M, et al. A phase III trial of docetaxel/carboplatin versus mitomycinC/ifosfamide/cisplatin (MIC) or mitomycin C/vinblastine/cisplatin (MVP) in patients with advanced non-small-cell lung cancer: a

randomized multicentre trial of the British Thoracic Oncology Group (BTOG1). Ann Oncol. 2006 Mar 7;17:1111-9. Epub 2006 Apr 7.

40.Thomas P, Robinet G, Gouva S, Fournel P, Lena H, Le Caer H, et al. Randomized multicentric phase II study of carboplatin/gemcitabineand cisplatin/vinorelbine in advanced non-small cell lung cancer GFPC 99-01 study. Lung Cancer. 2006;51:105-14.

41.Ohe Y, Ohashi Y, Kubota K, Tamura T, Nakagawa K, Negoro S, et al. Randomized phase III study of cisplatin plus irinotecan versuscarboplatin plus paclitaxel, cisplatin plus gemcitabine, and cisplatin plus vinorelbine for advanced non-small-cell lung cancer: four-

arm cooperative study in Japan. Ann Oncol. 2007;18:317-23.


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Appendices

Appendix A. Performance Status Scales

Description: Karnofsky ScaleKarnofskyScale (%)

Zubrod Scale(ECOG) Description: ECOG Scale

No complaints; no evidence of disease 100 0Fully active;

able to carry on all pre-disease activity

Able to carry on normal activity;

minor signs or symptoms of disease90

Normal activity with effort;

some signs or symptoms of disease80 1

Restricted in strenuous activity,

but ambulatory and able to carry out work

of a light or sedentary nature

Cares for self;

unable to carry on normal activity or to do active work

70

Requires occasional assistance,

but is able to care for most personal needs60 2

Out of bed more than 50% of time;ambulatory and capable of self-care, but

unable to carry out any work activities

Requires considerable assistance and

frequent medical care50

Disabled; requires special care and assistance 40 3In bed more than 50% of time;

capable of only limited self-care

Severely disabled; hospitalization indicated,

although death not imminent30

Very sick; hospitalization necessary;

requires active supportive treatment20 4

Bedridden; cannot carry out any self-care;

completely disabled

Moribund; fatal processes progressing rapidly 10

Dead 0

From Medina et al.3


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Appendix B. Current NSCLC Treatment Algorithms

Chemotherapy Regimens for Adjuvant Therapy

PUBLISHED CHEMOTHERAPY REGIMENS

Cisplatin 50 mg/m2 days 1 and 8

Vinorelbine 25 mg/m2 days 1, 8, 15, 22

Every 28 days for 4 cycles

Cisplatin 100 mg/m2 day 1

Vinorelbine 30 mg/m2 days 1, 8, 15, 22Every 28 days for 4 cycles

Cisplatin 75-80 mg/m2 day 1

Vinorelbine 25-30 mg/m2 days 1 + 8Every 21 days for 4 cycles


Etoposide 100 mg/m2 days 1-3Every 28 days for 4 cycles

Cisplatin 80 mg/m2 days 1, 22, 43, 64

Vinblastine 4 mg/m2 days 1, 8, 15, 22, then every 2 weeks after day 43Every 21 days for 4 cycles

OTHER ACCEPTABLE CISPLATIN-BASED REGIMENS


Gemcitabine 1000 mg/m2 days 1, 8Every 21 days

Cisplatin 75 mg/m2Docetaxel 75 mg/m2

Every 21 days

REGIMENS FOR PATIENTS WITH COMORBIDITIES OR PATIENTS NOT ABLE TO TOLERATE CISPLATIN

Paclitaxel 200 mg/m2 day 1

Carboplatin AUC 6 on day 1Every 21 days

Chemotherapy Regimens Used with Radiation Therapy (RT)

CONCURRENT CHEMOTHERAPY/RT REGIMENS

Cisplatin 50 mg/m2 on day 1, 8, 29, and 36

Etoposide 50 mg/m2 days 1-5, 29-33

Concurrent thoracic RT (total dose, 61 Gy) (preferred)

Cisplatin 100 mg/m2 day 1, 29

Vinblastine 5 mg/m2 weekly x 5 doses

Concurrent thoracic RT 60 Gy (preferred)

Paclitaxel 45-50 mg/m2 weekly over 1 hour

Carboplatin AUC = 2 mg/mL/min over 30 min weekly

Concurrent thoracic RT 63 Gy/7 weeks/34 fractions (category 2B)

SEQUENTIAL CHEMOTHERAPY/RT REGIMENS

Cisplatin 100 mg/m2 on day 1, 29

Vinblastine 5 mg/m2 weekly on days 1, 8, 15, 22, 29

Followed by RT with 60 Gy in 30 fractions beginning on day 50

Paclitaxel 200 mg/m2 every 3 weeks over 3 hours, 2 cycles

Carboplatin AUC 6, 2 cycles

Followed by thoracic RT 63 Gy beginning on day 42

CONCURRENT CHEMOTHERAPY/RT FOLLOWED BY CHEMOTHERAPY

Cisplatin 50 mg/m2 on day 1, 8, 29, 36

Etoposide 50 mg/m2

days 1-5, 29-33Concurrent thoracic RT (total dose, 61 Gy)

Docetaxel started 4-6 weeks after chemoradiation at an initial dose of 75 mg/m2 x 3 doses every 3 weeks (category 3)

Paclitaxel 45-50 mg/m2 weekly

Carboplatin AUC 2

Concurrent thoracic RT 63 Gy

Followed by 2 cycles of paclitaxel 200 mg/m2 and carboplatin AUC 6 (category 2B)

From NCCN Clinical Practice Guidelines2


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Appendix C. Summary of Trials


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About the Presenter

Mike Crowe came to Ferris State University in 2003 in pursuit of a degree in pharmacy.

He has worked for a retail pharmacy chain for over five years and in hospital pharmacy for

nearly a year. Following completion of his Pharm D, Mike will begin a residency with

Diplomat Specialty Pharmacy where he plans to contribute to their disease statemanagement programs both in continuation of current programs and in the development

of new ones. He has also taken a position as an instructor with Grand Rapids College. Mike

initially became interested in the topic of lung cancer due to case occurring within his

family. He specifically began to investigate cisplatin and carboplatin on the

recommendation of Dr. Saadeh. He is pleased to present his findings to you.

Documents

Mike Crowe_May 2009 Seminar Paper_Cisplatin v Carboplatin