Gemcitabine With or Without Capecitabine and/or Radiation Therapy or Gemcitabine With or Without Erlotinib in Treating Patients With Locally Advanced Pancreatic Cancer That Cannot Be Removed by Surgery

Randomized Multicenter Phase III Study in Patients With Locally Advanced Adenocarcinoma of the Pancreas: Gemcitabine With or Without Chemoradiotherapy and With or Without Erlotinib. Intergroup Study

RATIONALE: Drugs used in chemotherapy, such as gemcitabine and capecitabine, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Erlotinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Radiation therapy uses high-energy x-rays to kill tumor cells. It is not yet known which regimen of chemotherapy with or without erlotinib and/or radiation therapy is most effective in treating pancreatic cancer.

PURPOSE: This randomized phase III trial is studying giving gemcitabine together with or without capecitabine and/or radiation therapy to see how well it works compared with giving gemcitabine together with or without erlotinib in treating patients with locally advanced pancreatic cancer that cannot be removed by surgery.

OBJECTIVES:

Primary

• To assess whether administrating chemoradiotherapy in patients whose tumor is controlled after 4 months of induction chemotherapy (CT) increases survival compared with continuation of the same CT in patients with unresectable, locally advanced adenocarcinoma of the pancreas.

Secondary

• To assess whether erlotinib hydrochloride combined with gemcitabine hydrochloride and administered as maintenance treatment increases progression-free survival compared with gemcitabine hydrochloride alone and without maintenance treatment.
• To evaluate the response rate in the CT and chemoradiotherapy (CRT) arms.
• To evaluate tolerance to erlotinib hydrochloride as maintenance treatment after the end of CT or CRT.
• To study the predictive molecular factors (i.e., survivin, K-ras, EGFR, PTEN, or AKT) of survival.

OUTLINE: This is a multicenter study. Patients in the first randomization are stratified according to center and ECOG performance status (0-1 vs 2). Patients in the second randomization are stratified according to center and initial treatment arm (I vs II).

• First randomization: Patients are randomized to 1 of 2 treatment arms.

  • Arm I: Patients receive gemcitabine hydrochloride IV over 30 minutes on days 1, 8, 15, 22, 29, 36, and 43. Following the first evaluation, patients continue to receive gemcitabine hydrochloride on days 57, 64, 71, 85, 92, and 99 for a total of 4 months.
  • Arm II: Patients receive gemcitabine hydrochloride IV over 30 minutes on days 1, 8, 15, 22, 29, 36, and 43. Following the first evaluation, patients continue to receive gemcitabine hydrochloride on days 57, 64, 71, 85, 92, and 99. Patients also receive oral erlotinib hydrochloride once daily for 4 months.

After completion of treatment in the first randomization proceed to the second randomization.

• Second randomization: Patients are randomized to 1 of 4 treatment arms.

  • Arm I: Patients continue gemcitabine hydrochloride as in arm I in the first randomization on days 113, 120, and 127 and on days 141, 148, and 155 for 2 months in the absence of disease progression.
  • Arm II: Patients continue gemcitabine hydrochloride as in arm II in the first randomization on days 113, 120, and 127 and on days 141, 148, and 155 and oral erlotinib hydrochloride daily for 2 months followed by erlotinib hydrochloride alone as maintenance therapy in the absence of disease progression.
  • Arm III: Patients receive oral capecitabine twice daily and undergo radiotherapy beginning on day 127, 5 days a week, for 6 weeks, in the absence of disease progression.
  • Arm IV: Patients receive oral capecitabine twice daily and undergo radiotherapy beginning on day 127, 5 days a week, for 6 weeks. Beginning 15 days after completion of CRT, patients receive a reintroduction of oral erlotinib hydrochloride alone once daily in the absence of disease progression or unacceptable toxicity.

Tumor tissue will be analyzed for the relationship between biological markers and resistance to treatment.

After completion of study treatment, patients are followed every 2 months.

DISEASE CHARACTERISTICS:

• Histologically confirmed adenocarcinoma of the pancreas meeting the following criteria:

  • De novo locally advanced disease

  • Unresectable disease

  • Stage III according to the UICC classification

    • No distant metastases
    • No localized stage IA-IIB or metastatic stage IV disease according to UICC classification

  • Not considered for curative resection after pluridisciplinary discussion

PATIENT CHARACTERISTICS:

Inclusion criteria:

• ECOG performance status 0-2

• Life expectancy ≥ 12 weeks

• Polynuclear neutrophils ≥ 1.5 x 10^9/L

• Platelets ≥ 100 x 10^9/L

• Hemoglobin ≥ 9 g/dL

• Total bilirubin ≤ 1.5 times upper limit of normal (ULN)

  • For patients who have had a recent biliary drain and whose bilirubin is descending, a value of ≤ 3 times ULN is acceptable

• Creatinine ≤ 2 mg/dL

• AST and ALT ≤ 2.5 times ULN

• Alkaline phosphatase ≤ 5 times ULN

• Albumin ≥ 25 g/L

• Not pregnant or nursing

• Negative pregnancy test

• Fertile patients must use effective contraception during and for 3 months after completion of therapy

Exclusion criteria:

• Diarrhea ≥ grade 2 and/or uncontrolled diarrhea
• Affiliated with a social security regime
• Unable to follow instructions for psychological, familial, or geographical reasons
• Allergic to one of the ingredients in erlotinib hydrochloride
• Cancer within the past 5 years, except for in situ cancer of the neck of the uterus or basal cell skin cancer
• Severe infection
• Ophthalmic disease (i.e., inflammation, keratopathy, or infection)
• Symptomatic coronary or cardiac insufficiency, myocardial infarction, or stroke within the last 6 months
• Unable to take oral treatments
• Gastrointestinal disorders that could be associated with absorption disorders
• Untreated gastric or duodenal ulcer

PRIOR CONCURRENT THERAPY:

• No prior radiotherapy (including abdominal radiotherapy) or chemotherapy for any reason
• No prior anti-epidermal growth factor-receptor therapy