Clinical Decisions in Non-Driver NSCLC - Episode 3
Benjamin P. Levy, MD:When using an antiangiogenic drug with a platinum doublet, I think what we’ve learned from both the ECOG 4599 and REVEL trials is that when we add these drugs to a platinum doublet, it enhances the response. The response rates from some data with a platinum doublet can be as high as 35% or 40%. When you have response rates like that, I think it’s important that we consider using these drugs.
Maintenance therapy is so important for our patients with advanced-stage nonsmall cell lung cancer, particularly nonsquamous non–small cell lung cancer. For a patient in which I started on carboplatin/pemetrexed/bevacizumab, if they are a) tolerating the regimen and b) deriving a benefit as evidenced by scans, this is a patient who I would put on maintenance. I would put them on both maintenance pemetrexed and maintenance bevacizumab together every 3 weeks, and that’s important. The discussion about maintenance must start at the beginning of therapy. We cannot have this discussion after 4 to 6 cycles.
So, for patients who come inin which I’m considering a platinum doublet with or without bevacizumab—I have that discussion up front. I tell them, “You’re going to get 4 to 6 cycles. When we’re done, we’re going to drop one of the drugs, the carboplatin, and we’re going to continue the pemetrexed and the bevacizumab.” Maintenance works, maintenance improves survival, and most often, it’s tolerated. And when you have that, it’s important to deliver it. I don’t want patients to get confused, so I talk about this whole strategy up front. We’ve got very good data, even going back from ECOG 4599, which incorporated a maintenance strategy with bevacizumab, as well as data with pemetrexed, with the PARAMOUNT data showing that maintaining these drugs improves survival. So, I think survival is hard to come by in lung cancer trials, and when we see it, we need to incorporate that strategy that was exploited from the trial.
I usually give maintenance therapy for as long as a) the patient is tolerating it and b) the tumor is in check. Sometimes that could be months, it could be years for patients. I have several patients who have been on maintenance Alimta (pemetrexed) or maintenance Avastin (bevacizumab) for 2 or 3 years. Now, those are certainly outliers, but I generally try to give the drug every 3 weeks or both drugs, Alimta and Avastin, every 3 weeks for as long as they’re tolerating it, as long as their quality of life is maintained, and as long as the tumor is in check.
When patients’ tumors start to grow, I think we have to be very critical in our analysis of what we’re going to do next. We need to think about symptom burden, we need to think about how quickly the tumor is growing. But, importantly, we also need to look at the patient’s performance status. Those all have to go into an individualized treatment decision. I would say, for the most part, if a patient is progressing on maintenance or their tumor is growing on maintenance, this is an opportunity, of course, for a clinical trial if they’re not a part of one initially. At my institution, we certainly try to screen every patient for a second-line clinical trial. But outside of a clinical trial, I would say immunotherapy is very appropriate in this setting. I wouldn’t generally give docetaxel/ramucirumab as a second-line here. This is a patient who has garnered a long benefit from chemotherapy. This is an opportunity for immunotherapy or immunotherapy combinations under the auspices of a clinical trial.
Transcript edited for clarity.