1. www.oncologiapolmonare.it silvia.novello@unito.it
Studies in NSCLC Based on Gender and Smoking Differences: Rationale and Outcomes Silvia Novello University of Turin Thoracic Oncology Unit

2. Annual Age-Adjusted Cancer Death Rates Among Males/Females
for Selected Cancer Types, US,
100 20 40 60 80
100
Males
Females
Lung & Bronchus
Colon & Rectum
Stomach
Stomach
Colon & Rectum
Ovary 80
Prostate
Uterus
Liver
Breast
Leukemia
Lung & Bronchus
Lung & Bronchus
Pancreas
Pancreas 60
Rate per 100,000 Males
Rate per 100,000 Females
Lung & Bronchus 40 20
1930
1950
1970
1990
2004
1930
1950
1970
1990
2004
Year of Death
Year of Death
CA Cancer J Clin 2004; 54:9-15

3. Model of Smoking Epidemic
Smoke kills about 50% of smokers: there are 3-4 decades between prevalence peak and mortality peak for lung cancer
Lopez et al, Tobacco Control 1994

4. Lifetime Probability of Developing Cancer 1997-2001
Site Risk
Site Risk
All sites 1 in 2
Prostate 1 in 6
Lung & bronchus 1 in 13
All sites 1 in 3
Breast 1 in 7
Lung & bronchus 1 in 18
ACS, 2005

5. Meta-Analysis of 28 Lung Cancer Studies*
Relative Risk Ratios for Ever Smokers
Relative Risk Ratio
Histology
* 27 case-control
Khuder, Lung Cancer, 2001

7. Women and Lung Cancer Risk (smokers vs non-smokers)
Author Study Men Women n.cigarettes
Risch case packs/yr
Am J Epidemiol ’93 control
Zhang case packs/yr
J Natl Cancer Inst ’96 control
Harris case packs/yr
Int J Epidemiol ’93 control
Bach cohort no difference
J Natl Cancer Inst ’03
Bain cohort no difference
J Natl Cancer Inst ‘04

8. Cumulative Probability of Lung Cancer Death in CPS-II Men and Women by Smoking Status
Thun et al, Oncogene, 2002

9. Women and Lung Cancer
Female smokers are more likely to develop adenocarcinoma
than squamous cell carcinoma
Thun MJ et al:JNCI 1997; Fu JB et al: Chest 2005; Patel JD et al: JCO 2005
The BAC is two to four times more common among women
than among men
Thun MJ et al:JNCI 1997; Radzikowska E et al: Ann Oncol 2002; Fu JB et al: Chest 2005
Never-smokers with lung cancer have adenocarcinoma and
are 2.5 times more likely to be females than males
Wong MP et al: Cancer 2003
In some Asian countries never-smokers account for 70%
of women with lung cancer Wong MP et al: Cancer 2003

10. Some Suggested Explanations
DNA repair capacity
Gender differences in metabolism of carcinogens
Differences in proliferation/growth stimulation (GRPR)
Hormonal interactions

11. Host Cell Reactivation Assay
DNA Repair Capacity
Host Cell Reactivation Assay
Benzo[a]pyrene
Acetyl CoA
+ Chloramphenicol
Acetyl CoA
+ Chloramphenicol
Acetyl -Chloramphenicol
Test
Lymphocytes

12. DRC and Risk of Lung Cancer
Variable Adjusted OR (95% CI)
DRC (median) > < (1.2, 1.9)
Smoking Status
Never (1.0, 3.3)
Former (1.0, 1.9)
Current (1.2, 2.3)
n = 764 cases and 677 controls
Spitz et al, CEBP, 2003

13. DNA Repair Capacity Lung Cancer Cases
Variable No Mean % p-value SD for trend
Age (years) < ± 2.8 ±
 ± 3.2
Gender Male ± < Female ± 2.8
Spitz, CEBP, 2003

14. Induced Adduct Levels Lung Cancer Cases
Variable N Mean(%)SD P value
Age (yrs)
< ±
± 83.6
Gender
Male ± NS Female ± 89.4
Smoking status Never ± NS Former ± Current ± 97.0
Li et al, Cancer Res 2001

15. Gender differences in metabolism of carcinogens CYP1A1
CYPA1 codes for an enzyme which activates PAH-forming DNA adducts.
Significant correlation between CYP1A1 expression and DNA adduct levels (r= 0.50, p= 0.016)
Female smokers had significantly higher levels of adducts/pack-year and adducts/cigarette/day than men ( vs , P= 0.015)
Females had higher CYP1A1 levels than males ( units vs units, P= 0.016)
Mollerup, et al; Cancer Res; 1999: 59:

16. Gender differences in metabolism of carcinogens Glutathione S-transferase (GST)
GST deactivates carcinogens; the null genotype fails to deactivate carcinogens, resulting in prolonged exposure
GSTM1 null genotype associated with lung cancer (odds ratio: 2.04)
Odds ratio for GSTM1 null phenotype and WT
Female
(CI)
Male
Lung cancer
2.50
( )
1.40
( )
Lung cancer in smokers
3.03
( )
1.42
( )
Tang, et al; Carcinogenesis, 19: , 1998

17. Differences in proliferation/growth stimulation
GRP
Gastrin-Releasing Peptide (GRP): plays a role in neoplasia
by stimulating cell proliferation. Its effect is mediated mainly
through the GRPR.
The gene for GRPR is X-linked, located on chromosome
Xp22, near a cluster of genes that escape X-inactivation.
Women can have two actively transcribed alleles compared
with only one in men
Increased expression of the GRPR gene was noted when
human airway cells were exposed to oestrogens.
Shriver SP 2000, JNCI

18. Differences in proliferation/growth stimulation EGFR
Characteristics
Patients with mutation/total
In unselected pts
Adenocarcinoma
14/182 (8%)
15/152 (10%)
Women with adenocarcinoma
12/83 (15%)
Women non-smokers with adenocarcinoma
18/34 (53%)
ASCO 2004

19. Hormonal Interactions
Early age at menopause (≤ 40 yrs) is associated with reduced risk of lung adenocarcinoma (OR=0.3)
HRT is associated with  risk of adenocarcinoma (OR=1.7)
Interaction between HRT, smoking and the development of lung adenocarcinoma (OR=32.4)
Taioli and Wynder:JNCI 1994
Late menopause and short menstrual cycles were associated with increased risk of lung cancer
Siegfried JM: The Lancet Oncology 2001
 risk of lung carcinoma in women with family history of reproductive cancer
Sellers: Genetic Epidem 1991

20. Hormonal Interactions
β-estradiol induces
proliferation in NSCLC cells and anti-estrogens block this effect Kiuper, Endocrinology 1997
Oestrogens may be involved in lung tumorigenesis at different levels:
As ER ligands activating cell proliferation
Via ERs in the plasma membrane causing interactions between ERs and
growth factors such as EGF and IGF (in EGFR and ER+ cells)
Oestrogens may alter metabolic activation of carcinogens (modulations
of CY1A1, CY1B1) Stabile: Cancer Res 2005

21. Cross-Talk Cascade of ER Activation
Growth factors
Estrogen
IGFR
Tamoxifen
EGFR / HER2
Plasma
Membrane
MoAb P P P P P
SOS P
TKI
RAS
PI3-K
FTI
RAF
Cell
Survival
Akt
SERD P
MEK AI
CCI P ER
p90RSK
MAPK
To complicate matters further we also want to look at the status of co-activators and repressors as part of the analysis of signalling pathways. P P
Cytoplasm
Cell
Growth
p160 ER
CBP
Basal
Transcription
Machinery
ERE P
ER Target Gene Transcription P
Nucleus
Johnston, S. 2004

22. Relative Ki67 Expression Stabile, et al. Cancer Res, 2005
Decreased Cell Proliferation in Lung Tumors Treated with Gefitinib and Fulvestrant
120
100 80 *
Relative Ki67 Expression 60 ** 40 ** 20
control
fulvestrant
gefitinib
fulvestrant +
gefitinib
Treatments
P-value compared to control: *<0.05, **<0.005
Stabile, et al. Cancer Res, 2005

23. Eligibility: 2 or more prior chemo regimens
UW/UPitt Pilot Study of Gefitinib + Faslodex in Post-menopausal Women with Advanced Recurrent NSCLC
Eligibility: 2 or more prior chemo regimens
Treatment: 250 mg gefitinib mg Faslodex IM monthly
Objectives: response rate, TTP, survival
Laboratory Objectives:
- ER and EGFr
- CYP3A polymorphisms
Traynor AM, Schiller J, JCO 2005

24. Hormone Replacement Therapy and Lung Cancer Risk
Some positive
Type of Study N
Risk of lung Ca with HRT
95% CI
Taioli,
JNCI, 1994
Case control
180
1.7
All studies derived from secondary data or exploratory analysis

25. Hormone Replacement Therapy and Lung Cancer Risk
Some show no increase in risk
Type of Study N
Risk of lung Ca with HRT
95% CI
Adams,Int J Cancer, 1989
Cohort study
23,244
1.3
Wu, Cancer Res, 1998
Case control
336
Women's Health Initiative, JAMA, 2002
Cohort
16,690
1.04
Blackman, Pharmacoepidemiol Drug Saf, 2002
Case Control
662
1.0
All studies derived from secondary data or exploratory analysis

26. Hormone Replacement Therapy and Lung Cancer Risk
Some show REDUCED risk of lung cancer with HRT
Type of study N
Risk of lung Ca with HRT
95% CI
Ettinger, Ob Gynecol, 1996
454
0.78
Krenzer, 1993
Case control
1723
0.83
Olson, Ob Gyne, 1993
Cohort
29,508
0.24
Schabath, Clin Ca Res, 2004
Case Control
1008
0.66
All studies derived from secondary data or exploratory analysis

27. Sex as a predictive factor
Study N Unfavorable in
Multivariate Analysis
Radzikowska ( ) , Male, poor PS, advanced
Polish population, all stage, non surgical treatment,
>50 yrs, SCLC
Ouellete ( ) Male, advanced stage
French population, cohort
Moore ( ) , Male, age >65, advanced
Single institution, all stage, large cell, no surgery
Visbal ( ) , Male, older age, high grade,
Single institution, advanced stage, treatment,
consecutive cohort adenocarcinoma*
Relative risk (RR) of death for MEN = 1.15 (p=0.001)
NO differences in overall mean survival
BUT women lived longer at each stage
Overall median survival 12.4 mo vs 10.3mo (p<.001) and survival advantage for all stages
RR for MEN= 1.2
*smoking status/dose, comorbidy interaction with cause of death, not significant

28. NSCLC: completely resected diseases
Author
# Women
Survival
MinamiR (#1242 consec )
[adavntage also for st I &III,
adenoca & > 60yrs]
FergusonR (#451)
AlexiouP (#833) UK
337
186
252
5yr 69% p<.005
st I OS
109vs50 mo p .008
5yr 48%vs36.5% p<0.01
OS p

29. NSCLC: completely resected diseases
EVEN CONSIDERING OTHER DEATH CAUSES
2.1
Bouchardy, et al. Cancer, 1999

30. ALPI Multivariate Analysis
Variable HR
95% CI
P Value
Age (5-yr interval)
1.06
.051
Stage II
III
2.00
3.15
.0001
Histology-Squamous
0.86
.094
Gender – Male(86%)
1.32
.034
Complete Dissection
0.89
.164
Chemotherapy
0.96
.566
Similar Data from UFT, Kato et al.
Scagliotti GVS, JNCI 2003

31. NSCLC: locally advanced disease
Werner WasikR (RTOG)
#1,999
- 9 studies
OS 11.4 vs 9.9 mo
AlbainP (SWOG)
#126
st IIIA, IIIB
OS 21 vs 12 mo (p0.08)
AlbainP (RTOG 93-09)
#429 (35%)
st IIIA
> OS in women
(p=0.051)

32. NSCLC: advanced disease*
Favourable factors in
Group N Stage multivariate analysis
MemorialR IIIB/IV Women, normal LDH ,
(O’Connell et al) good PS, no bone mts,
≤ 2 sites mts
ECOGR IV Women, PS 0, no bone mts,
(Finkelstein et al) no liver mts, trials no weight loss,
non-large cell istol.
SWOGR , IV Women, PS 0-1,
(Albain et al) “cisplatin-based” therapy,
13 trials age ≤ 70 yrs
male
female
P Value
MULTIVARIATE
1 yr survival rate
16%
26%
0.005
male
female
P Value
MULTIVARIATE
median survival
8.8 mo
12.4 mo
0.001
Women is a strong indipendent factor for improved survival
*first and second generation chemotherapy

33. ECOG 1594 Study # Pts St. IV,% ORR,% MST (mos.) G4 ANC,% Plts,%
Neuro,%
ECOG 1594
DDP-TAX
DDP-GEM
DDP-TXT
Cb-TAX
292
288
293
290 91
21.3 21
17.3
15.3
8.1
7.4
8.3 57 39 49 43 2 29 1 5 9 10
HA Wakelee JTO 2006

34. Patient outcomes for ECOG 1594
Women (433)
Men (726)
P value
Response rate (%)
Median PFS (mo)
Median survival time (mo) 19
3.8
9.2 mo
3.5
7.3
0.99
0.022
0.004
- Separately for each arm, trend for improved survival mantained; statistical significance was LOST
HA Wakelee JTO 2006

35. Toxicity all grade in ECOG 1594
Women (431)
Men (726)
P value
Nausea (%)
Vomiting (%)
Alopecia (%)
Neurosensory (%)
Neuropsychiatric (%)
Cardiac Toxicity ≥ g3 (%) 83 65 64 49 22
4.1 70 52 53 42 14
7.6
<0.0001
0.0003
0.02
0.001
HA Wakelee JTO 2006

36. Bevacizumab in Advanced NSCLC: Efficacy by Gender
Parameter
Males
Females PC
(n=230)
PCB
(n=191)
(n=162)
(n=190)
OS, mo
8.7
11.7*
13.1
13.3
PFS, mo
4.3
6.3*
5.3
6.2*
RR, % 16
29* 14
41*
*Statistically significant
No survival benefit for females despite 4-fold increase in RR and statistically significant difference for PFS
A number of potential explanations (eg, statistical chance, imbalance of unmeasured prognostic factors, or a true difference)
Brahmer et al. J Clin Oncol. 2006;24(No 18S):373s. Abstract 7036.

37. Survival by Treatment - Males
J Brahmer ASCO 2006

38. Survival by Treatment - Females
J Brahmer ASCO 2006

39. Vandetanib (ZD6474) With Carboplatin and Paclitaxel as First-Line NSCLC Therapy: Schema
Run-In Phase
Randomized Phase
Vandetanib 200 mg
Paclitaxel 200 mg/m2
Carboplatin AUC 6 mg/mL·min
(n=15)
Vandetanib 300 mg
(n=73) [discontinued]
Vandetanib 300 mg
Paclitaxel 200 mg/m2
Carboplatin AUC 6 mg/mL·min
(n=56)
First-Line NSCLC
First-Line NSCLC
Vandetanib 300 mg
Paclitaxel 200 mg/m2
Carboplatin AUC 6 mg/mL·min
(n=10)
ZD6474 With Carboplatin and Paclitaxel as First-Line NSCLC Therapy:
Trial Design
The clinical value of ZD6474 alone and in combination with carboplatin and paclitaxel (CP) as first-line therapy is being assessed in an ongoing, randomized, double-blind study of patients with previously untreated, locally advanced (stage IIIB) or metastatic (stage IV) NSCLC
A safety run-in phase was conducted to establish the appropriate dose of ZD6474 to be administered in combination with CP, consisting of 21-day treatment periods in which subjects received daily oral doses of ZD6474 (200 mg or 300 mg) in combination with CP (carboplatin, target AUCss = 6 mg/mL·min; paclitaxel, 200 mg/m2 IV). After 6 subjects in the ZD mg dose group completed at least 6 weeks of treatment with no safety concerns, additional patients were enrolled at the ZD mg dose level
Placebo
Paclitaxel 200 mg/m2
Carboplatin AUC 6 mg/mL·min
(n=52)
Objectives:
Appropriate Dose in Combination Therapy,
Pharmacokinetics, Survival
Heymach et al., IASLC 2005, Abstract P-497
Heymach et al., ASCO 2007, Abstract 7544
Heymach J, West H, Kerr R, et al. ZD6474 in combination with carboplatin and paclitaxel as first-line treatment in patients with NSCLC: results of the run-in phase of a two-part randomized phase II study. Lung Cancer. 2005;49(suppl 2):S247-S248. Absract P-497.

40. Vandetanib With Carboplatin and Paclitaxel (CP) as First-Line NSCLC Therapy: Efficacy
Vandetanib/CP
n = 56
Placebo/CP
n = 52 HR
P Value
ORR
32%
25% -
Median OS
10.2 months
11.9 months
1.07
.595
Median PFS
24.0 weeks
23.1 weeks
0.76
.098*
Exploratory Analysis (females)
n = 17
n = 15
28.6 weeks
11.7 weeks
0.47
.037
≥ 8.6 months
5.8 months
0.52
.113
No significant differences in PFS or OS based on histology were observed.
*Met prespecified significance level of P < .2
Heymach et al., ASCO 2007, Abstract 7544

41. ZD6474 plus docetaxel vs docetaxel in previously treated NSCLC
A randomized, double-blind, two-part, multicenter study
Run-in phase
Randomized phase*
ZD mg
Docetaxel 75 mg/m2
n=42
ZD mg
Docetaxel 75 mg/m2
n=4
ZD mg
Docetaxel 75 mg/m2
n=44
2nd-line NSCLC
2nd-line NSCLC
ZD mg
Docetaxel 75 mg/m2
n=11
Placebo
Docetaxel 75 mg/m2
n=41
JV Heymach, ASCO 2006

42. Males vs females: exploratory analysis
Hazard ratios and 95% confidence intervals
ZD mg + doc (n=42) vs placebo + doc (n=41)
ZD mg + doc (n=44) vs placebo + doc (n=41)
Time to progression
Time to death
Males
Females
All patients
ZD mg + doc (n=42) vs placebo + doc (n=41)
ZD mg + doc (n=44) vs placebo + doc (n=41)
JV Heymach, ASCO 2006

43. EGFR Tyrosine Kinase Inhibitors Second and Third Line Therapy
Work better in women than men
Gefitinib and erlotinib studies: females  RR, more symptom improvement, longer OS (univariate), but no difference in benefit phase III study erlotinib
Biologic basis for difference by sex complex: interactions with frequency of activating mutations, EGFR+ (by IHC/amplification), adenocarcinoma or BAC histology, non-smoking status

44. EGFR Tyrosine Kinase Inhibitors
Female sex is predictive of response:
- Symptoms improvement: 50% vs 31% (p 0.006)
- Radiographic regression: 19% vs 3% (p=0.001) with 82% of responses among women
Kris MG, JAMA 2003

45. BR.21 Trial: Overall Survival by Gender
_____ Erlotinib Female
_____ Placebo Female
_____ Erlotinib Male
_____ Placebo Male
Interaction p = n.s.
Months
Shepherd, NEJM, 2005

46. Is there an interaction between the ER and EGFr pathways?
EGFR protein expression is down-regulated in response to estrogen
EGFR protein expression is up-regulated when estrogen is depleted
Suggests “cross-talk” between these two pathways

47. Paclitaxel Poliglumex (PPX)
Macromolecule that combines paclitaxel with poly-L- glutamic acid
Into the cell broken in its active form by cathepsin B (regulated by estrogen) minimize systemic exposure & prolong exposure to active drug

48. Paclitaxel 225 mg/mq + CBDCA AUC 6 Q3w ELIGIBILITY CRITERIA chemonaive
STELLAR 3
PPX 210 mg/mq + CBDCA AUC Q3w
versus
Paclitaxel 225 mg/mq + CBDCA AUC Q3w
ELIGIBILITY CRITERIA
chemonaive
advanced NSCLC
PS2
STRATIFIED BY
disease stage
sex
brain mts
geography
The composite analysis of STELLAR 3 and 4 shows a statistically significant survival benefit for women receiving PPX (p=0.03)
The presence of estrogen appear to make PPX a more effective drug
PIONEER (Paclitaxel Poliglumex Investigating Outcomes in NSCLC: Establishig Estrogen Response) study is ongoing
STELLAR 4
PPX 175 mg/mq Q3w
versus
GMC 1200 mg/mq d1,8,15 Q4w OR NVB 30 mg/mq d 1,8,15 Q3w
Ross H, ASCO 2006

49. SCLC: limited disease Albain (10 SWOG trials from 1976 to1988) male
Favourable factors in
Group N Multivariate analysis
Danish Cox: women, good PS,
(Osterlind et al) normal sodium e uric acid
CALGB R Cox: women, good PS,
(Spiegelman et al) age <60 yrs
SWOG R , Cox: women, PS 0-1, caucasian,
(Albain et al) conc. CT/RT, LDH
1, RPA: women, LDH nn,
no pleural effusion,age<70 yrs
Albain (10 SWOG trials from 1976 to1988)
male
female
MST LD ED
17.7mo no
24.4mo
differences

50. Small Cell Lung Cancer Survival by Sex: retrospective review (4 trials)
Singh, S. et al. J Clin Oncol; 23:

51. SCLC: Toxicity and outcomes by sex
1006 Patients (648 m, 358 f)
on 4 trials of similar chemotherapy
No difference in treatment delivered or toxic deaths, but greater treatment delays in females, with more toxicity (anemia, neutropenia, stomatitis, emesis)
Greater toxicity females significant in multivariate model
Females RR higher and overall survival (p<.0001)
Singh, S. et al. J Clin Oncol; 23:

52. Conclusion
A better understating of the genetic, metabolic, and hormonal factors in women represents a research priority
Evidence suggests that the development of lung cancer is different in women compared with men
Women with lung cancer live longer than men with lung cancer, regardless of therapy and stage
Sex as stratification factor in prospective clinical trials