Single-agent chemotherapy trials in small-cell lung cancer, 1970 to 1990: the case for studies in previously treated patients.

PURPOSE: This review was undertaken (1) to determine the antitumor activity of agents studied in phase II trials in small-cell lung cancer (SCLC) patients, (2) to evaluate the adequacy of published trials, (3) to determine if previously treated patients are suitable for phase II trials in SCLC, and (4) to develop an improved design for phase II trials. DESIGN: English-language, single-agent efficacy trials in SCLC, published from 1970 to 1990, were reviewed. Study design and reporting of results were assessed for clinical and statistical methodology. Response rates observed in previously treated patients were compared with those observed in previously untreated patients. RESULTS: One hundred forty-one articles evaluating 57 agents in 3,042 patients were reviewed. Eleven drugs were active (defined as a response rate greater than or equal to 20% in a trial with greater than or equal to 14 assessable patients), and 12 were inactive. Due to methodologic problems with the clinical trials, the usefulness of the remaining 34 drugs (60%) remains uncertain. Deficiencies identified in trials include inappropriate sample sizes, poorly defined response criteria, and failure to report important prognostic factors. When studied in adequate trials, all agents known to be active in SCLC had an observed response rate greater than or equal to 10% in previously treated patients. CONCLUSIONS: Over the past 2 decades, phase II trials in SCLC have failed in their primary task of effectively identifying agents that warrant further clinical study and rejecting inactive agents. If only previously treated patients had been entered into these trials, no useful agent would have been missed provided that a lower observed response rate had been used as evidence of antitumor activity. We propose a two-stage sequential study design, entering previously treated patients, for future phase II trials in SCLC.

The prostaglandin paradox: additive inhibition of neutrophil function by aspirin-like drugs and the prostaglandin E1 analog misoprostol.

Nonsteroidal antiinflammatory drugs (NSAID) are thought to act in part by inhibiting prostaglandin H (PGH) synthase which diminishes release of inflammatory prostaglandins (PG). Paradoxically, PG of the E series also have antiinflammatory properties. We therefore studied the combined effects of NSAID and PGE1 on neutrophil activation. Incubation of neutrophils with a PGE1 analog, misoprostol (miso; 1 microM; 5 min, 37 degrees), reduced superoxide anion generation in response to the chemoattractant fmet-leu-phe (FMLP) to 70.7 +/- 7% of control (p less than 0.01). Piroxicam (10 microM) independently reduced FMLP dependent superoxide anion generation to 63.7 +/- 7.4% (p less than 0.01) of control. Addition of miso to piroxicam reduced superoxide anion production to 37.4 +/- 1.9%, an inhibition that exceeded that observed with either drug alone. Similarly, the addition of miso enhanced the inhibitory effects of indomethacin and sodium salicylate on superoxide anion generation, and of all 3 NSAID on other neutrophil functions (degranulation, aggregation and global rises in cytosolic calcium). Miso (1 microM) and NSAID, alone or in combination, did not inhibit superoxide anion generation in response to the calcium ionophore A23187 or phorbol myristate acetate, agents that bypass G protein depending signaling pathways, and that do not induce a rise in cytosolic cyclic AMP (cAMP). Therefore, our data clearly show that miso at micromolar concentrations, augments the inhibitory effects of NSAID on neutrophil activation via a mechanism dependent upon signal transduction across the plasma membrane.