Drug products: Abraxane, Apealea, Paclical, Pacligen, Paclitaxel, Paclitaxel Accord, Paclitaxel Actavis, Paclitaxel Ebewe, Paclitaxel Fresenius Kabi, Paclitaxel Pfizer, Paclitaxel ratiopharm, Paclitaxel Teva, Pacovary, Paxene, Pazenir, Taxol
ATC code: L01CD01
Female sex is correlated with higher exposure and greater risk of paclitaxel side effects. Data on sex-related differences in treatment efficacy in patients with non-small cell lung cancer (NSCLC) treated with paclitaxel suggest better outcomes in women, but this positive trend is not limited to the treatments containing paclitaxel. In general, female sex and younger age are associated with a better prognosis for NSCLC.
Generally, women mount stronger innate and adaptive immune responses than men . Women with lung cancer have a more favorable survival compared to men . The 5-year survival is 17 percent among men, and 24 percent among women, in Sweden .
The incidence of lung cancer has decreased among men since from 1980s but has increased significantly among women, which reflects women's changing smoking habits. Now the proportion of smoking women is greater than the proportion of smoking men. In Sweden lung cancer made up 6.1% of all yearly cases of cancer, year 2016. The incidence was higher among women (6.8%, n=2067), compared to men (5.4% , n=1824) .
Pharmacokinetics and dosing
A retrospective population analysis on 86 men and 82 women with solid tumors shows patient’s sex to affect paclitaxel distribution and elimination. Women reach saturation of the peripheral compartment at lower plasma levels (0.83 vs. 1.74 mmol/l), have 20% lower plasma maximal elimination capacities and a 20% lower maximal transport rate to the first peripheral compartment than in men. However, women also have a longer time to saturation of drug elimination (1 vs. 0.5 h) . According to the textbook “Sex and gender differences in pharmacology”, the maximum plasma concentration is higher in females, even after a body-surface-adjusted dose. According to the authors different muscle/fat ratios and transport processes (e.g., due to differing p-glycoprotein activity) may explain the different saturation concentrations and the longer maximal transport rate in females . These pharmacokinetic differences lead to an increased time above the toxicological threshold concentration in women and might explain the increased toxicity compared to male patients .
Women on average display higher expression and activity of CYP3A4. Sex-related differences in exposure could be of relevance for several substrates of the CYP3A family .
Eastern Cooperative Oncology Group (ECOG) E1594 trial randomized patients with advanced non-small cell lung cancer (NSCLC) to one of four platinum doublets (two included paclitaxel) and found that all four regimens had comparable efficacy. Eligible patients (726 men and 431 women) were included in an analysis that showed similar response rates (19% for both; p = 0.15). The median survival time for women, however, was signiﬁcantly longer, 9.2 months for women (95% CI, 8.1–10.4) versus only 7.3 months for men (95% CI, 6.8–8.0 months) (p = 0.004 log-rank test). Men were slightly older. However there was no difference in response, toxicity, or survival by age .
In another study several factors including patient’s sex obtained retrospectively by medical chart review and their role in outcome were analyzed. Eligible patients (147 men and 80 women) with unresectable stage IIIB-IV NSCLC who received first-line chemotherapy of carboplatin and paclitaxel were included. The median survival time was 11.9 months for men and 22.2 months for women (p < 0.001). The median progression free survival was also longer in women (5.3 vs. 4.4 months, p = 0.0081) . However, according to the authors, other factors like a more aggressive tumor in men and a higher percentage of never-smokers among female patients may have played a role .
However, a better outcome has been observed for female patients with NSCLC even with regimens not including paclitaxel [7, 8], or when paclitaxel was presented in both arms . In general, female sex and younger age ≤70 years are associated with better prognosis for NSCLC .
Toxicity is generally greater in women than in men [5, 6]. Significant higher frequency of toxicity (nausea, vomiting, alopecia, neurosensory, neuropsychiatric and cardiac toxicity grade 3 or higher) among women was observed . Yamamoto et al. noted grade 3–4 leukopenia in 15% of male and 39% of female patients (p <0.001) .
Reproductive health issues
Paclitaxel, like other mitosis inhibitors, may be harmful to the fetus and should not be given during early pregnancy. For more information regarding teratogenic aspects, please consult Janusmed Drugs and Birth Defects (in Swedish, Janusmed fosterpåverkan).
Date of litterature search: 2020-10-01
- Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol. 2016;16(10):626-38. PubMed
- Vera Regitz-Zagrosek. Sex and Gender Differences in Pharmacology. Springer-Verlag Berlin Heidelberg; 2012.
- Socialstyrelsen. Cancer i siffror 2018. Socialstyrelsen [www]. [updated 2018-06-10, cited 2020-10-01]. länk
- Joerger M, Huitema ADR, van den Bongard DHJG, Schellens JHM, Beijnen JH. Quantitative effect of gender, age, liver function, and body size on the population pharmacokinetics of Paclitaxel in patients with solid tumors. Clin Cancer Res. 2006;12(7):2150-7. länk
- Wakelee HA, Wang W, Schiller JH, Langer CJ, Sandler AB, Belani CP et al. Survival differences by sex for patients with advanced non-small cell lung cancer on Eastern Cooperative Oncology Group trial 1594. J Thorac Oncol. 2006;1(5):441-6. PubMed
- Yamamoto H, Sekine I, Yamada K, Nokihara H, Yamamoto N, Kunitoh H, Ohe Y, Tamura T. Gender differences in treatment outcomes among patients with non-small cell lung cancer given a combination of carboplatin and paclitaxel. Oncology. 2008;75(3):169-74. länk
- Shinkai T, Eguchi K, Sasaki Y, Tamura T, Ohe Y, Kojima A et al. A prognostic-factor risk index in advanced non-small-cell lung cancer treated with cisplatin-containing combination chemotherapy. Cancer Chemother Pharmacol. 1992;30(1):1-6. PubMed
- O'Connell JP, Kris MG, Gralla RJ, Groshen S, Trust A, Fiore JJ et al. Frequency and prognostic importance of pretreatment clinical characteristics in patients with advanced non-small-cell lung cancer treated with combination chemotherapy. J Clin Oncol. 1986;4(11):1604-14. PubMed
- J P O'Connell, M G Kris, R J Gralla, S Groshen, A Trust, J J Fiore, D P Kelsen, R T Heelan, R B Golbey. Frequency and prognostic importance of pretreatment clinical characteristics in patients with advanced non-small-cell lung cancer treated with combination chemotherapy . Lancet Oncol. 2019;20(7):924-937. länk
- Chansky K, Sculier JP, Crowley JJ, Giroux D, Van Meerbeeck J, Goldstraw P et al. The International Association for the Study of Lung Cancer Staging Project: prognostic factors and pathologic TNM stage in surgically managed non-small cell lung cancer. J Thorac Oncol. 2009;4(7):792-801. PubMed
- Concise (INSIKT). Kalmar: eHälsomyndigheten. 2018 [cited 2019-03-14.] länk
Reviewed by: Diana Rydberg, Carl-Olav Stiller
Approved by: Karin Schenck-Gustafsson