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Originally published as JCO Early Release 10.1200/JCO.2006.07.9525 on April 23 2007

Journal of Clinical Oncology, Vol 25, No 15 (May 20), 2007: pp. 1960-1966
© 2007 American Society of Clinical Oncology.

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Erlotinib Plus Gemcitabine Compared With Gemcitabine Alone in Patients With Advanced Pancreatic Cancer: A Phase III Trial of the National Cancer Institute of Canada Clinical Trials Group

Malcolm J. Moore, David Goldstein, John Hamm, Arie Figer, Joel R. Hecht, Steven Gallinger, Heather J. Au, Pawel Murawa, David Walde, Robert A. Wolff, Daniel Campos, Robert Lim, Keyue Ding, Gary Clark, Theodora Voskoglou-Nomikos, Mieke Ptasynski, Wendy Parulekar

From the Divisions of Medical Oncology, Hematology, and Surgical Oncology, Princess Margaret Hospital, Toronto; National Cancer Institute of Canada Clinical Trials Group, Kingston; Algoma District Cancer Program, Sault Ste Marie, Ontario; Cross Cancer Institute, Edmonton, Alberta, Canada; the Australasian Gastrointestinal Tumor Group, Sydney, Australia; Norton Healthcare Pavilion, Louisville, KY; UCLA Medical Center, Los Angeles, CA; M. D. Anderson Cancer Centre, Houston, TX; OSI Pharmaceuticals, Boulder, CO; Sourasky Medical Centre, Tel Aviv, Israel; Great Poland Centre for Oncology, Poznan, Poland; Confidence Medical Centre, San Isidro, Argentina; and the National University Hospital, Singapore, Singapore

Address reprint requests to Malcolm J. Moore, MD, Department of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, 610 University Ave, Toronto, Canada M5G 2M9; e-mail: malcolm.moore{at}uhn.on.ca

Purpose Patients with advanced pancreatic cancer have a poor prognosis and there have been no improvements in survival since the introduction of gemcitabine in 1996. Pancreatic tumors often overexpress human epidermal growth factor receptor type 1 (HER1/EGFR) and this is associated with a worse prognosis. We studied the effects of adding the HER1/EGFR-targeted agent erlotinib to gemcitabine in patients with unresectable, locally advanced, or metastatic pancreatic cancer.

Patients and Methods Patients were randomly assigned 1:1 to receive standard gemcitabine plus erlotinib (100 or 150 mg/d orally) or gemcitabine plus placebo in a double-blind, international phase III trial. The primary end point was overall survival.

Results A total of 569 patients were randomly assigned. Overall survival based on an intent-to-treat analysis was significantly prolonged on the erlotinib/gemcitabine arm with a hazard ratio (HR) of 0.82 (95% CI, 0.69 to 0.99; P = .038, adjusted for stratification factors; median 6.24 months v 5.91 months). One-year survival was also greater with erlotinib plus gemcitabine (23% v 17%; P = .023). Progression-free survival was significantly longer with erlotinib plus gemcitabine with an estimated HR of 0.77 (95% CI, 0.64 to 0.92; P = .004). Objective response rates were not significantly different between the arms, although more patients on erlotinib had disease stabilization. There was a higher incidence of some adverse events with erlotinib plus gemcitabine, but most were grade 1 or 2.

Conclusion To our knowledge, this randomized phase III trial is the first to demonstrate statistically significantly improved survival in advanced pancreatic cancer by adding any agent to gemcitabine. The recommended dose of erlotinib with gemcitabine for this indication is 100 mg/d.

published online ahead of print at www.jco.org on April 23, 2007.

Supported in part by OSI Pharmaceuticals, Melville, NY.

Presented in part at the American Society of Clinical Oncology Gastrointestinal Symposium, Hollywood, FL, January 27-29 2005; and the 41st Annual Meeting of the American Society of Clinical Oncology, Orlando, FL, May 13-17, 2005.

A list of participating investigators can be found in the online-only Acknowledgment.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.


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S. Ali, S. Banerjee, A. Ahmad, B. F. El-Rayes, P. A. Philip, and F. H. Sarkar
Apoptosis-inducing effect of erlotinib is potentiated by 3,3'-diindolylmethane in vitro and in vivo using an orthotopic model of pancreatic cancer
Mol. Cancer Ther., June 1, 2008; 7(6): 1708 - 1719.
[Abstract] [Full Text] [PDF]


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Cancer Res.Home page
J. N. Contessa, M. S. Bhojani, H. H. Freeze, A. Rehemtulla, and T. S. Lawrence
Inhibition of N-Linked Glycosylation Disrupts Receptor Tyrosine Kinase Signaling in Tumor Cells
Cancer Res., May 15, 2008; 68(10): 3803 - 3809.
[Abstract] [Full Text] [PDF]


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The OncologistHome page
J. Nieto, M. L. Grossbard, and P. Kozuch
Metastatic Pancreatic Cancer 2008: Is the Glass Less Empty?
Oncologist, May 1, 2008; 13(5): 562 - 576.
[Abstract] [Full Text] [PDF]


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Cancer Res.Home page
A. Jimeno, A. C. Tan, J. Coffa, N.V. Rajeshkumar, P. Kulesza, B. Rubio-Viqueira, J. Wheelhouse, B. Diosdado, W. A. Messersmith, C. Iacobuzio-Donahue, et al.
Coordinated Epidermal Growth Factor Receptor Pathway Gene Overexpression Predicts Epidermal Growth Factor Receptor Inhibitor Sensitivity in Pancreatic Cancer
Cancer Res., April 15, 2008; 68(8): 2841 - 2849.
[Abstract] [Full Text] [PDF]


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JCOHome page
J. Baselga and N. Rosen
Determinants of RASistance to Anti-Epidermal Growth Factor Receptor Agents
J. Clin. Oncol., April 1, 2008; 26(10): 1582 - 1584.
[Full Text] [PDF]


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JCOHome page
R. G. Amado, M. Wolf, M. Peeters, E. Van Cutsem, S. Siena, D. J. Freeman, T. Juan, R. Sikorski, S. Suggs, R. Radinsky, et al.
Wild-Type KRAS Is Required for Panitumumab Efficacy in Patients With Metastatic Colorectal Cancer
J. Clin. Oncol., April 1, 2008; 26(10): 1626 - 1634.
[Abstract] [Full Text] [PDF]


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Ann OncolHome page
F. Cappuzzo, G. Finocchiaro, E. Rossi, P.A. Janne, C. Carnaghi, C. Calandri, K. Bencardino, C. Ligorio, F. Ciardiello, T. Pressiani, et al.
EGFR FISH assay predicts for response to cetuximab in chemotherapy refractory colorectal cancer patients
Ann. Onc., April 1, 2008; 19(4): 717 - 723.
[Abstract] [Full Text] [PDF]


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NEJMHome page
F. Ciardiello and G. Tortora
EGFR Antagonists in Cancer Treatment
N. Engl. J. Med., March 13, 2008; 358(11): 1160 - 1174.
[Full Text] [PDF]


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JCOHome page
C. K. Daugherty, M. J. Ratain, E. J. Emanuel, A. T. Farrell, and R. L. Schilsky
Ethical, Scientific, and Regulatory Perspectives Regarding the Use of Placebos in Cancer Clinical Trials
J. Clin. Oncol., March 10, 2008; 26(8): 1371 - 1378.
[Abstract] [Full Text] [PDF]


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JCOHome page
S. Boeck and V. Heinemann
Second-Line Therapy in Gemcitabine-Pretreated Patients With Advanced Pancreatic Cancer
J. Clin. Oncol., March 1, 2008; 26(7): 1178 - 1179.
[Full Text] [PDF]


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Clin. Cancer Res.Home page
D. Laheru, E. Lutz, J. Burke, B. Biedrzycki, S. Solt, B. Onners, I. Tartakovsky, J. Nemunaitis, D. Le, E. Sugar, et al.
Allogeneic Granulocyte Macrophage Colony-Stimulating Factor-Secreting Tumor Immunotherapy Alone or in Sequence with Cyclophosphamide for Metastatic Pancreatic Cancer: A Pilot Study of Safety, Feasibility, and Immune Activation
Clin. Cancer Res., March 1, 2008; 14(5): 1455 - 1463.
[Abstract] [Full Text] [PDF]


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The OncologistHome page
H. Burris III and C. Rocha-Lima
New Therapeutic Directions for Advanced Pancreatic Cancer: Targeting the Epidermal Growth Factor and Vascular Endothelial Growth Factor Pathways
Oncologist, March 1, 2008; 13(3): 289 - 298.
[Abstract] [Full Text] [PDF]


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Journal of Pharmacy PracticeHome page
A. A. Garcia
Small Molecules: Big Changes in the Cancer Treatment Paradigm
Journal of Pharmacy Practice, February 1, 2008; 21(1): 17 - 35.
[Abstract] [PDF]


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Ann OncolHome page
S. Boeck, T. Hoehler, G. Seipelt, R. Mahlberg, A. Wein, A. Hochhaus, H.-P. Boeck, B. Schmid, E. Kettner, M. Stauch, et al.
Capecitabine plus oxaliplatin (CapOx) versus capecitabine plus gemcitabine (CapGem) versus gemcitabine plus oxaliplatin (mGemOx): final results of a multicenter randomized phase II trial in advanced pancreatic cancer
Ann. Onc., February 1, 2008; 19(2): 340 - 347.
[Abstract] [Full Text] [PDF]


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Ann OncolHome page
E. Van Cutsem, C. Verslype, P. Beale, S. Clarke, R. Bugat, A. Rakhit, S. H. Fettner, U. Brennscheidt, A. Feyereislova, and J.-P Delord
A phase Ib dose-escalation study of erlotinib, capecitabine and oxaliplatin in metastatic colorectal cancer patients
Ann. Onc., February 1, 2008; 19(2): 332 - 339.
[Abstract] [Full Text] [PDF]


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JCOHome page
A. Grothey, E. E. Hedrick, R. D. Mass, S. Sarkar, S. Suzuki, R. K. Ramanathan, H. I. Hurwitz, R. M. Goldberg, and D. J. Sargent
Response-Independent Survival Benefit in Metastatic Colorectal Cancer: A Comparative Analysis of N9741 and AVF2107
J. Clin. Oncol., January 10, 2008; 26(2): 183 - 189.
[Abstract] [Full Text] [PDF]


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J Oncol PractHome page
M. A. Tempero
How I Treat Pancreatic Ductal Adenocarcinoma
J. Oncol. Pract, January 1, 2008; 4(1): 46 - 47.
[Full Text] [PDF]


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Toxicol PatholHome page
D. W. Hedley, S. Chow, C. Goolsby, and T. V. Shankey
Pharmacodynamic Monitoring of Molecular-Targeted Agents in the Peripheral Blood of Leukemia Patients Using Flow Cytometry
Toxicol Pathol, January 1, 2008; 36(1): 133 - 139.
[Abstract] [Full Text] [PDF]


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Arch SurgHome page
G. Butturini, D. D. Stocken, M. N. Wente, H. Jeekel, J. H. G. Klinkenbijl, K. E. Bakkevold, T. Takada, H. Amano, C. Dervenis, C. Bassi, et al.
Influence of Resection Margins and Treatment on Survival in Patients With Pancreatic Cancer: Meta-analysis of Randomized Controlled Trials
Arch Surg, January 1, 2008; 143(1): 75 - 83.
[Abstract] [Full Text] [PDF]


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Clin. Cancer Res.Home page
G. Folprecht, J. Tabernero, C.-H. Kohne, C. Zacharchuk, L. Paz-Ares, F. Rojo, S. Quinn, E. Casado, R. Salazar, R. Abbas, et al.
Phase I Pharmacokinetic/Pharmacodynamic Study of EKB-569, an Irreversible Inhibitor of the Epidermal Growth Factor Receptor Tyrosine Kinase, in Combination with Irinotecan, 5-Fluorouracil, and Leucovorin (FOLFIRI) in First-Line Treatment of Patients with Metastatic Colorectal Cancer
Clin. Cancer Res., January 1, 2008; 14(1): 215 - 223.
[Abstract] [Full Text] [PDF]


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JCOHome page
N. Normanno and A. De Luca
Erlotinib in Pancreatic Cancer: Are Tumor Cells the (only) Target?
J. Clin. Oncol., December 20, 2007; 25(36): 5836 - 5837.
[Full Text] [PDF]


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JCOHome page
J. A. Ajani
The Area Between the Curves Gets No Respect: Is It Because of the Median Madness?
J. Clin. Oncol., December 1, 2007; 25(34): 5531 - 5531.
[Full Text] [PDF]


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Cancer Res.Home page
Z. Shi, X.-X. Peng, I.-W. Kim, S. Shukla, Q.-S. Si, R. W. Robey, S. E. Bates, T. Shen, C. R. Ashby Jr., L.-W. Fu, et al.
Erlotinib (Tarceva, OSI-774) Antagonizes ATP-Binding Cassette Subfamily B Member 1 and ATP-Binding Cassette Subfamily G Member 2 Mediated Drug Resistance
Cancer Res., November 15, 2007; 67(22): 11012 - 11020.
[Abstract] [Full Text] [PDF]


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The OncologistHome page
A. Rajasekhar and T. J. George Jr.
Gemcitabine-Induced Reversible Posterior Leukoencephalopathy Syndrome: A Case Report and Review of the Literature
Oncologist, November 1, 2007; 12(11): 1332 - 1335.
[Abstract] [Full Text] [PDF]


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JCOHome page
M. H. Kulke, L. S. Blaszkowsky, D. P. Ryan, J. W. Clark, J. A. Meyerhardt, A. X. Zhu, P. C. Enzinger, E. L. Kwak, A. Muzikansky, C. Lawrence, et al.
Capecitabine Plus Erlotinib in Gemcitabine-Refractory Advanced Pancreatic Cancer
J. Clin. Oncol., October 20, 2007; 25(30): 4787 - 4792.
[Abstract] [Full Text] [PDF]


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JCOHome page
S. P. Desai, E. Ben-Josef, D. P. Normolle, I. R. Francis, J. K. Greenson, D. M. Simeone, A. E. Chang, L. M. Colletti, T. S. Lawrence, and M. M. Zalupski
Phase I Study of Oxaliplatin, Full-Dose Gemcitabine, and Concurrent Radiation Therapy in Pancreatic Cancer
J. Clin. Oncol., October 10, 2007; 25(29): 4587 - 4592.
[Abstract] [Full Text] [PDF]


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JCOHome page
D. Ferrari and P. Foa
Targeted Therapies: Cui Prodest?
J. Clin. Oncol., October 10, 2007; 25(29): 4691 - 4692.
[Full Text] [PDF]


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JCOHome page
R. A. Miksad, L. Schnipper, and M. Goldstein
Does a Statistically Significant Survival Benefit of Erlotinib Plus Gemcitabine for Advanced Pancreatic Cancer Translate Into Clinical Significance and Value?
J. Clin. Oncol., October 1, 2007; 25(28): 4506 - 4507.
[Full Text] [PDF]


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JCOHome page
M. J. Moore, H. J. Au, and W. Parulekar
In Reply
J. Clin. Oncol., October 1, 2007; 25(28): 4508 - 4508.
[Full Text] [PDF]


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JCOHome page
M. Mandala, C. Moro, R. Labianca, and G. Ferretti
Erlotinib in Pancreatic Cancer Patients: Do We Need More Information From the NCIC CTG Trial?
J. Clin. Oncol., September 20, 2007; 25(27): 4320 - 4321.
[Full Text] [PDF]


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Ann OncolHome page
S Boeck, A Wollenberg, and V Heinemann
Leukocytoclastic vasculitis during treatment with the oral EGFR tyrosine kinase inhibitor erlotinib
Ann. Onc., September 1, 2007; 18(9): 1582 - 1583.
[Full Text] [PDF]


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GutHome page
P. Ghaneh, E. Costello, and J. P Neoptolemos
Biology and management of pancreatic cancer
Gut, August 1, 2007; 56(8): 1134 - 1152.
[Full Text] [PDF]


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Clin. Cancer Res.Home page
R. Perez-Soler
Erlotinib: Recent Clinical Results and Ongoing Studies in Non Small Cell Lung Cancer
Clin. Cancer Res., August 1, 2007; 13(15): 4589s - 4592s.
[Abstract] [Full Text] [PDF]


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Clin. Cancer Res.Home page
B. Wacker, T. Nagrani, J. Weinberg, K. Witt, G. Clark, and P. J. Cagnoni
Correlation between Development of Rash and Efficacy in Patients Treated with the Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor Erlotinib in Two Large Phase III Studies
Clin. Cancer Res., July 1, 2007; 13(13): 3913 - 3921.
[Abstract] [Full Text] [PDF]


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JCOHome page
E. Van Cutsem, C. Verslype, and P. A. Grusenmeyer
Lessons Learned in the Management of Advanced Pancreatic Cancer
J. Clin. Oncol., May 20, 2007; 25(15): 1949 - 1952.
[Full Text] [PDF]



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