"May 14, 2013 -- Actress and activist Angelina Jolie's recent decision to have a preventive double mastectomy highlights the difficult choices facing women who find out they have a high risk for breast cancer because of their genes.
Mechanism Of Action
Epirubicin is an anthracycline cytotoxic agent. Although it is known that anthracyclines can interfere with a number of biochemical and biological functions within eukaryotic cells, the precise mechanisms of epirubicin's cytotoxic and/or antiproliferative properties have not been completely elucidated.
Such intercalation triggers DNA cleavage by topoisomerase II, resulting in cytocidal activity. Epirubicin also inhibits DNA helicase activity, preventing the enzymatic separation of double-stranded DNA and interfering with replication and transcription. Epirubicin is also involved in oxidation/reduction reactions by generating cytotoxic free radicals. The antiproliferative and cytotoxic activity of epirubicin is thought to result from these or other possible mechanisms.
Epirubicin is cytotoxic in vitro to a variety of established murine and human cell lines and primary cultures of human tumors. It is also active in vivo against a variety of murine tumors and human xenografts in athymic mice, including breast tumors.
Epirubicin pharmacokinetics are linear over the dose range of 60 to 150 mg/m² and plasma clearance is not affected by the duration of infusion or administration schedule. Pharmacokinetic parameters for epirubicin following 6-to 10-minute, single-dose intravenous infusions of ELLENCE at doses of 60 to 150 mg/m² in patients with solid tumors are shown in Table 4. The plasma concentration declined in a triphasic manner with mean half-lives for the alpha, beta, and gamma phases of about 3 minutes, 2.5 hours, and 33 hours, respectively.
Table 4: Summary of Mean (±SD) Pharmacokinetic
Parameters in Patients a with Solid Tumors Receiving Intravenous
ELLENCE 60 to 150 mg/m²
|Dose b (mg/m²)||Cmax c (μg/mL)||AUCd (μg•h/mL)||t½ e (hours)||CLf (L/hour)||Vssg (L/kg)|
|60||5.7 ± 1.6||1.6 ± 0.2||35.3 ± 9||65 ± 8||21 ± 2|
|75||5.3 ± 1.5||1.7 ± 0.3||32.1 ± 5||83 ± 14||27 ± 11|
|120||9.0 ± 3.5||3.4 ± 0.7||33.7 ± 4||65 ± 13||23 ± 7|
|150||9.3 ± 2.9||4.2 ± 0.8||31.1 ± 6||69 ± 13||21 ± 7|
|aAdvanced solid tumor cancers, primarily of the lung
bN=6 patients per dose level
cPlasma concentration at the end of 6 to 10 minute infusion
dArea under the plasma concentration curve
eHalf-life of terminal phase
gSteady state volume of distribution
Following intravenous administration, epirubicin is rapidly and widely distributed into the tissues. Binding of epirubicin to plasma proteins, predominantly albumin, is about 77% and is not affected by drug concentration. Epirubicin also appears to concentrate in red blood cells; whole blood concentrations are approximately twice those of plasma.
Epirubicin is extensively and rapidly metabolized by the liver and is also metabolized by other organs and cells, including red blood cells. Four main metabolic routes have been identified:
(1) reduction of the C-13 keto-group with the formation of the 13(S)-dihydro derivative, epirubicinol; (2) conjugation of both the unchanged drug and epirubicinol with glucuronic acid; (3) loss of the amino sugar moiety through a hydrolytic process with the formation of the doxorubicin and doxorubicinol aglycones; and (4) loss of the amino sugar moiety through a redox process with the formation of the 7-deoxy-doxorubicin aglycone and 7-deoxy-doxorubicinol aglycone. Epirubicinol has in vitro cytotoxic activity one-tenth that of epirubicin. As plasma levels of epirubicinol are lower than those of the unchanged drug, they are unlikely to reach in vivo concentrations sufficient for cytotoxicity. No significant activity or toxicity has been reported for the other metabolites.
Epirubicin and its major metabolites are eliminated through biliary excretion and, to a lesser extent, by urinary excretion. Mass-balance data from 1 patient found about 60% of the total radioactive dose in feces (34%) and urine (27%). These data are consistent with those from 3 patients with extrahepatic obstruction and percutaneous drainage, in whom approximately 35% and 20% of the administered dose were recovered as epirubicin or its major metabolites in bile and urine, respectively, in the 4 days after treatment.
Effect of Age
A population analysis of plasma data from 36 cancer patients (13 males and 23 females, 20 to 73 years) showed that age affects plasma clearance of epirubicin in female patients. The predicted plasma clearance for a female patient of 70 years of age was about 35% lower than that for a female patient of 25 years of age. An insufficient number of males > 50 years of age were included in the study to draw conclusions about age-related alterations in clearance in males. Although a lower ELLENCE starting dose does not appear necessary in elderly female patients, and was not used in clinical trials, particular care should be taken in monitoring toxicity when ELLENCE is administered to female patients > 70 years of age [see PATIENT INFORMATION].
Effect of Gender
In patients ≤ 50 years of age, mean clearance values in adult male and female patients were similar. The clearance of epirubicin is decreased in elderly women.
Effect of Race
The influence of race on the pharmacokinetics of epirubicin has not been evaluated.
Effect of Hepatic Impairment
Epirubicin is eliminated by both hepatic metabolism and biliary excretion and clearance is reduced in patients with hepatic dysfunction. In a study of the effect of hepatic dysfunction, patients with solid tumors were classified into 3 groups. Patients in Group 1 (n=22) had serum AST (SGOT) levels above the upper limit of normal (median: 93 IU/L) and normal serum bilirubin levels (median: 0.5 mg/dL) and were given ELLENCE doses of 12.5 to 90 mg/m² . Patients in Group 2 had alterations in both serum AST (median: 175 IU/L) and bilirubin levels (median: 2.7 mg/dL) and were treated with an ELLENCE dose of 25 mg/m² (n=8). Their pharmacokinetics were compared to those of patients with normal serum AST and bilirubin values, who received ELLENCE doses of 12.5 to 120 mg/m² . The median plasma clearance of epirubicin was decreased compared to patients with normal hepatic function by about 30% in patients in Group 1 and by 50% in patients in Group 2. Patients with more severe hepatic impairment have not been evaluated [see DOSAGE AND ADMINISTRATION, and WARNINGS AND PRECAUTIONS].
Effect of Renal Impairment
No significant alterations in the pharmacokinetics of epirubicin or its major metabolite, epirubicinol, have been observed in patients with serum creatinine < 5 mg/dL. A 50% reduction in plasma clearance was reported in four patients with serum creatinine ≥ 5 mg/dL [see WARNINGS AND PRECAUTIONS and DOSING AND ADMINISTRATION]. Patients on dialysis have not been studied.
Effect of Paclitaxel
The administration of paclitaxel (175-225 mg/m² as a 3-hour infusion) immediately before or after epirubicin (90 mg/m² as bolus) caused variable increases in the systemic exposure (mean AUC) of epirubicin ranging from 5% to 109%. At same doses of epirubicin and paclitaxel, the mean AUC of the inactive metabolites of epirubicin (epirubicinol and 7-deoxy-aglycone) increased by 120% and 70%, respectively, when paclitaxel was immediately administered after epirubicin. Epirubicin had no effect on the exposure of paclitaxel whether it was administered before or after paclitaxel.
Effect of Docetaxel
The administration of docetaxel (70 mg/m² as 1-hour infusion) immediately before or after epirubicin (90 mg/m² as bolus) had no effect on the systemic exposure (mean AUC) of epirubicin. However, the mean AUC of epirubicinol and 7-deoxy-aglycone increased by 22.5% and 95%, respectively, when docetaxel was immediately administered after epirubicin compared to epirubicin alone. Epirubicin had no effect on the exposure of docetaxel whether it was administered before or after docetaxel.
Effect of Cimetidine
Coadministration of cimetidine (400 mg twice daily for 7 days starting 5 days before chemotherapy) increased the mean AUC of epirubicin (100 mg/m²) by 50% and decreased its plasma clearance by 30% .
Drugs metabolized by cytochrome P-450 enzymes
No systematic in vitro or in vivo evaluation has been performed to examine the potential for inhibition or induction by epirubicin of oxidative cytochrome P-450 isoenzymes.
Adjuvant Treatment Of Breast Cancer
Two randomized, open-label, multicenter studies evaluated the use of ELLENCE Injection 100 to 120 mg/m² in combination with cyclophosphamide and fluorouracil for the adjuvant treatment of patients with axillary-node positive breast cancer and no evidence of distant metastatic disease (Stage II or III). Study MA-5 evaluated 120 mg/m² of ELLENCE per course in combination with cyclophosphamide and fluorouracil (CEF-120 regimen). This study randomized premenopausal and perimenopausal women with one or more positive lymph nodes to an ELLENCE-containing CEF-120 regimen or to a CMF regimen. Study GFEA-05 evaluated the use of 100 mg/m² of ELLENCE per course in combination with fluorouracil and cyclophosphamide (FEC-100). This study randomized pre-and postmenopausal women to the FEC-100 regimen or to a lower-dose FEC-50 regimen. In the GFEA-05 study, eligible patients were either required to have ≥ 4 nodes involved with tumor or, if only 1 to 3 nodes were positive, to have negative estrogen-and progesterone-receptors and a histologic tumor grade of 2 or 3. A total of 1281 women participated in these studies. Patients with T4 tumors were not eligible for either study. Table 5 shows the treatment regimens that the patients received. Relapse-free survival was defined as time to occurrence of a local, regional, or distant recurrence, or disease-related death.
Table 5: Treatment Regimens Used in Phase 3 Studies of
Patients with Early Breast Cancer
|CEF-120 (total, 6 cycles)b N=356CMF (total, 6 cycles) N=360||Cyclophosphamide||75 mg/m² PO, d 1-14, q 28 days|
|ELLENCE||60 mg/m² IV, d 1 & 8, q 28 days|
|Fluorouracil||500 mg/m² IV, d 1 & 8, q 28 days|
|Cyclophosphamide||100 mg/m² PO, d 1-14, q 28 days|
|Methotrexate||40 mg/m² IV, d 1 & 8, q 28 days|
|Fluorouracil||600 mg/m² IV, d 1 & 8, q 28 days|
|FEC-100 (total, 6 cycles) N=276 FEC-50 (total, 6 cycles) N=289 Tamoxifen 30 mg daily x 3 years, postmenopausal women, any receptor status||Fluorouracil||500 mg/m² IV, d 1, q 21 days|
|ELLENCE||100 mg/m² IV, d 1, q 21 days|
|Cyclophosphamide||500 mg/m² IV, d 1, q 21 days|
|Fluorouracil||500 mg/m² IV, d 1, q 21 days|
|ELLENCE||50 mg/m² IV, d 1, q 21 days|
|Cyclophosphamide||500 mg/m² IV, d 1, q 21 days|
|aIn women who underwent lumpectomy, breast irradiation was
to be administered after completion of study chemotherapy.
bPatients also received prophylactic antibiotic therapy with trimethoprim-sulfamethoxazole or fluoroquinolone for the duration of their chemotherapy.
cAll women were to receive breast irradiation after the completion of chemotherapy.
In the MA-5 trial, the median age of the study population was 45 years. Approximately 60% of patients had 1 to 3 involved nodes and approximately 40% had ≥ 4 nodes involved with tumor. In the GFEA-05 study, the median age was 51 years and approximately half of the patients were postmenopausal. About 17% of the study population had 1 to 3 positive nodes and 80% of patients had ≥ 4 involved lymph nodes. Demographic and tumor characteristics were well-balanced between treatment arms in each study.
Relapse-free survival (RFS) and overall survival (OS) were analyzed using Kaplan-Meier methods in the intent-to-treat (ITT) patient populations in each study. Results were initially analyzed after up to 5 years of follow-up and these results are presented in the text below and in Table 6. Results after up to 10 years of follow-up are presented in Table 6. In Study MA-5, ELLENCE-containing combination therapy (CEF-120) showed significantly longer RFS than CMF (5-year estimates were 62% versus 53%, stratified logrank for the overall RFS p=0.013). The estimated reduction in the risk of relapse was 24% at 5 years. The OS was also greater for the ELLENCE-containing CEF-120 regimen than for the CMF regimen (5-year estimate 77% versus 70%; stratified logrank for overall survival p=0.043; non-stratified logrank p=0.13). The estimated reduction in the risk of death was 29% at 5 years.
In Study GFEA-05, patients treated with the higher-dose ELLENCE regimen (FEC-100) had a significantly longer 5-year RFS (estimated 65% versus 52%, logrank for the overall RFS p=0.007) and OS (estimated 76% versus 65%, logrank for the overall survival p=0.007) than patients given the lower dose regimen (FEC-50). The estimated reduction in risk of relapse was 32% at 5 years. The estimated reduction in the risk of death was 31% at 5 years. Results of follow-up up to 10 years (median follow-up = 8.8 years and 8.3 years, respectively, for Study MA-5 and Study GFEA-05) are presented in Table 6.
Although the trials were not powered for subgroup analyses, in the MA-5 study, improvements in favor of CEF-120 vs. CMF were observed, in RFS and OS both in patients with 1-3 node positive and in those with > 4 node positive tumor involvement. In the GFEA-05 study, improvements in RFS and OS were observed in both pre-and postmenopausal women treated with FEC-100 compared to FEC-50.
Table 6: Efficacy Results from Phase 3 Studies of
Patients with Early Breast Cancer*
|MA-5 Study||GFEA-05 Study|
|RFS at 5 yrs (%)||62||53||65||52|
|2-sided 95% CI||(0.60, 0.96)||(0.52, 0.89)|
|Logrank Test stratified**||(p = 0.013)||(p = 0.007)|
|OS at 5 yrs (%)||77 | 70||76 | 65|
|2-sided 95% CI||(0.52, 0.98)||(0.51, 0.92)|
|Logrank Test stratified**||(p = 0.043) (unstratified p = 0.13)||(p = 0.007)|
|RFS at 10 yrs (%)||51 | 44||49 | 43|
|2-sided 95% CI||(0.63, 0.95)||(0.62, 0.99)|
|Logrank Test stratified**||(p = 0.017) (unstratified p = 0.023)||(p = 0.040) (unstratified p = 0.09)|
|OS at 10 yrs (%)||61 | 57||56 | 50|
|2-sided 95% CI||(0.65, 1.04)||(0.58, 0.96)|
|Logrank Test stratified**||(p = 0.100) (unstratified p = 0.18)||(p = 0.023) (unstratified p = 0.039)|
|*Based on Kaplan-Meier estimates
**Patients in MA-5 were stratified by nodal status (1-3, 4-10, and > 10 positive nodes), type of initial surgery (lumpectomy versus mastectomy), and by hormone receptor status (ER or PR positive ( ≥ 10 fmol), both negative ( < 10 fmol), or unknown status). Patients in GFEA-05 were stratified by nodal status (1-3, 4-10, and > 10 positive nodes).
†Hazard ratio: CMF:CEF-120 in MA-5, FEC-50:FEC-100 in GFEA-05
The Kaplan-Meier curves for RFS and OS from Study MA-5 are shown in Figures 3 and 4 and those for Study GFEA-05 are shown in Figures 5 and 6.
Figure 3: Relapse-Free
Survival in Study MA-5
Figure 4: Overall Survival
in Study MA-5
Figure 5: Relapse-Free
Survival in Study GFEA-05
Figure 6: Overall Survival
in Study GFEA-05
See Table 6 for statistics on 5 and 10 year analyses.
Last reviewed on RxList: 12/30/2014
This monograph has been modified to include the generic and brand name in many instances.
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