**7. Clinical trials**

*Chronobiology - The Science of Biological Time Structure*

stage and probably altered immune function [73–75, 76].

rhythm to the prognosis (survival) in LC patients [19, 20].

**6.2 Host marker rhythms**

proliferation in lung or other tissues.

Mazzocoli et al. assessed altered time neuroendocrine-immune system function in lung cancer patients [75]. Circadian rhythmicity with night acrophases was validated in the control group for hormone serum level (melatonin, TRH, TSH, GH,) and for lymphocyte subset variation (CD3-, CD4-, HLA DR-, CD20-, and CD25-expressing cells). Cortisol, CD6, CD8 bright, CD8 dim, CD16, TcR-delta-1, and delta-TcS1 presented circadian rhythmicity with acrophase in the morning/at noon. In LC patients cortisol, TRH, TSH, and GH serum level and all lymphocyte subsets (except for CD4) showed some altered circadian rhythmicity. Mesor of cortisol, TRH, GH, IL-2, and CD16 was increased, whereas that of TSH, IGF-1, CD8, CD8 bright, TcR-delta-1, and delta-TcS1 was decreased [75]. Peak times however are related similar to those of control subjects [75]. The melatonin/cortisol mean nocturnal level ratio was also decreased in LC patients [75, 76]. Taken together, these results suggested that lung cancer is associated with alteration in the proportions and 24-h profiles of various lymphocyte subsets; this may be related to disease

Lissoni et al. also observed in NSCLC treated by chemotherapy (+/− melatonin) that lymphopenia and altered cortisol rhythmicity were associated with worsened quality of life (QOL), loss of psychosexual identity, and lower spiritual and faith scores [77, 78].

The persistence of a circadian time structure like that of control normal subjects seems to be an independent prognostic factor, at least in advanced breast or colon cancers [10, 18, 79, 80]. As stated earlier, the strongest circadian rhythms are those of cortisol (with the clinical interest being the morning-afternoon gradient) and melatonin (with a nighttime peak) [2, 4]. Noninvasive easy-to-repeat assessment techniques have been validated for the determination of the 24-h time structure: titrations of cortisol and melatonin in the saliva and 6-hydroxymelatonin sulfate in the urine [81]. Nocturnal urinary 6-sulfatoxymelatonin is also correlated with the proliferation of cell nuclear antigen (PCNA) in lung tumors [68]. Thus, its determination might constitute a noninvasive tool to estimate circadian tumor cell

Cortisol diurnal rhythm and slope have been related to survival in metastatic breast cancer patients by Sephton et al. [18]. Similarly, the same authors together with Chinese counterparts could also link the quality of persistent diurnal cortisol

Assessment of the rest-activity circadian cycle by actometry measurements also

[1, 4, 5, 82–84]. In advanced colorectal cancer, it was demonstrated in two studies that patients retaining a prominent rest-activity circadian rhythm will enjoy better quality of life and sleep, less fatigue, less depression, and improved survival [82–84]. Such evaluations were proposed to lung cancer patients and validated [82–84]. Focan et al. evaluated rest-activity rhythms in 28 advanced NSCLC before chronotherapy [83]. Better general physical activity and circadian rhythmicity were recorded in those patients receiving also corticosteroids [83]. Hrushesky and his group also studied circadian function in NSCLC patients by actigraphic recordings [82, 84]. They tried to correlate the rest-activity rhythms with sleep disturbances, quality of life (European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30)) and mood (anxiety; depression—HADS—hospital anxiety and depression scale) [82, 84]. All patients suffered from severe disturbances of daily sleep-activity cycles, but each patient also maintained some degree of circadian organization. QOL measurements were correlated with circadian destruc-

seems an easy way to estimate the general circadian profile of individuals

tors, fatigue prominent during daytime, and altered moods [82, 84].

**84**

#### **7.1 General considerations**

During the last decade, the management of NSCLC has evolved [86–97]. Platinum-based chemotherapy remains the standard front-line in treatment of advanced unresectable NSCLC in which cisplatin or carboplatin are combined with another chemotherapeutic agent such as taxanes, pemetrexed, or gemcitabine [87]. However the results in terms of response rate, progression-free survival, and median overall survival remained stable over time [86–97].

Thus, progresses confirmed by phase III trials came from targeted and immunotherapeutic biological approaches. Targeted therapies against EGFR mutations and anaplastic lymphoma kinase (ALK) gene rearrangement have improved the survival in a small proportion of patients whose tumors were expressing these molecular abnormalities [88–91].

Also the recent development and success of immune checkpoint inhibition of programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4) for treating metastatic cancers seemed to open a new pavement for fruitful research [86, 92–97].

Unfortunately to the best of our knowledge, despite precise theoretical observations depicted related to circadian expression, on targets of TKI inhibitors, EGFR blockers, antiangiogenic agents, and immune active-agents (lymphoid system; PD1; PDL1), by now no study has been launched to take into account any chronobiological considerations!

### **8. Chemotherapy**

As a matter of fact, in NSCLC, only a few studies deal with considerations on temporal dimension for drug delivery.

Studies from Focan et al. have already been mentioned and reviewed elsewhere [14]. In the first pioneered study [14, 28], a significant better tumor outcome was observed in the group treated at the better dosing time, thus from 10 am for a 40-h sequential schedule [14]. In the second phase III trial using etoposide and cisplatin, despite varying toxicities, there were no differences in overall drug dose intensities nor in tumor outcome gauged by the frequency of tumor responses as well as survival [62]. On the contrary, Krakowski et al. observed an increased dose intensity of drugs when given at their best circadian schedule [63].

According to the results of the phase I-II trial described [59] that had confirmed diurnal tolerance of a complex infusion regimen including 5FU, Fol, and carboplatin for 5 days every 3 weeks, a phase II study was further performed on 68 advanced NSCLC previously untreated patients with the best circadian schedule [3, 14]. Tumor evolution remained within the frame of the literature, but patients enjoyed an improved therapeutic index [3, 14].

Lissoni et al. successively performed small randomized trials (with 20–40 patients per group) in advanced NSCLC patients [67, 68, 77, 78]. They observed progressive improvement of tumor outcome (response rate; 1-year survival, etc.) and quality of life through the association with standard cisplatin-based chemotherapy, melatonin, and sometimes interleukin-2 (IL2) [67, 68, 77, 78]. They have reviewed their results on 370 cases suffering from NSCL and gastrointestinal tract cancers [78]. They confirmed a higher rate of tumor responses and better long-term survival in patients who had received melatonin [78]. These observations were linked to positive circadian effects in cancer-relevant psycho-neuroendocrine and immune pathways [77, 78]. According to these authors, a high degree of faith may positively influence the efficacy of chemotherapy and the clinical evolution of NSCLC by improving the lymphocyte-mediated antitumor immune response and probably general host circadian rhythmicity [78].

Hrushesky's group performed also a randomized blinded trial on 84 advanced NSCLC patients receiving chemotherapy with etoposide and cisplatin together with melatonin or placebo (personal communication). Those patients receiving melatonin during the evening enjoyed higher response rates (29 vs. 8–11%) and longer survival in multivariate analysis (personal communication).

Two meta-analyses appeared to confirm survival benefits associated with melatonin therapy in cancer patients [98, 99]. One analysis has focused upon 8 trials that used a dosage of 20 mg of melatonin, while the second one reviewed 21 clinical trials on solid tumors using various doses of melatonin [98, 99]. Both analyses report that the administration of melatonin reduces the relative risk of death at 1 year by an average of 37%, doubles the frequency of complete response, and reduces the prevalence and/or severity of chemotherapy-induced nausea/vomiting, hypotension, and hematological toxicity. Thus some authors consider melatonin as a probable effective treatment for human NSCLC [100]!

#### **9. Targeted treatments**

Despite advances in research and a better understanding of the molecular pathways of NSCLC, few effective therapeutic options are available for most patients with NSCLC without druggable targets, especially for patients with squamous cell NSCLC [86–91].

Chrono-PKs of erlotinib have been investigated in rodents [55, 56]. On the other hand, Iurisci et al. observed an improvement of circadian rest-activity rhythms together with a relief of symptoms in a limited trial on advanced NSCLC patients [101].

Nevertheless, no trial taking into account temporal dimension has been launched at present time.

#### **10. Immunotherapy**

Immune checkpoint inhibitors such as anti-cytotoxic T-lymphocyte antigen-4 or anti-programmed death 1 (PD-1) or programmed death-ligand 1 (PD-L1) have induced durable response rates across a broad range of solid tumors. In NSCLC, pembrolizumab and similar antibodies have replaced chemotherapy as first-line

**87**

*Integration of Chronobiological Concepts for NSCLC Management*

nonsquamous histology irrespective of PD-L1 expression [92–97].

treatment for patients with PD-L1 tumor proportion score (TPS) of at least 50% [92–97], while pembrolizumab plus platinum and pemetrexed for those with

As discussed in previous chapters, it is conceivable to consider the temporal (diurnal) dimension when administering either targeted or immunologic treatments to lung cancer patients, but, to the best of our knowledge, no study on that subject has been launched to date. We could regret this lack of interest, while dissection of molecular pathways of the circadian clock system has been awarded in

In a single non-randomized limited study, gamma knife radiosurgery for brain metastases of NSCLC was delivered either in the morning (10.00 am to 12:30 pm, 58 cases) or in the afternoon (12:30 pm to 3:00 pm, 39 cases) [102]. Patients treated in the morning enjoyed better tumor local control at 3 months (97 vs. 67%), longer survival (9.5 months vs. 5 months), and a lower rate of central nervous system (CNS)-related cause of death. Those results, which may be related to circadian susceptibility of target cancer cells (? more cells in G2-M phase; more apoptosis in the morning?), prompted the activation of a prospective randomized RTOG study

With another methodology, Badiyan et al. [103] reevaluated the impact of daytime on tumor outcomes after stereotactic radiosurgery (SRS), in 437 patients NSCLC treated for CNS metastases. They confirmed a cut point of 11:41 am for

In this review, we have tried to gather pertinent animal and human data supporting the need to take into account temporal dimensions (i.e., circadian) for prevention and treatment of human NSCLC. The importance of biological rhythmicity was evidenced regarding carcinogenesis, molecular biology and genetics, cells kinetics, apoptosis, DNA repair mechanisms, platinum resistance, etc. These

Some randomized clinical trials for human LC have confirmed chronotolerance and probably chronoefficacy of combined chemotherapy. Furthermore, theoretical considerations allow to propose the application of chronobiological concepts to improve the management of human NSCLC either by working on the host circadian rhythmicity and on circadian variation of targets expression, such EGFR and VEGF receptors, or on the new molecular targets or pathways also circadian varying in

Similarly circadian variations in multiple immunological pathways warrant further interest. These considerations would bring hope to improve overall tumor outcome by optimizing "classical" therapeutic index of chemotherapies but also circadian host rhythmicity by acting on the central clock (i.e., by TKI administration) and/or molecular machinery (receptors, various enzymatic pathways, DNA

Also the potential role of melatonin as resynchronizing agent and as a potentially

Eventually the increased toxicity of chemotherapy in women is intriguing,

peculiarly when host circadian rhythmicity seemed to be implicated.

providing the highest predictive value for overall survival [103].

observations are fully applicable to human NSCLC.

their expression (e.g., ERCC1, DNA repair, Tip 60, etc.).

metabolism and repair, immunology pathways, etc.).

active agent warrants further evaluations.

*DOI: http://dx.doi.org/10.5772/intechopen.85710*

whose results have not yet been published.

2017 with a Nobel Prize!

**11. Radiotherapy**

**12. Conclusions**

*Integration of Chronobiological Concepts for NSCLC Management DOI: http://dx.doi.org/10.5772/intechopen.85710*

treatment for patients with PD-L1 tumor proportion score (TPS) of at least 50% [92–97], while pembrolizumab plus platinum and pemetrexed for those with nonsquamous histology irrespective of PD-L1 expression [92–97].

As discussed in previous chapters, it is conceivable to consider the temporal (diurnal) dimension when administering either targeted or immunologic treatments to lung cancer patients, but, to the best of our knowledge, no study on that subject has been launched to date. We could regret this lack of interest, while dissection of molecular pathways of the circadian clock system has been awarded in 2017 with a Nobel Prize!

#### **11. Radiotherapy**

*Chronobiology - The Science of Biological Time Structure*

probably general host circadian rhythmicity [78].

survival in multivariate analysis (personal communication).

a probable effective treatment for human NSCLC [100]!

**9. Targeted treatments**

launched at present time.

**10. Immunotherapy**

an improved therapeutic index [3, 14].

According to the results of the phase I-II trial described [59] that had confirmed diurnal tolerance of a complex infusion regimen including 5FU, Fol, and carboplatin for 5 days every 3 weeks, a phase II study was further performed on 68 advanced NSCLC previously untreated patients with the best circadian schedule [3, 14]. Tumor evolution remained within the frame of the literature, but patients enjoyed

Lissoni et al. successively performed small randomized trials (with 20–40 patients per group) in advanced NSCLC patients [67, 68, 77, 78]. They observed progressive improvement of tumor outcome (response rate; 1-year survival, etc.) and quality of life through the association with standard cisplatin-based chemotherapy, melatonin, and sometimes interleukin-2 (IL2) [67, 68, 77, 78]. They have reviewed their results on 370 cases suffering from NSCL and gastrointestinal tract cancers [78]. They confirmed a higher rate of tumor responses and better long-term survival in patients who had received melatonin [78]. These observations were linked to positive circadian effects in cancer-relevant psycho-neuroendocrine and immune pathways [77, 78]. According to these authors, a high degree of faith may positively influence the efficacy of chemotherapy and the clinical evolution of NSCLC by improving the lymphocyte-mediated antitumor immune response and

Hrushesky's group performed also a randomized blinded trial on 84 advanced NSCLC patients receiving chemotherapy with etoposide and cisplatin together with melatonin or placebo (personal communication). Those patients receiving melatonin during the evening enjoyed higher response rates (29 vs. 8–11%) and longer

Two meta-analyses appeared to confirm survival benefits associated with melatonin therapy in cancer patients [98, 99]. One analysis has focused upon 8 trials that used a dosage of 20 mg of melatonin, while the second one reviewed 21 clinical trials on solid tumors using various doses of melatonin [98, 99]. Both analyses report that the administration of melatonin reduces the relative risk of death at 1 year by an average of 37%, doubles the frequency of complete response, and reduces the prevalence and/or severity of chemotherapy-induced nausea/vomiting, hypotension, and hematological toxicity. Thus some authors consider melatonin as

Despite advances in research and a better understanding of the molecular pathways of NSCLC, few effective therapeutic options are available for most patients with NSCLC without druggable targets, especially for patients with squamous cell NSCLC [86–91]. Chrono-PKs of erlotinib have been investigated in rodents [55, 56]. On the other hand, Iurisci et al. observed an improvement of circadian rest-activity rhythms together with a relief of symptoms in a limited trial on advanced NSCLC patients [101]. Nevertheless, no trial taking into account temporal dimension has been

Immune checkpoint inhibitors such as anti-cytotoxic T-lymphocyte antigen-4 or anti-programmed death 1 (PD-1) or programmed death-ligand 1 (PD-L1) have induced durable response rates across a broad range of solid tumors. In NSCLC, pembrolizumab and similar antibodies have replaced chemotherapy as first-line

**86**

In a single non-randomized limited study, gamma knife radiosurgery for brain metastases of NSCLC was delivered either in the morning (10.00 am to 12:30 pm, 58 cases) or in the afternoon (12:30 pm to 3:00 pm, 39 cases) [102]. Patients treated in the morning enjoyed better tumor local control at 3 months (97 vs. 67%), longer survival (9.5 months vs. 5 months), and a lower rate of central nervous system (CNS)-related cause of death. Those results, which may be related to circadian susceptibility of target cancer cells (? more cells in G2-M phase; more apoptosis in the morning?), prompted the activation of a prospective randomized RTOG study whose results have not yet been published.

With another methodology, Badiyan et al. [103] reevaluated the impact of daytime on tumor outcomes after stereotactic radiosurgery (SRS), in 437 patients NSCLC treated for CNS metastases. They confirmed a cut point of 11:41 am for providing the highest predictive value for overall survival [103].

#### **12. Conclusions**

In this review, we have tried to gather pertinent animal and human data supporting the need to take into account temporal dimensions (i.e., circadian) for prevention and treatment of human NSCLC. The importance of biological rhythmicity was evidenced regarding carcinogenesis, molecular biology and genetics, cells kinetics, apoptosis, DNA repair mechanisms, platinum resistance, etc. These observations are fully applicable to human NSCLC.

Some randomized clinical trials for human LC have confirmed chronotolerance and probably chronoefficacy of combined chemotherapy. Furthermore, theoretical considerations allow to propose the application of chronobiological concepts to improve the management of human NSCLC either by working on the host circadian rhythmicity and on circadian variation of targets expression, such EGFR and VEGF receptors, or on the new molecular targets or pathways also circadian varying in their expression (e.g., ERCC1, DNA repair, Tip 60, etc.).

Similarly circadian variations in multiple immunological pathways warrant further interest. These considerations would bring hope to improve overall tumor outcome by optimizing "classical" therapeutic index of chemotherapies but also circadian host rhythmicity by acting on the central clock (i.e., by TKI administration) and/or molecular machinery (receptors, various enzymatic pathways, DNA metabolism and repair, immunology pathways, etc.).

Also the potential role of melatonin as resynchronizing agent and as a potentially active agent warrants further evaluations.

Eventually the increased toxicity of chemotherapy in women is intriguing, peculiarly when host circadian rhythmicity seemed to be implicated.
