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  • BMS-232632 Pitch_B2.ppt
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    1. 1. Pancreatic Cancer: Highlights from the 42nd Annual Meeting of the American Society of Clinical Oncology, 2006 Muhammad Wasif Saif, M.D. Associate Professor Yale University School of Medicine New Haven, CT, USA
    2. 2. Abstract Despite advances in our understanding of the molecular and genetic basis of pancreatic cancer, the disease remains a clinical challenge. Gemcitabine, the standard chemotherapy for pancreatic cancer, offers modest improvement of tumor-related symptoms and marginal advantage of survival. New approaches, alone and in combination with gemcitabine, are being developed to combat this cancer. Combination chemotherapy trials incorporating gemcitabine, cisplatin, 5-fluorouracil, oxaliplatin, or irinotecan generally show improved outcomes in objective response rates but with little or no improvement in survival in phase III trials. In this article, the author describes the key studies presented at the Annual Meeting of ASCO, held in Atlanta, GA from June 2nd to 6th. The studies discussed here include the following: RTOG 9704 (#4007), FFCD-SFRO study (#4008), meta-analysis of gemcitabine plus cisplatin and gemcitabine plus oxaliplatin vs. gemcitabine alone (GERCOR #4003), and ECOG 6201 (Late Breaking Abstract #4004). Based on the results presented at the annual meeting, it comes to us that patients with locally advanced vs. metastatic pancreatic cancer should be studied separately, better understanding of the biology of pancreatic cancer is mandatory and evaluation of novel agents is crucial. We as oncologist have to change our attitudes towards clinical trials and need to think beyond a trial design such as gemcitabine vs. drug of our choice. Environment within which research is being conducted also has to be changed and last but not the least, access to trials for patients with pancreatic cancer is the key step in the fight against pancreatic cancer.
    3. 3. What did we know already? What we learn? What we miss? What we do next? Lessons from ASCO 2006
    4. 4. Lessons from ASCO 2006 What did we know already? What we learn? What we miss? What we do next?
    5. 5. Median Survival of Patients with Pancreatic Cancer (Staley’s Classification, 1996) [1] Localized/Resectable 15-19 months 10% Locally Advanced 6-10 months 30% Metastatic/Advanced 3-6 months 60% [1] Staley CA, et al. Pancreas 1996; 12:373-80.
    6. 6. Adjuvant Chemo and Chemo-XRT No clear consensus on adjuvant therapy for pancreas cancer GITSG [2]: 43 pts randomized into two groups: XRT/bolus 5-FU  weekly 5-FU x 2 years vs. Observation Median survival 20 and 11 months, respectively  favoring Chemo-XRT arm ESPAC – 1 [3]: No benefit for Chemo-XRT (P=0.24) Significant overall benefit for Chemotherapy(P<0.001) CONKO-001 [4]: Randomize to: Gemcitabine vs. Observation Disease free survival: 14.2 m vs. 7.5 m (P<0.001) GITSG: Cancer 1987 ESPAC-1: Lancet 2003 [2] Cancer 1987; 59:2006-10. [3] Neoptolemos JP, et al. Lancet 2001; 358:1576-85. [4] Neuhaus P, et al. J Clin Oncol 2005, 23(16S):4013.
    7. 7. Locally Advanced Disease Chemo-XRT may improve survival compared to XRT alone Chemotherapy is equivalent to the combination of Chemo-XRT in randomized trials No randomized trials comparing gemcitabine to Chemo-XRT was available till FFCD-SFRO study presented at ASCO 2006 GITSG [5] # Pts Median survival Local failure rate 1-year 1.5-year XRT (60 Gy/10 weeks) only 25 5.3 monts 24% 10% 5% XRT (40 Gy/6 weeks) + 5-FU 83 8.4 monts 26% 35% 20% XRT (60 Gy/10 weeks) + 5-FU 86 11.4 monts 27% 46% 20% Survival [5] Moertel CG, et al. Cancer 1981; 48:1705-10.
    8. 8. Gemcitabine Pivotal Studies: Results [6] Rothenberg ML, et al. Ann Oncol 1996; 7:347-53. [7] Burris HA 3rd, et al. J Clin Oncol 1997; 15:2403-13. Rothenberg [6] Burris [7] Burris [7] Gemcitabine 5-FU Partial response 6 (9.5%) 3 (5.4%) 0 Stable disease 17 (27%) 22 (39.3%) 11 (19.3%) Progressive disease 20 (31.7%) 19 (33.9%) 34 (59.6%) Survival: median 3.9 months 5.7 months 4.4 months 6-month 31% 46% 31% 9-month 15% 24% 6% 12-month 4% 18% 2% Time to progression 2.5 months 2.1 months 0.9 months Clinical benefit Response 17 (27%) 15 (23.8%) 3 (4.8%) (P=0.0025) (P=0.0002) (P=0.0022)
    9. 9. Developmental Strategies of Gemcitabine-Based Therapies in Pancreas Cancer: 4 Approaches In doublets/ Triplets of cytotoxics With radiation By fixed dose rate infusion With targeted therapies Gemcitabine II I III IV
    10. 10. Fixed Dose-Rate Gemcitabine Gemcitabine is a pro-drug that must be phosphorylated to its active metabolites, gemcitabine diphosphate and triphosphate Conversion of gemcitabine to the active triphosphate form is saturable with standard rates of infusion Gemcitabine infused at a fixed dose rate of 10 mg/m2/min optimizes triphosphate accumulation
    11. 11. Gemcitabine Metabolism Gemcitabine (dFdC) Cell membrane dFdC-DNA dFdC Deoxycytidine deaminase Deoxycytidine kinase dF-dCMP dF-dCTP dFdU dF-dCDP
    12. 12. What Did We Know Before? Advanced Pancreatic Cancer Gemcitabine used Median 1-year Author 30-min infusion 5.7 months 18% Burris [7] Fixed dose rate (FDR) 7.8 months 24% Tempero [8] GemOx 9.2 months 36% Louvet [9] [7] Burris HA 3rd, et al. J Clin Oncol 1997; 15:2403-13. [8] Tempero M, et al. J Clin Oncol 2003; 21:3402-8. [9] Louvet C, et al. J Clin Oncol 2005; 23:3509-16. Survival
    13. 13. Lessons from ASCO 2006 What did we know already? What we learn? What we miss? What we do next?
    14. 14. Pancreatic Cancer Update Adjuvant I. RTOG 9704 (Abstract #4007) [10] Locally advanced I. FFCD-SFRO study (Abstract #4008) [11] Metastatic I. GERCOR: Gem/cisplatin vs. GemOx vs. Gem alone (Abstract #4003) [12] II.ECOG 6201: 30-min vs. FDR vs. GemOx (Late Breaking Abstract #4004) [13] [10] Regine WF, et al. J Clin Oncol 2006; 24(18S, Part I):4007. [11] Chauffert B, et al. J Clin Oncol 2006; 24(18S, Part I):4008. [12] Louvet C, et al. J Clin Oncol 2006; 24(18S, Part I):4003. [13] Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004.
    15. 15. Pancreatic adenocarcinoma, status-post resection: T1-4, N0/N1 July 1998 – July 2002 538 patients in the trial (pancreatic head carcinoma: 381) 442 patients eligible and analyzable (22 no CA19-9, >8 weeks post op.) More T3/4 disease in the Gem arm (P=0.013) Regine WF, et al. J Clin Oncol 2006; 24(18S, Part I):4007. [10] RTOG 9704: Adjuvant Trial in Pancreatic Ca
    16. 16. Random 5-FU 250 mg/m2/day for 3 weeks Gemcitabine 1,000 mg/m2 weekly for 3 weeks XRT 50.4 Gy + 5-FU (250 mg/m2/day) 5-FU 250 mg/m2/day for 12 weeks Gemcitabine 1,000 mg/m2 weekly for 12 weeks RTOG 9704: Treatment A B Regine WF, et al. J Clin Oncol 2006; 24(18S, Part I):4007. [10]
    17. 17. RTOG 9704: Toxicity Arm A Arm B > Grade 3 Hem 2% 14%* > Grade 3 non-Hem 58% 58% Ability to complete Chemo 88% 90% Ability to complete XRT 86% 88% * No difference in febrile neutropenia Regine WF, et al. J Clin Oncol 2006; 24(18S, Part I):4007. [10]
    18. 18. Regimen Arm A (n=187) Arm B (n=194) Median survival (months) 20.6 36.9 P=0.047 HR=0.79 (95% CI=0.63-0.99) 3-yearr survival 21% 32% When analysis was inclusive of patients with body/tail tumors (n=442) no significant difference in survival was found (P=0.20). RTOG 9704: Survival Pancreatic head Ca (n=381) Regine WF, et al. J Clin Oncol 2006; 24(18S, Part I):4007. [10]
    19. 19. RTOG 9704: Conclusions Addition of gemcitabine to 5-FU/XRT improves survival in head pancreatic cancer Addition of gemcitabine increases hematologic toxicity, but manageable ? New standard to be considered ESPAC-3 [14]: Randomize to Gemcitabine vs. 5-FU vs. Observation Ongoing [14] National Cancer Research Network Trials Portfolio, 2004. (ISRCTN 37494643)
    20. 20. ESPAC–3: Trial Design Patients with adenocarcinoma of the pancreas having ‘curative’ resection Randomization stratified by resection margins Gemcitabine5-FU/FA Observation FA (20 mg/m2 iv bolus), 5-FU (425 mg/m2 iv bolus) 5 days every 28 days, x6 cycles 1,000 mg/m2 iv infusion once weekly x3 wks, 1 wk rest, x6 cycles National Cancer Research Network Trials Portfolio, 2004. (ISRCTN 37494643) [14]
    21. 21. FFCD-SFRO study Rationale:  The GITSG studies have shown a greater survival after 5 FU-based Chemo-XRT than XRT radiotherapy [5] or polychemotherapy alone [15] in patients with locally advanced non metastatic pancreatic cancer  Gemcitabine is more active than 5-FU in advanced pancreatic cancer [7]  This randomized trial evaluated whether initial Chemo-XRT adds to modern gemcitabine in term of overall survival. Chauffert B, et al. J Clin Oncol 2006; 24(18S, Part I):4008. [11] Phase III trial comparing Chemo-XRT (cisplatin and 5-FU) followed by gemcitabine vs. gemcitabine alone in patients with locally advanced pancreatic cancer [5] Moertel CG, et al. Cancer 1981; 48:1705-10. [7] Burris HA 3rd, et al. J Clin Oncol 1997; 15:2403-13. [15] J Natl Cancer Inst 1988; 80:751-5.
    22. 22. FFCD-SFRO: Study Design Stratification: • PS (WHO) • Center • Exp surgery or not Patients with locally advanced nonmetatstaic pancreatic cancer Randomization 5-FU + cisplatin + XRT Gemcitabine Gemcitabine Induction Maintenance Randomized Phase III Study Chauffert B, et al. J Clin Oncol 2006; 24(18S, Part I):4008. [11]
    23. 23. FFCD-SFRO Study: G 3-4 Toxicities 5-FU + cisplatin + XRT Gemcitabine Neutropenia 60% 23% Febrile neutropenia 0 2% Anemia 3.4% 1.7% Thrombocytopenia 8.5% 0 Nausea/Vomiting 20% 10% Diarrhea 7% 0 Cutaneous 0 3% Chauffert B, et al. J Clin Oncol 2006; 24(18S, Part I):4008. [11]
    24. 24. FFCD-SFRO Study: Survival Survival 5-FU + cisplatin + XRT Gemcitabine Median (months) 8.4 14.3 P=0.014 6 months 78% 82% 12 months 24% 51.4% Chauffert B, et al. J Clin Oncol 2006; 24(18S, Part I):4008. [11]
    25. 25. FFCD-SFRO Study: Conclusions Gemcitabine alone allowed a significant overall survival in locally advanced nonmetatstatic pancreatic cancer Increased toxicity and decreased maintenance gemcitabine in patients with initial Chemo-XRT may explain this difference Study was stopped before the planned inclusion due to lower survival with initial Chemo-XRT when compared to Gem alone
    26. 26. Pooled Analysis of 2 Randomized Trials GERCOR/GISCAD Intergroup Study and a German Multicenter Study Gem + platinum compound Gem alone Patients (n=503) n=252 n=251 ECOG PS = 0 40% 35% Distant metastases 72% 73% Pathological grading = 3 34% 38% Louvet C, et al. J Clin Oncol 2006; 24(18S, Part I):4003. [12]
    27. 27. Meta-Analysis: Results GERCOR/GISCAD Intergroup Study and a German Multicenter Study Gem + platinum compound Gem alone P value; HR Progression-free survival 5.5 months 3.5 months P=0.003 HR: 0.66 Overall survival 8.3 months 6.7 months P=0.031 HR: 0.77 Louvet C, et al. J Clin Oncol 2006; 24(18S, Part I):4003. [12]
    28. 28. Meta-Analysis: Results in Stratified Patients GERCOR/GISCAD Intergroup Study and a German Multicenter Study Louvet C, et al. J Clin Oncol 2006; 24(18S, Part I):4003. [12] Progression-free survival Overall survival Months HR (95% CI) Months HR (95% CI) Stage of disease Locally advanced vs. 5.8 0.66 (0.54-0.81) 10.1 0.68 (0.55-0.82) Metastatic 3.5 P<0.001 6.9 P<0.001 Performance status ECOG 0 vs. 5.8 0.49 (0.15-0.77) 10.6 0.59 (0.49-0.72) ECOG 1-2 3.5 P<0.001 6.4 P<0.001
    29. 29. Meta-Analysis: Conclusions GERCOR/GISCAD Intergroup Study and a German Multicenter Study  PS 0 pts may achieve a greater benefit in progression-free survival (5.8 vs. 3.5 months; HR 0.49, P<0.001) and overall survival (10.6 vs. 6.4 months; HR 0.59, P<0.001) from treatment with a gemcitabine/platinum doublet  This is similar to data reported by Hermann [16] with gemcitabine + capecitabine  Stage of disease and PS remain important prognostic factors  Careful PS evaluation and stratification is important  Specific studies according to stage: locally advanced vs. advanced should be done [16] Herrmann R, et al. J Clin Oncol 2005; 23(16S Part I):LBA4010. Louvet C, et al. J Clin Oncol 2006; 24(18S, Part I):4003. [12]
    30. 30. Meta-Analysis: Comparison to Other Gemcitabine-Based Combinations Evidence from Randomized Trials Regimen No. of cases Survival (months) HR P value Gem + platinum-analog vs. Gem alone (meta-analysis) 503 8.3 6.7 0.77 0.031 Gem + capecitabine vs. Gem alone [16] 533 7.4 6.0 0.80 0.026 Gem + erlotinib vs. Gem alone [17] 530 6.4 5.9 0.81 0.034 [16] Herrmann R, et al. J Clin Oncol 2005; 23(16S Part I):LBA4010. [17] Moore MJ, et al. J Clin Oncol 2005; 23(16S):1.
    31. 31. Gemcitabine administration: 30-min vs. FDR Gemcitabine dose intensity across single agent and combined arms Platinum analogs (oxaliplatin is not cisplatin) It is not know how many pts received XRT prior Impact of these differences cannot be implicated Meta-Analysis: Differences in Groups
    32. 32. Meta-Analysis: Pitfalls Obvious Extent of disease Performance status It will take a lot of patients to show a difference Oxaliplatin is not cisplatin 30-min gemcitabine is not FDR gemcitabine  Pharmacologic basis  Toxicity  Cost (time of infusion)
    33. 33. ECOG 6201: Advanced Pancreatic Cancer Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. [13] Random Gemcitabine 1,000 mg/m2 30 min i.v. weekly x7 on 1 off , then x3 on 1 off Gemcitabine 1,500 mg/m2 150 min i.v. (10 mg/m2/min FDR) weekly x3 on 1 off Gem 1,000 mg/m2, FDR, day 1 Oxaliplatin 100 mg/m2, day 2 every 14 days A n=280 B n=277 C n=276 March 2003 – March 2005: 833 patients Median follow-up: 5.7 months Males: 53% - PS 0-1: 88% - Metastases: 88%
    34. 34. Primary: To determine whether either FDR gemcitabine or GemOx increases survival compared with standard 30-min infusion Secondary: Progression-free survival Toxicity Quality of life ECOG 6201: Objectives Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. [13]
    35. 35. Adenocarcinoma or poorly differentiated No > grade 2 peripheral neuropathy Prior adjuvant Chemo-XRT allowed No prior gemcitabine or oxaliplatin ECOG PS > 2 ECOG 6201: Inclusion Criteria Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. [13]
    36. 36. ECOG 6201: Worst Toxicity Arm A Arm B Arm C Grade 3 4 3 4 3 4 Neutrophils 19% 15% 29% 31% 10% 14% Platelets 12% 0 29% 0 10% <1% Hemoglobin 8% 2% 15% 3% 4% 1% Nausea 7% 0 8% <1% 14% <1% Vomiting 5% 0 5% 1% 10% 1% Infection 2% 1% 5% <1% 1% 0 Peripheral neuropathy 0 0 <1% 0 9% 0 Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. [13]
    37. 37. ECOG 6201: Response rate (RECIST) Response Arm A Arm B Arm C Complete/partial 5% 10% 9% Stable disease 29% 29% 29% Progressive disease 26% 24% 24% Unknown 41% 37% 38% Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. [13]
    38. 38. ECOG 6201: Survival and HR Survival Arm A Arm B Arm C Median (months) 5.0 (4.5-5.6) 6.0 (5.4-6.9) 6.5 (6.1-6.8) 1-year 17% 21% 21% HR 95% CI 30 min vs. FDR (A vs. B) 1.21 1.00-1.45 P=0.053 30 min vs. GemOx (A vs. C) 1.22 0.73-1.05 P=0.045 Survival by disease extent Locally advanced Advanced Median (months) 9.1 5.4 P=0.001 Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. [13]
    39. 39. ECOG 6201: Conclusions  Both FDR and GemOx had approximately 1 month longer median overall survival than standard Gem, but not statistically significant  Survival outcome with 30 min gemcitabine is persistent  Median overall survival: slightly less than other trials:  Study design, such as locally advanced and metastatic patients, need to be studied separately  FDR and GemOx with increased toxicity:  Hematologic, nausea and vomiting with FDR  Neuropathy with GemOx  ECOG 6201 adds to multiple studies that showed adding another cytotoxic to gemcitabine does not add any benefit to the modest survival by gemcitabine alone  Progression-free survival and quality of life not given at the meeting
    40. 40. Lessons from ASCO 2006 What did we know already? What we learn? What we miss? What we do next?
    41. 41. Promising New Regimens in the Cooperative Groups Gemcitabine + bevacizumab [18] Median survival of 8.8 months Now in randomized trial vs. gemcitabine alone Gemcitabine + cetuximab [19] Promise in this regimen was a 1-year survival rate of 32% Erlotinib data adds encouragement to this trial Now in randomized trial vs. gemcitabine alone Irinotecan + docetaxel [20] Ignored largely, but phase II trial had a 9-month median survival Being tested in a multi-institutional trial with or without cetuximab to confirm this data [18] Kindler HL, et al. J Clin Oncol 2005; 23:8033-40. [19] Xiong HQ, et al. J Clin Oncol 2004; 22:2610-6. [20] Kurtz JE, et al. Hepatogastroenterology 2003; 50:567-70.
    42. 42. Lessons from ASCO 2006 What did we know already? What we learn? What we miss? What we do next?
    43. 43. Promise from Non-Clinical Trials Better understanding of the biology of pancreatic cancer is emerging New mouse models show promise as potentially more predictive than the old models Newer imaging techniques may help to gauge disease better Palliative care is improving We can’t underestimate this as data suggest that improved pain control alone impacts on survival in this disease
    44. 44. Gemcitabine Alone Can Oncologists Change? R A N D O M I Z E Gemcitabine + Your Drug Here
    45. 45. What Really Needs to Change? Oncologist attitudes towards clinical trials Environment within which research is being conducted Access to trials for patients
    46. 46. What Actions Need to Be Taken to Change?  Study design:  Locally advanced and metastatic patients need to be studied separately  Appropriate trial size:  Gemcitabine + cisplatin may have been underpowered  Gemcitabine + erlotinib may have been overpowered  Advocacy input needs to be sought early:  How much benefit is enough to a patient?  How much toxicity is too much for a patient?  Regulatory environment:  Gemcitabine vs. drugs X + Y wins no FDA approval and may never be able to happen
    47. 47. Conclusions  30-min Gem vs. FDR?  Revisit platinum compounds  probably not  FFCD  another study negating benefit of platinum compounds  Need to identify surrogates for survival  Accelerate testing new drugs, including targeted agents  Move more quickly to adjuvant setting  Focus on 2nd Line Rx as most 1st Line regimens failed in the last decade  Standardize our approach: design, analysis, reporting  Move away from “ONE SIZE FITS ALL” approach to TAILORED patient management
    48. 48. References 1. Staley CA, et al. Pancreas 1996; 12:373-80. 2. Cancer 1987; 59:2006-10. 3. Neoptolemos JP, et al. Lancet 2001; 358:1576-85. 4. Neuhaus P, et al. J Clin Oncol 2005, 23(16S):4013. 5. Moertel CG, et al. Cancer 1981; 48:1705-10. 6. Rothenberg ML, et al. Ann Oncol 1996; 7:347-53. 7. Burris HA 3rd, et al. J Clin Oncol 1997; 15:2403-13. 8. Tempero M, et al. J Clin Oncol 2003; 21:3402-8. 9. Louvet C, et al. J Clin Oncol 2005; 23:3509-16. 10. Regine WF, et al. J Clin Oncol 2006; 24(18S, Part I):4007. 11. Chauffert B, et al. J Clin Oncol 2006; 24(18S, Part I):4008. 12. Louvet C, et al. J Clin Oncol 2006; 24(18S, Part I):4003. 13. Poplin E, et al. J Clin Oncol 2006; 24(18S, Part I):LBA4004. 14. National Cancer Research Network Trials Portfolio, 2004. (ISRCTN 37494643) 15. J Natl Cancer Inst 1988; 80:751-5. 16. Herrmann R, et al. J Clin Oncol 2005; 23(16S Part I):LBA4010. 17. Moore MJ, et al. J Clin Oncol 2005; 23(16S):1. 18. Kindler HL, et al. J Clin Oncol 2005; 23:8033-40. 19. Xiong HQ, et al. J Clin Oncol 2004; 22:2610-6. 20. Kurtz JE, et al. Hepatogastroenterology 2003; 50:567-70.
    49. 49. Keywords bevacizumab; capecitabine; cetuximab; Cisplatin; Chemotherapy, Adjuvant; gemcitabine; Epidermal Growth Factor; erlotinib; Fluorouracil; oxaliplatin; Pancreatic Neoplasms; Radiation; Radiotherapy, Adjuvant; Receptor, Epidermal Growth Factor; Review; Vascular Endothelial Growth Factor A Abbreviations ASCO: American Society of Clinical Oncology; CONKO: Charité Onkologie - clinical studies in GI cancers; ECOG: Eastern Cooperative Oncology Group; EGFR: epidermal growth factor receptor; ESPAC: European Study Group of Pancreatic Cancer; FA: folinic acid; FDR: fixed dose rate; FFCD-SFRO: Federation Francophone de Cancerologie Digestive and Societe Francaise de Radiotherapie Oncologique; Gem: gemcitabine; GemOx: gemcitabine plus oxaliplatin; GERCOR: Groupe d'Etude et de Recherche en Cancreologie Onco-Radiotherapic; GISCAD: Italian Group for the Study of Gastrointestinal Tract Carcinomas; GITSG: Gastro-Intestinal Study Group; HR: hazard ratio; LBA: late breaking abstract; PS: performance status; RECIST: Response Evaluation Criteria in Solid Tumors; RTOG: Radiation Therapy Oncology Group; XRT: radiation/radiotherapy
    50. 50. The author is grateful to the authors/presentors of the major studies discussed in this review article: Chauffert B. Unite INSERM 517, Faculty of Medicine, 7, Boulevard Jeanne d'Arc, BP 87900, 21079, Dijon, France. bchauffert@dijon.fnclcc.fr (FCCD-SFRO). Louvet C. Institut National de la Sante et de la Recherche Medicale (INSERM), Unit 643 and Institut de Transplantation et de Recherche en Transplantation (ITERT), Nantes, France. christophe.louvet@sat.ap-hop-paris.fr (meta-analysis: GERCOR/GISCAD). Poplin EA. Cancer Center of New Jersey, New Brunswick, New Jersey 08901, USA. poplinea@umdnj.edu (ECOG 6201) Regine WF. University of Maryland School of Medicine, Radiation Oncology Clinical, Gudelsky Tower; Room GGK-17E, Baltimore, MD 21201, USA. wregine@umm.edu (RTOG 9704) Correspondence Muhammad Wasif Saif Section of Medical Oncology - Yale University School of Medicine 333 Cedar Street; FMP 116 New Haven, CT 06520 - USA Phone: +1-203.737.1569 Fax: +1-203.785.3788 E-mail: wasif.saif@yale.edu Acknowledgement

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