Омела белая Viscum album Mistletoe
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- 2.2. Patient Recruitment and Screening Statistics
- 2.3. Study Eligibility Criteria
- 2.4. Study Design and Outcomes
- 2.5. Participants and Data Collection Procedures
- 2.6. Analytic Plan
2. Materials and Methods2.1. Mistletoe Extract Quality and Content VerificationA whole plant mistletoe extract (HELIXOR Apis (A), growing on fir trees), Lot 021224 and Lot 0406, was used and supplied by Helixor, GmbH, Rosenfeld, Germany. Study agent content analyses was performed by the manufacturer. Product content verification analyses were conducted by Lawrence Livermore National Laboratories, Livermore, CA, USA. Verification analyses were consistent with the manufacturer's analyses and showed no evidence for product contamination with pesticides, heavy metals, or the prescription drugs listed. The Helixor mistletoe extract was assayed for approximately 60 elemental species by inductively-coupled-plasma/mass spectrometry (ICP-MS). In addition, Helixor A mistletoe extract was assayed for a variety of pesticides and street drugs including stimulants, narcotics, and tranquilizers using gas chromatography-mass spectroscopy GC-MS. Liquid Chromatography-Mass Spectrometry (LC-MS and LC-MS/MS) analysis of Helixor mistletoe formulation for commonly used oncology drugs was negative. Helixor A mistletoe extract was assayed by thin-layer chromatography (TLC) via a QA/QC protocol supplied by Helixor. TLC assay results of the submitted Helixor solution were very similar to those expected from the Helixor QA/QC protocol. Both lots were tested in parallel up to this final assay performed on 14 February 2006. Lot 021224 contained 3.4 (±0.2) For the study, two lots of mistletoe were manufactured, as the period of study enrollment spanned more than 2 years. The initial mistletoe lot was tested for ML-I and ML-III stability at the beginning of the study, and at 6, 15, and 18 months. ML-I and ML-III concentrations remained stable for 2 years. 2.2. Patient Recruitment and Screening StatisticsThe protocol, informed consent, and patient recruitment materials were reviewed and approved by the National Cancer Institute's Institutional Review Board (IRB) on July 15, 2002 and by the National Naval Medical Center's IRB on December 12, 2002 (study number 02-AT-0260). A total of 704 persons expressed interest in this study and were contacted over this five year study. Forty-four persons (6%) were enrolled on-study after meeting all study eligibility criteria and signing written informed consent. 2.3. Study Eligibility CriteriaPatients with histologically confirmed treated or untreated, advanced pancreatic or non-small cell lung cancer (NSCLC), or recurrent metastatic colorectal or breast cancer were eligible for study participation. Additionally, study participants needed to be able and willing to administer daily subcutaneous injections of mistletoe by themselves or with assistance. 2.4. Study Design and OutcomesThe objective of this two stage, dose escalation phase I clinical trial was to observe the safety of the combination of gemcitabine and subcutaneously injected mistletoe extract in a population with advanced solid cancers and limited treatment options. The study design, and rationale for this two agent, dose escalation paradigm, is published elsewhere [43]. In brief, in stage I, a fixed dose of gemcitabine (750  mg/m2) was administered intravenously on day 1 and day 8 of a 3-week cycle with an escalating mistletoe dose (1 mg, 5 mg, 10 mg, 20 mg, 50 mg, 100 mg, 200 mg, and 250 mg/day subcutaneously). As the manufacturer recommends mistletoe dosing from 50 to 200 mg, this dosing covered a range from 20% to 125% of the manufacturer recommended dose, which was considered a reasonable dosing range in a drug where there is precedence for clinical use and there are no prospective dosing data in combination with GEM. In stage II, a fixed mistletoe daily dose (as determined in stage I) was administered with gemcitabine in 20% dose increments per dose level (900, 1080, 1380, and 1560 mg/m2, resp., with the maximum dose being more than 50%, higher than the manufacturer recommended dose of 1000 mg/m2) [43]. This stage of the study examined whether participants' ability to tolerate gemcitabine would be differentially affected by concurrently administered mistletoe injections. Enrollment of 3 patients per dose level was planned. Grade 3 nonhematologic and grade 4 hematologic events were considered dose limiting toxicities (DLT). If three patients enrolled in a dose level successfully completed three cycles of the gemcitabine-mistletoe regimen with no DLT, then subsequently enrolled patients were assigned to the next higher dosage level. However, if 1 DLT occurred, an additional 1–3 patients were added to the cohort at that dose level for a maximum of 6 patients per dose level. The occurrence of 2 DLTs in one dosage level was considered to represent the maximum tolerated dose (MTD).
Primary study outcomes were the MTD and DLT of the combination regimen and the plasma gemcitabine pharmacokinetics alone and in combination with mistletoe extract. Secondary study outcomes were neutrophil count recovery, the stimulation of selected plasma cytokine levels (IL-6, IL-12, IFNγ, and TNF-α), the time to production and the circulating plasma concentrations of mistletoe lectin-1 (ML-1) and mistletoe lectin-3 (ML-3) antibodies, measured as IgG1-4 subclasses, and tumor response. 2.5. Participants and Data Collection ProceduresEnrolled participants were evaluated and treated in the hematology-oncology clinic at the National Naval Medical Center by the study investigators and NCI fellows. Prior to signing informed consent, the study investigators informed the participants about the purpose and methods of the study and explained where the study was in terms of stage and dose escalation. Once enrolled on-study, one of the study investigators instructed the study participant and family members on how to administer the daily subcutaneous mistletoe injections, with special attention to rotating the sites of injection and avoiding reinjection in the same area. Each participant (or family member) demonstrated successful subcutaneous administration of the mistletoe extract and was supplied with study supplies (i.e., sterile syringes, alcohol swabs, and sharps containers). Participants were informed that localized skin reactions, including discomfort at the injection site, redness, and itching, were commonly reported and were advised to inform the study staff if any skin reactions or other adverse events occurred. Laboratory values were monitored twice a week, and clinical on-study evaluations were performed every cycle. CT scans were performed at baseline, and every 3 cycles. Adverse events were monitored weekly by the study investigators using ToxGrade, a software program designed for this study using the Common Terminology Criteria for Adverse Events (CTCAEv3) guidelines. Study data were tracked in a database monitored by the EMMES Corporation (Rockville, MD, USA). Independent study monitoring was provided by EMMES and KAI (both in Rockville, MD, USA). 2.6. Analytic PlanThe primary aim of this phase I study was to investigate the safety and toxicity of the mistletoe/GEM treatment regimen. As such, adverse events (any clinical event while on-study, considered related to mistletoe or gemcitabine based on published effects of the respective agents [44] rated as not related, possibly related, likely related, or definitely related), number of dose limiting toxicities, and clinical response (defined as progressive/stable disease or partial response at the time patients as assessed every 3 cycles and/or when patients were taken off of the study at disease progression, using RECIST criteria) are reported with corresponding descriptive statistics for the 44 study participants. Secondary analyses included used Kaplan Meier [45] to assess time from study enrollment to death. Progression free survival and time to progression were initially considered but were difficult quantities to assess due to the lack of precise measurement of progression and assessment bias even when a rigorous definition is used (U.S. Food and Drug Administration CDER and CBER. Guidance for Industry Clinical Trial Endpoints for the Approval of Cancer Drugs and Biologics http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm071590.pdf May 2007), and as such, time to disease progression analyses are not included in this paper. An exploratory aim of the study was to examine potential trends of mistletoe and gemcitabine escalation on immune functioning. The a priori hypothesis was that ANC values would increase over the course of treatment; however, each group to be assessed had a small sample size. The Jonckheere-Terpstra trend test [46] was used to examine absolute neutrophil count (ANC) trends across time and across varying levels of gemcitabine and mistletoe treatments. This nonparametric statistical approach is similar to a Kruskal-Wallis test and has more power than the Kruskal-Wallis when there is a priori ordering of the populations from which the samples are drawn. Pharmokinetics analyses used area under the curve analyses and plasma concentrations (CP, nmol/mL) from 20 minutes to 25 minutes following the infusion, comparing between cycle 1 (gemcitabine alone) and cycle 3 (gemcitabine plus mistletoe) using a Wilcoxon signed rank test. |