Chemotherapy for Non Small Cell Lung Cancxer


Start with the basic principles about chemotherapy(here) for non-small cell lung cancer from the NCCN (here), and go here to understand PS or performance score.) In general two drug regimens like Platinol (cisplatin) plus Navelbine (vinorelbine) or Etoposide or Velban (vinblastine) and if the patient cannot tolerate cisplatin then Paraplatin (carboplatin) combined with Taxol (paclitaxel) or Taxotere (docetaxel) or Gemzar (gemcitabine) are options. Avastin (Bevacizumab) may be added to the chemo if the cancer is not squamous, the patient does not have a bleeding problem or brain metastases. In a patient who is a non-smoker with a cancer EGFR + it may be worth adding Tarceva (erlotinib) or Erbitux (go here). If the patient progresses on chemotherapy then second line chemotherapy with docetaxel or Alimata (premetrexid) or erlotinib may be an option . Reports of taxane/platinum combinations have shown relatively high response rates, significant 1-year survival, and palliation of lung cancer symptoms, response rates have been in the range of 27% to 53% with 1-year survival rates of 32% to 54%. the combination of cisplatin and paclitaxel was shown to have a higher response rate than the older combination of cisplatin and etoposide. A prospective randomized study compared 4 commonly used platinum-based chemotherapy regimens for patients with stage IIIB or IV non-small cell lung cancer: cisplatin/paclitaxel, gemcitabine/cisplatin, cisplatin/docetaxel, and carboplatin/paclitaxel. No regimen was found to have a significantly better response rate or survival.The response rate for all 1158 eligible patients was 19%, while the median survival was 7.9 months (95% confidence interval, 7.3 to 8.5 months).

Rather than chemotherapy alone, some of the new molecular targeted drugs are making an impact. Iressa has not worked out, but Tarceva has been shown to prolong survival by 45% for chemo-resistant cancers and when Avastin was added to chemoRx median survival went from 10.2 months to 12.5 months. More on Avastin here. The newest drugs for lung cancer include Iressa , Pemetrexed (Alimta), Tarceva (erlotinib), Erbitux (cetuximab). Tarceva and Iressa only benefit certain patients (go here). If the patient has a mutated form of EGFR then Iressa may be superior to chemotherapy ( go here).

In general the impact of chemotherapy for non-small cell lung cancer has not been as helpful as it has been for small cell lung cancer, (see editorial by Carney.) Giving chemotherapy right after surgery (so called adjuvant chemotherapy) is effective in breast cancer but for lung cancer less effective (5% absolute survival benefit, see the 2003 study from IALT.)

At the 2002 ASCO meeting they presented the CALGB 9730 trial for patients with advanced NSCL showing the benefit of two drugs (Carboplatin/Taxol) compared to Taxol alone. Even older patients ( over 70y) has improved survival with the combination (8 months versus 5.8 months) And though patients with low performance score had much worse survival (PS 0-1 8.8 mos versus PS 2 3.0 months, even the PS 2 benefited from the combination 4.7 mos versus 2.4 months survival.) The data are noted below and more data on the next page.


Drugs	Response Rate	Median Survival	Survival at 1 year
Taxol	17%	6.7 months	33%
Taxol/ Carboplatin	29%	8.8 months	37%