Clinical and pharmacologic study of the epirubicin and paclitaxel combination in women with metastatic breast cancer

Purpose: A pharmacokinetic interaction may cause increased cardiotoxicity of paclitaxel (PTX) and high cumulative dose of doxorubicin. We tested antitumor activity, tolerability, and pharmacokinetics of the lesser cardiotoxic epirubicin (EPI) and PTX (ET combination). Patients and Methods: Twenty-seven women with untreated metastatic breast cancer, median age of 56 years, and prominent visceral involvement (74%) were studied. Three-weekly EPI (90 mg/m2) and PTX (200 mg/m2over 3 hours) were given for a maximum nine cycles. EPI was administered 24 hours before PTX (E → T) in cycle 1, and 15 minutes before PTX (ET) thereafter. EPI, epirubicinol (EOL), EPI-glucuronide (EPI-glu), EOL-glucuronide (EOL-glu), PTX, and 6α-OH-PTX were measured in plasma and urine in 14 women. Results: Patients received 205 cycles of ET and a median EPI dose of 720 mg/m2. Grade 4 neutropenia (49% of cycles) was the most frequent toxicity. Cardiac contractility was decreased in five patients. Mild congestive heart failure occurred in two (7.4%). Response rate was 76% (28% complete). Median overall survival was 29 months. On the basis of intrapatient comparison in the first 24 hours of E → T and ET cycles, PTX did not affect EPI disposition, but significantly increased plasma exposure to EOL (by 137%), EPI-glu (threefold) and EOL-glu (twofold). Urinary excretion of EPI dose went from 8.2% in E → T to 11.8% in ET cycles. Clearance of PTX was 30% slower in ET than E → T. ET cycles caused lower neutrophil nadir than E → T (644 ± 327 v 195 ± 91, P < .05) Conclusion: ET is feasible, devoid of excessive cardiac toxicity, and active. A reciprocal pharmacokinetic interference between the two drugs has pharmacodynamic consequences, and suggests a direct effect of PTX on EPI metabolism requiring ad hoc investigation.