OVERVIEW OF CHEMOTHERAPY FOR ADVANCED STAGE IIIB-IV NON SMALL CELL LUNG CANCER 1

Chemotherapeutics in lung cancer are rapidly evolving, with new drugs, new routes of drug administration and and new schedules. In his presentation, Professor Gebbia addresses a number of important clinical issues that have arisen in this field and presents recent evidence that guides current treatment strategies in advanced NSCLC. View article powerpoint (large file warning)

Specific areas covered in the presentation include:- Performance status 0-1 a) CBDCA or CDDPb) Platinum-free or basedc) Doublets or Tripletsd) New chemotherapy drugse) Biologics- Performance status 2- Elderly patients- Second-line therapy (even a third-line ?)PERFORMANCE STATUS 0-1 PATIENTS (Patients able to carry out pre-disease performance without restriction, or only restricted in strenuous physical activity but still able to carry out work activities.) Data from phase III trials suggests that chemotherapy for fit patients with advanced NSCLC (poor prognosis stage IIIB, IV) improves survival; improves performance status and cancer related symptoms; improves quality of life; is cost-effective and is superior to best supportive care.The chemotherapeutic regimen should include CDDP (cisplatin) when possible; should be started early and should not exceed 6 cycles. The most widely employed CDDP-based regimens include: CDDP + Vinorelbine; CDDP + Gemcitabine; CDDP + Paclitaxel; CDDP + Docetaxel; and CDDP + Irinotecan. A number of randomised trials (ECOG and SWOG phase III trials, as well as CALGB, TAX 326, NCCGS, and EUROPEAN trials) comparing new doublet chemotherapeutic regimens have not indicated superiority of any one combination chemotherapy regimen over another for the treatment of metastatic NSCLC. (Ettinger DS, Sidney Kimmerl Cancer Center at JHU, The Oncologist 7 : 226-233, 2002) (Schiller et al.). There is a choice of treatments rather than a treatment of choice in stage IIIb-IV NSCLC. Choice should be based on familiarity with chemotherapy, expected toxicity, convenience of administration, and costs.These conclusions are reflected in the 2004 American Society of Clinical Oncology Guidelines which state that for non-resectable stage III NSCLC, chemotherapy plus radiotherapy prolongs survival and is appropriate for patients with good performance status. The guidelines recommend 2-4 cycles of a platinum-based combination chemotherapy regimen in addition to radiotherapy, which should be no less than the biologic equivalent of 60 Gy in 1.8 to 2.0 Gy fractions.Platinum-free regimens:Although CDDP-based chemotherapy is the standard treatment for fit patients with stage IIIB-IV NSCLC, non-CDDP based combinations with new drugs are effective, and may represent a valid therapeutic choice if CDDP needs to be avoided.The use of CDBCA in combination with newer drugs seems to be a good therapeutic choice for unfit patients or if the oncologist wants to maintain patients’ quality of life unchanged in terms of side-effects. Three-drug regimens:Phase III trials have shown no survival advantage of three-drug regimens over two-drug regimens, with higher toxicity. Three-drug regimens should not be considered a standard therapy and their use should be reserved to experimental trials (i.e. pre-operative chemotherapy).