Oral Topotecan Appears Promising in Treatment of Ovarian Cancer and Small-Cell Lung Cancers

NEW YORK—Although IV topo-tecan (Hycamtin) has been in use for several years and has shown activity in a number of different malignancies, oncologists now are turning their attention to delivering this camptothecin analog orally to maximize its effectiveness.

In a presentation at the Chemotherapy Foundation symposium, Howard A. Burris III, MD, of the Sarah Cannon Cancer Center, Nashville, said that oral topotecan offers more than an “interesting and useful way” of delivering a topoisomerase I inhibitor. “It also opens the door for the exploration of a variety of schedules and combinations.”

Because the cytotoxicity of topotecan appears to be specific to the S-phase of the cell cycle, prolonged exposure at that point could lead to increased activity against cancer cells.

“Numerous preclinical studies, both in vitro and in vivo, have demonstrated better efficacy with topotecan utilizing prolonged vs short-term exposure,” Dr. Burris said. “Developing an oral formulation would greatly facilitate schedules using multiple days of administration to allow optimal drug exposure.”

In one study of intravenous vs oral dosing, the oral route was shown to have a longer mean exposure time with a bioavailability of between 30% and 40%. Researchers postulate that greater absorption of the active lactone is due to the lower pH of the GI tract. This results in the increase in half-life measurements with oral formulations.

Another phase I trial of oral topotecan evaluated twice daily dosing for 21 consecutive days, but unexpected grade 2-3 diarrhea occurred during the third week of therapy. The maximum tolerated dose was 0.5 mg/m² twice daily.

Ten-Day Schedule

Studies of topotecan given as a 21-day continuous infusion have shown that optimal down-regulation of topoisomerase I on peripheral blood cells occurs after 10 days. The oral schedule then was shortened to 10 days, again given twice daily and repeated every 21 days. Dose-limiting toxicities included grade 2-3 diarrhea and noncumulative myelosuppression. A phase II trial using an oral topotecan dose of 0.7 mg/m² twice daily for 10 days every 21 days showed similar toxicities.

The current dose commonly used in trials of intravenous topotecan is 1.5 mg/m²/d for 5 days every 21 days. Toxicities include neutropenia and thrombocytopenia. There are minimal GI side effects.

Comparison of the clinical pharmaco-dynamics of oral topotecan schedules showed that the type and degree of toxicity are related to the schedule (number of days of consecutive administration) rather than the AUC per course, Dr. Burris said. “Clearly, the prolonged schedules result in greater intestinal effects, whereas shorter schedules are limited by granulocytopenia,” he said.

Intermittent Dosing

Trials are underway to explore intermittent oral dosing, for example, 5 days a week, repeated weekly for 3 to 4 weeks, followed by 1 week of rest. “The purpose here is twofold,” he said. “This will diminish the occurrence of diarrhea and possibly alter one mechanism of resistance, upregulation of topoisomerase II.”

He reported that phase II trials utilizing this 5-day schedule of 2.3 mg/m²/d are underway in a number of tumor types, including ovarian cancer and small-cell lung cancer (SCLC).

“Preliminary results from the trials in patients with refractory ovarian cancer are promising,” he said, “with a response rate of approximately 20% and an excellent toxicity profile of 19% grade 4 neutropenia; 4% grade 3 anemia; 13% grade 3-4 thrombocytopenia; no grade 3 diarrhea; and 10% grade 2 alopecia.”

Randomized trials comparing 5-day dosing schedules of IV topotecan (1.5 mg/m²) vs oral topotecan (2.3 mg/m²) are underway in refractory ovarian cancer and previously treated SCLC. Initial data are encouraging, he said.