calgb 80101 postoperative adjuvant chemoradiation for gastric or ge junction adenocarcinoma using...
TRANSCRIPT
CALGB 80101
Postoperative adjuvant chemoradiation for gastric or GE junction adenocarcinoma using ECF before and after 5-FU/radiotherapy compared to bolus 5-
FU/LV before and after 5-FU/radiotherapy: Intergroup trial CALGB 80101
CS Fuchs, JE Tepper, D Niedzwiecki, D Hollis, HJ Mamon, RS Swanson, DG Haller,
T Dragovich, SR Alberts, G Bjarnson, CG Willett, PC Enzinger, RM Goldberg, AP Venook, RJ Mayer
CALGB 80101
CALGB 80101: Participating Groups
Cancer and Leukemia Group B
Eastern Cooperative Oncology Group
North Central Cancer Treatment Group
National Cancer Institute of Canada
Southwest Oncology Group
Radiation Treatment Oncology Group
Clinical Trials Support Unit (NCI)
CALGB 80101
Background• INT 0116 demonstrated improved survival with post-
operative adjuvant 5-FU/LV/RT compared to surgery alone*
– Post-op 5-FU/LV/RT was associated with reduction in local-regional recurrences
– Reductions in distant relapse were less apparent
• MAGIC trial found improved outcome with perioperative ECF**
• Could the benefit associated with post-op 5-FU/LV/RT be improved with a potentially more active systemic regimen (ECF) than 5-FU/LV?
*(N Eng J Med 2001) **(N Engl J Med. 2006)
CALGB 80101
Pre-RT Chemo (1 cycle)
Chemo with RT (45 Gy)
Post-RT Chemo (2 cycles)
Epirubicin 50 mg/m2 d1
Multicenter Pilot Study of Adjuvant Chemoradiation After Resection of Gastric or GE Junction Adenocarcinoma
Cisplatin 60 mg/m2 d1
5-FU CI 200 mg/m2
d1-21
5-FU CI 200 mg/m2/d
Epirubicin 40 mg/m2 d1
Cisplatin 50 mg/m2 d1
5-FU CI 200 mg/m2
d1-21
Grade 3 or Higher Toxicity
Pilot Study (N = 20) INT 0116 (N = 281)
Hematologic 30% (6/20) 54%
Gastrointestinal 35% (7/20) 33%
CALGB 80101
CALGB 80101: Study Schema
R
A
N
D
O
M
I
Z
E
5-FU/LV: 5-FU 425 mg/m2 d1-5, LV 20 mg/m2 d1-5
RT: 45 Gy (1.8 Gy X 25 fractions) with 5-FU 200 mg/m2/d CI
ECF (pre-RT): Epirubicin 50 mg/m2 d1, Cisplatin 60 mg/m2 d1, &
5-FU 200 mg/m2/d CI d1-21
ECF (post-RT): Epirubicin 40 mg/m2 d1, Cisplatin 50 mg/m2 d1, &
5-FU 200 mg/m2/d CI d1-21
5-FU/LV
X1
5-FU/LV
X2
5-FU IVCI
RT
ECF
X1
ECF
X2
5-FU IVCI
RT
CALGB 80101
CALGB 80101: Study Endpoints
Primary
• Overall survival
Secondary
• Disease-free survival
• Adverse events
CALGB 80101
Randomization
• 1:1
• Stratification factors:
– T1/T2 vs. T3 vs. T4
– Lymph node involvement: 0 vs. 1-3 vs. ≥ 4
– ≥ 7 nodes examined vs. < 7 examined/unknown
• Sample size
– N = 540 (270 per arm)
– 80% power to detect a 30% improvement in OS comparing ECF to 5-FU/LV (Median OS: 49 versus 36 months; alpha = 0.05)
CALGB 80101
Eligibility Criteria
• GE junction or gastric adenocarcinoma
• En bloc resection; negative resection margins
• Extension beyond muscularis propria or nodal involvement; M1 disease excluded
• No prior chemo or radiotherapy
• ECOG PS: 0-2
CALGB 80101
Eligibility Criteria (continued)
• Adequate hematologic, renal, and hematologic function
• < 2 lbs weight loss on 2 measurements over 1 week
• 3 to 12 weeks following surgery
• Evaluation by radiation oncologist
CALGB 80101
Study Accrual: 4/30/03 to 5/29/09
CALGB 80101
Baseline Characteristics
Characteristic5FU/LV
N=280ECFN=266
Age (years)
Median (range) 59 (23-81) 59 (28-83)
Sex
Male 69% 67%
ECOG PS
0 47% 54%
1 50% 44%
2 3% 2%
CALGB 80101
Baseline Characteristics5FU/LV
N=280ECFN=266
Depth of tumor
T1 or T2 47% 47%
T3 48% 49%
T4 5% 4%
Positive lymph nodes
0 16% 15%
1-3 36% 36%
≥ 4 48% 49%
Nodes examined
< 7 13% 10%
7-14 37% 29%
≥ 15 50% 61%
CALGB 80101
Baseline Characteristics5FU/LV
N=280ECFN=266
Tumor Location
GE junction 24% 23%
Proximal 9% 6%
Corpus/Distal 47% 57%
NOS or multicentric 20% 15%
Race
White 76% 71%
Black 11% 15%
Asian 8% 9%
Other 5% 5%
CALGB 80101
Reasons for Treatment Cessation
Reasons5FU/LV
N=280ECFN=266
Completed treatment 75% 69%
Progressive disease 5% 3%
Adverse event 10% 16%
Death 4% 1%
Withdrew 4% 8%
Other 2% 3%
CALGB 80101
Quality Assurance for Radiotherapy
• 15% of the treatment plans were found to contain major deviations
CALGB 80101
Major (Grade ≥ 3) Adverse Events 5FU/LV ECF
Nausea 17% 15%
Diarrhea 15% 7%
Mucositis 15% 7%
Dehydration 9% 4%
Anorexia 16% 13%
Fatigue 11% 13%
Neutropenia 52% 48%
Grade ≥ 4 Neutropenia 33% 19%
Death 3% (8) 0% (1)
CALGB 80101
0 1 2 3 4 5 6 7
Years from Study Entry
0.0
0.2
0.4
0.6
0.8
1.0
Pro
po
rtio
n S
urv
ivin
g
ECF5-FU
Overall Survival by Arm
P, log rank = 0.80
CALGB 80101Overall Survival by Treatment Arm
CALGB 80101
Arm Median OS* 3-year OS 5-year OS Hazard Ratio (95% CI)
5-FU/LV 36.6 mos 50% 41%
ECF 37.8 mos 52% 44% 1.03 (0.80-1.34)
*P, log rank = 0.80
CALGB 80101Overall Survival by Treatment Arm
CALGB 80101
P, log rank = 0.99
0 1 2 3 4 5 6 7
Years from Study Entry
0.0
0.2
0.4
0.6
0.8
1.0
Pro
po
rtio
n S
urv
ivin
g D
isea
se-F
ree
ECF5-FU
Disease_Free Survival by Arm
CALGB 80101Disease-Free Survival by Treatment Arm
CALGB 80101
Arm Median DFS 3-yr DFS 5-yr DFS Hazard Ratio (95% CI)
5-FU/LV 30.1 mos 46% 35%
ECF 28.2 mos* 47% 38% 1.00 (0.79-1.27)
*P, log rank = 0.99
CALGB 80101Disease-Free Survival by Treatment Arm
CALGB 80101
MaleFemale
Age ≥ 60
Age < 60
GE jxnProximal
Distal
T 1/2T 3/4
0 pos nodes1-3 pos nodes≥ 4 pos nodes
PS 0PS 1-2
< 7 nodes exam7-14 nodes exam≥ 15 nodes exam
Favors ECF Favors 5-FU/LV
HRs (95% CI) for Mortality According to Baseline Characteristics
CALGB 80101
CALGB 80101 INT 0116
5-FU/LV ECF 5-FU/RT Control
Median OS(mos)
37 38 36 27
CALGB 80101 and INT 0116Overall Survival by Treatment
CALGB 80101
Conclusion
Following curative resection of gastric or GE jxn
adenocarcinoma, post-operative chemoradiotherapy
using ECF & 5-FU/RT does not improve survival when
compared to 5-FU/LV & 5-FU/RT
CALGB 80101
Acknowledgements
We wish to thank:
• all the patients and families who participated in the trial
and
• all the participating centers.