New Biological Insights and Recent Therapeutic Advances in the Management of Lung Cancer: A Clinical Investigator Think Tank
Algorithm for maintenance treatment after a first-line platinum-based doublet
4:56 minutes.
TRANSCRIPTION:
DR TSAO: So a young adenocarcinoma, no new mutations, right? So usually my go-to adjuvant is going to be a platinum/pemetrexed-based with or without the bev. So if I’m doing carbo/pemetrexed, I always will do pemetrexed maintenance. If I do carbo/pem/bev, I usually do continue the bev and the pem maintenance. And how I decide, aside from the typical bevacizumab eligibility issues, is, is this patient someone who really wants to be very aggressive, that you want to milk as much as you can out? Or is this somebody who is likely going to have a lot of side effects, is not exactly the most robust of young patient? DR LOVE: What about choice of platinum? DR TSAO: So in the metastatic setting, I typically go with carbo. DR LOVE: So that’s kind of a little mini algorithm right there, Jeff. Agree or disagree? DR OXNARD: I’m more like, in a young patient who has no cisplatin contraindications I’m likely to use cisplatin. If I use cisplatin, I don’t use bevacizumab — if I’m using carboplatin and they need a response, I might add bevacizumab to increase the strength. DR LOVE: If you’re using cis, you don’t use bev. Why is that? DR OXNARD: Cis/gem with or without bev was a negative trial. DR LOVE: Hmm. And what about maintenance in, particularly, the patient who ends up starting out with carbo/pem/bev, a common initial therapy? I don't know if you use that, but when you do, Anne says she uses both pem and bev maintenance. Is that what you do? DR OXNARD: I think pemetrexed is the more important maintenance agent, but it can depend on which toxicities. If you’re having hoarseness and complaining about hoarseness and hypertension, I’ll drop the bev. If you’re having platelet problems, I might drop the pem. More likely, they end up on pem for a longer period. DR LANGER: I’m pretty much similar to Anne. I can’t remember the last time I used cisplatin in metastatic disease, with the exception of patients I’ve inherited from Memorial. And then very frequently they switch over, often quite quickly, to carbo. Carbo/pem/bev, if they’re nonsquamous. We can argue whether bev really adds anything there. We’ve never done the formal Phase III trial in that setting. I think the time to have done that has probably come and gone. For maintenance, definitely pem, often pem and bev together. Frequently, the insurance company makes the decision for me. They will refuse to fund the combination. And again, you could argue cost. We don’t have any Phase III data showing a survival advantage for the combo versus either single agent in the maintenance setting. And hopefully, the ongoing Eastern Cooperative Oncology Group trial 5508 will address that. But if you look at the 2 trials, the subanalysis from PointBreak, there was about a 2-month median survival difference. Again, it wasn’t — in fact, we’ve never seen a p-value for that, and if you look at AVAPERL, about a three and a half-month difference, which unfortunately was not statistically significant. The trial was underpowered for that, but clearly a PFS benefit. So again, if they’re tolerating it well, no major toxicities, I don’t have an insurance contraindication, I’ll usually give the 2 together until some toxicity develops. For squamous, it’s almost always a taxane with carbo. DR SPIGEL: I guess kind of the same. I mean, for nonsquamous it’s carbo/pem is what I use. Four cycles and maintenance pem for squamous, like what Corey just said. Have dabbled with nab paclitaxel. DR LOVE: I didn’t hear bev in there. You don’t use it? DR SPIGEL: No bev anymore. DR LOVE: No bev anymore. Interesting. Mark? DR KRIS: I give bev to anybody who doesn’t have a contraindication. And I have very few contraindications. I’d give pem/cis and bev whenever I could. If I couldn’t give cis, I’d give paclitaxel with pem and bev. For adenos. For squamous, probably albumin-bound paclitaxel/cis would be my best one, docetaxel/cis, a taxane and cis. DR LOVE: What’s your general algorithm, though, along the lines of what he said here in terms of initial therapy and maintenance in metastatic adeno? DR CARBONE: So my algorithm is the ECOG trial as my first priority. And so it’s carbo/tax/bev, carbo/pac/bev with maintenance randomization. But off protocol, I’ve been giving carbo/pem with pem maintenance. DR LOVE: And what about bev? DR CARBONE: Typically I’ve gone away from bev, even though I was involved in all the trials that showed its benefit. And I do believe it’s an active regimen, but carbo/pem with pem maintenance is really well tolerated and doesn’t have a lot of the problems that bev has. |