1. Current Knowledge and Rationale Gastro-esophageal (GE) cancers are a highly aggressive
disease and are one of the major causes of cancer-related death in the world. Despite
improvements in surgical and radiation techniques and the availability of newer agents,
the prognosis of recurrent GE cancers remains very poor (1-4). GE cancers comprise one
of the solid organ cancers with a high fatality rate. Although 5,600 (2.8%) of the
estimated 196,900 newly diagnosed cancers in Canada in 2015 were GE cancer, 4,100 (5.2%)
of the 78,000 cancer related deaths were from GE cancers (3). The need for novel
strategies to improve current therapy is therefore vital in the management of GE cancer.
In many clinical trials, the treatment of metastatic gastric and esophageal cancers has
merged, and the majority of patients with gastric, esophageal, or GE cancers are treated
with a parallel chemotherapeutic regimens. The goal of treatment in patients with
metastatic GE cancer is to control the disease, to maintain or improve quality of life,
and to prolong survival. In a meta-analysis of three trials comparing chemotherapy
versus best supportive care, there was a significant benefit in overall survival in
favor of chemotherapy (hazard ratio [HR] 0.37; 95% CI 0.24 -0.55) (5). Hence,
chemotherapy should be considered for patients with appropriate performance status.
In general combination chemotherapy has been associated with higher response rates, and
better progression free survival (PFS), and overall survival (OS) compared with single
agent chemotherapy. For most patients with GE cancers combination chemotherapy
represents the standard of care.
The ECF (epirubicin, cisplatin, 5-fluorouracil) remains one of the reference regimens
for the first-line treatment of metastatic GE cancers. However, when both oxaliplatin
(O) and capecitabine (X) are substituted for cisplatin (C) and 5FU (F), respectively in
the ECF regimen (EOX, EOF, ECX), outcomes are at least as good as with ECF (6). FOLFOX
has also been compared to ECF with comparable results. An intergroup phase 2 trial
evaluated ECF, irinotecan and cisplatin (IC), or FOLFOX in combination with cetuximab,
and concluded that response rates, PFS, and median OS were comparable in the ECF and
FOLFOX groups. FOLFOX-based regimen required fewer treatment modifications compared with
other regimens (7).
Irinotecan-based regimens also appeared to be superior to cisplatin/5FU in response
rates and survival being in the 10-12 month range (8,9). A randomized phase 3 trial
evaluated 416 patients with advanced gastric or esophagogastric junction (EGJ)
adenocarcinoma who were assigned to either FOLFIRI or ECX (10). There were no
significant differences in median PFS, OS, or response rates between the two regimens.
Time to treatment failure favored FOLFIRI (5.1 versus 4.2 months). Furthermore, FOLFIRI
was better tolerated overall (rate of grade 3 or 4 toxicity 69 versus 84% with ECX).
Although docetaxel based regimens such as DCF have shown significant improvement in
response, PFS, and OS compared to cisplatin/5-FU, it is a more toxic regimen with a
higher rates of grade 3 or 4 toxicities and is not commonly used in Canada (11-13).
Despite a large number of randomized trials, there is no globally accepted, standard
first-line chemotherapy regimen in advanced HER2 negative GE cancer. A meta-analysis of
first-line chemotherapy trials for metastatic GE cancers involving 10,249 patients in 50
trials that incorporated 17 different chemotherapy regimens with 37 direct comparisons
showed that anthracycline-containing triplets such as ECF or EOX and the
docetaxel-containing triplet DCF were more toxic but not superior to fluoropyrimidine
doublets with respect to PFS or OS (14). Although fluoropyrimidine
noncisplatin-containing doublets, fluoropyrimidine-cisplatin doublets, and all triplet
regimens showed significant improvements in overall survival compared with
fluoropyrimidine alone, a fluoropyrimidine-noncisplatin doublet containing oxaliplatin
(FOx) or irinotecan (FI) significantly improved OS compared with a fluoropyrimidine plus
cisplatin doublet (for FI, the HR for death was 0.85, 95% CI 0.71-0.99; for FOx, the HR
was 0.83, 95% CI 0.71-0.98). The cisplatin/fluoropyrimidine doublet was also associated
with more grade 3 or 4 toxicity. Furthermore, an individual patient data meta-analysis
of the GASTRIC group involving 4245 patients of 55 eligible trials concluded that there
was no role for epirubicin in combination with a fluoropyrimidine and a platinum agent
(15).
Hence, based on efficacy and toxicity profiles, fluoropyrimidine doublets FOLFOX or
FOLFIRI are the preferred first-line therapy over cisplatin doublets, anthracycline
triplets, and DCF. A substantial number of patients who have disease progression after a
first-line chemotherapy may not undergo further active therapy, mainly because of
deterioration of their performance status or side effects-related to previous
treatments. Although the combinations of 5-FU with irinotecan and oxaliplatin
(FOLFOXIRI) is an active regimen in colorectal and pancreatic cancer, it has been
associated with a higher rate of adverse effects. Furthermore, this regimen is currently
administered at the two major treatment centers in Saskatchewan requiring frequent
long-distance travel.
The LOGIC study aims to evaluate efficacy and toxicity of a novel regimen comprised of
biweekly FOLFOX for two cycles alternating with FOLFIRI for two cycles (FOLFOX-FOLFIRI)
as the first-line therapy for patients with previously untreated metastatic GE cancers.
This novel schedule will expose the patients to three active agents in the first-line
setting without the toxicity that is typically associated when all of three drugs are
given together. Furthermore, since oxaliplatin is associated with significant
neuropathy, decreasing the exposure of this drug in an alternating schedule can result
in less cumulative neurotoxicity and an increased use of second-line treatment.
2. Research Questions and Hypothesis
- Whether a novel treatment regimen comprised of biweekly FOLFOX alternating with
FOLFIRI as a first-line therapy for patients with previously untreated metastatic
GE cancers is as effective and less toxic compared to the other available two- and
three-drug regimens?
- Whether an early fluorodeoxyglucose-positron emission tomography (FDG-PET) scan
response and other biomarkers correlate with better PFS and OS in patients with
metastatic GE cancer who are treated with FOLFOX alternating with FOLFIRI?
- What is rate of second-line therapy in patients with metastatic GE cancer who
received first-line FOLFOX alternating with FOLFIRI?
- We hypothesize that this novel regimen FOLFOX-FOLFIRI is less toxic but at least as
effective as the other two- and three-drug regimens available in metastatic GE
cancer and that an early FDG-PET response is associate with a better PFS rate. We
also hypothesize that this novel regimen is associated with low rate of decline in
QOL at 3 and 6 months.
3. Objectives
3.1 Primary Objectives
- To evaluate progression-free survival of patients with metastatic GE cancer who are
treated with FOLFOX-FOLFIRI.
- To determine correlation between various clinical and pathological biomarkers
including an early FDG-PET scan response and progression free survival and QOL of
patients who are treated with FOLFOX-FOLFIRI.
3.2 Secondary Objectives
- To assess the quality of life of patients who are treated with FOLFOX alternating
with FOLFIRI.
- To determine the response rate, time to treatment failure, and overall survival of
patients who are treated with FOLFOX alternating with FOLFIRI.
- To evaluate treatment toxicities, including the rate of neurotoxicity with FOLFOX
alternating with FOLFIRI.
4. Eligibility Criteria 4.1 Inclusion Criteria
- Adult patients (≥18 years older) with histologically proven HER2 negative
adenocarcinoma or poorly differentiated carcinoma of the esophagus, GE junction
tumors, and gastric cancer.
- Measurable or assessable metastatic disease.
- Performance status World Health Organization (WHO) 0-2 and life expectancy of
greater than 3 months.
- No previous chemotherapy for advanced disease.
- Adequate functioning of the bone marrow, liver, and kidneys. 4.2 Exclusion Criteria
- Breastfeeding or pregnancy.
- Active second primary cancer except in situ cancer or non-melanoma skin cancer.
- Cerebral metastases or leptomeningeal carcinomatosis.
- Severe or uncompensated concomitant medical conditions including peripheral
neuropathy.
5. Methods
5.1 Study design
- The LOGIC trial is a single arm phase 2 study. 5.2 Sample size
- Based on response rates of 40-50% with combination chemotherapy in the randomized
trials, to achieve 80% power the required sample in this single arm study is N=36
with 5% significance level and two-sided test. At this power we will be able to do
appropriate analyses and meaningful comparison of efficacy and toxicity.
5.3 Recruitment timeline
• Each year approximately 100 patients are diagnosed with gastric, esophageal, and
gastro-esophageal cancer in Saskatchewan. Unfortunately, most patients either have
advanced disease at diagnosis or develop recurrent cancer after curative treatment.
Based on that we estimated that each month we will be able to recruit 2 to 3 patients at
the two major cancer centers (the Saskatoon Cancer Center and the Allan Blair Cancer
Center) in Saskatchewan and recruitment will be completed in 18-24 months.
5.4 Analysis
• Response rates and stable disease rates will be summarized by percentages and their
95% CI. Survival curves will be analyzed using the Kaplan-Meier method, and differences
between groups will be analyzed using log-rank test. The efficacy and toxicities of this
novel regime will be compared with the historical control from the publish literature.
Correlation will be significant at the 0.05 level (two tailed). Univariate analyses will
be done to assess various clinical and pathologic factors for their correlation with
prognosis and if feasible a multivariate analysis will be performed. Linear mixed models
will be used to assess changes over time for overall QOL and for separate components of
QOL.
6. Chemotherapy Regimen
6.1 FOLFOX Drug Dosage Timing Oxaliplatin 85 mg/m2 Day 1 Leucovorin 400 mg/m2 Day 1
Fluorouracil 400 mg/m2 Day 1 Fluorouracil 2400 mg/m2 48 hrs infusion
- for patients with ECOG P 6.2 FOLFIRI Drug Dosage Timing Irinotican 180 mg/m2 Day 1
Leucovorin 400 mg/m2 Day 1 Fluorouracil 400 mg/m2 Day 1 Fluorouracil 2400 mg/m 48
hrs infusion
- for patients with ECOG P
7. Assessment, interventions, and follow-up visits 7.1 Baseline Assessment
- Pretreatment patient evaluation includes a complete clinical history and physical
examination, full blood counts, renal and liver function tests (bilirubin, AST,
alkaline phosphatase), albumin, electrolytes, magnesium, calcium, serum
carcinoembryonic (CEA) level measurements, and CT scan of the thorax, abdomen, and
pelvis (a baseline scan within 4 weeks of start of treatment, and then with every
4th cycles).
- Responses will be evaluated with standard Response Evaluation Criteria in Solid
Tumors (RECIST) by means of CT scans and will be complemented by an FDG-PET/CT
scan.
7.2 Follow-up visits
• Patients will be seen prior to the second cycle of FOLFOX and FOLFIRI and before every
other infusion with medical history, examination and CBC and differential, platelets,
creatinine, LFT's (bilirubin, AST, alkaline phosphatase), electrolytes, albumin, and
blood Pressure measurement.
7.3 Dose Modification
- Toxicity will be graded according to the National Cancer Institute (NCI) Common
Toxicity Criteria Version 4.
- Specific drug reductions and management of neurotoxicity will be made in accordance
with published recommendations for FOLFOX and FOLFIRI at the discretion of treating
oncologist.
7.4 Response Assessment
• Responses will be evaluated with standard Response Evaluation Criteria in Solid Tumors
(RECIST) by means of CT scans and will be complemented by an FDG-PET/CT scan.
7.5 Treatment Duration A maximum of 12 cycles is planned, but treatment could be
continued off the protocol in patients without disease progression in cases of clinical
benefit. Second-line chemotherapy will be left to the discretion of the treating
physician.
8. Quality of Life
- Quality of life (QOL) focuses on patient construct. Physical health, functional
status, sexual, and psychosocial domains are considered key elements in QOL
measurement. The European Organization for Research and the Treatment of Cancer
(EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) along with the EORTC
Esophago-Gastric Cancer Module (QLQ-OG25).
- The EORTC QLQ-C30 is a widely used instrument for measuring general cancer QOL. It
consists of 30 items and patients responses are transformed to produce 0-100 scores
on five functional scales, nine symptom scales and a scale representing global
quality of life. Higher functional scale scores indicate better QOL whereas higher
symptom scale/item scores indicate higher level of symptoms.
- The QLQ-OG25 has six scales, dysphagia, eating restrictions, reflux, odynophagia,
pain and anxiety. The QLQ-OG25 is recommended to supplement the EORTC QLQ-C30 when
assessing HRQL in patients with esophageal, junctional or gastric cancer (16). Both
English and French versions of questionnaire are available. The QOL will be
measured at baseline and then every four weeks till disease progression.
9. Correlative science
- Positron Emission Tomography is commonly used to complement anatomic imaging in
cancer management (17). A CT-PET scan allows for images representing both anatomic
and metabolic properties. A PET/CT has emerged as an effective tool for diagnostic
and therapeutic evaluation in many types of cancers, including GE cancers. Evidence
has suggested that FDG-PET/CT seems to be an effective noninvasive tool for
response assessment in GE cancer (18,19). Early FDG-PET response will be correlated
with PFS and QOL.
- In addition, the correlation between outcomes and various biomarkers such as tumor
grade, lymphocyte to neutrophil ratio, E-cadherin, fibroblast growth factor
receptor, TP53, and microsatellite instability will be evaluated.
Immunohistochemical analysis of paraffin embedded tumor specimens using antibodies
against several biomarkers including P53, MLH1, MSH2, MSH6, PMS2, E-cadherin,
fibroblast growth factor receptor, and Ki-67 will be performed. In addition, we
will use the plasma proteome database (http://www.plasmaproteomedatabase.org) to
identify novel biomarkers. The purpose of these analyses is to identify
differentially expressed tumor-specific genes that code for the plasma proteome.
- We will select tumor markers based on their gradient of differential expression and
examine at least four markers using ELISA assays in patient's plasma samples (at 0
and 2 months of treatment) to assess their predictive and prognostic values.
10. Significance
- Based on the indirect evidence that anthracycline-containing triplets such as ECF
or EOX or docetaxel-containing triplets such as DCF are more toxic but not superior
to fluoropyrimidine doublets such as FOLFOX or FOLFIRI, this study aims to develop
an effective novel but potentially less toxic regimen in the management of
metastatic GE cancers, offering the possibility of longer disease control as a
result of 100% exposure to two active doublets in a first-line treatment setting
and an improvement in the rate of salvage second line therapy.
- Furthermore, this study will evaluate an early FDG-PET/CT response and various
other clinical and pathological variables and their correlation with PFS and QOL
using this novel regimen with an ultimate goal to improve care of this highly fatal
cancer. The results will be used for future collaboration and development of a late
phase trial at the national level.
11. Knowledge Translation
- The research findings will be presented to health professionals, patients and their
family and decision makers using various platform. The findings will be shared with
P & T committee and PFAC members. The result will be presented to the Western
Canadian Gastrointestinal Cancer groups. The findings will be published in the peer
reviewed scientific journals and will be presented at international, national and
local conferences.
