What treatment options do you consider in the first-line setting for patients such as Robert, who lack actionable mutations (e.g.; EGFR, ALK)?
In the first line setting for those patients who do not have actionable oncogenic drivers, the standard of care is chemotherapy. In advanced disease, it's really choosing the appropriate platinum-based doublet, which we base upon the histology of the patient. We kind of think of squamous options as different than non-squamous options. This gentleman with large-cell carcinoma obviously has a non-squamous option.
The two platforms of platinum-based doublets I would consider in this gentleman would be carboplatin with either pemetrexed or paclitaxel. There are others, but I think in practice today those are the two that rise to the top as the two first choices. The other option that we consider is do you add a drug like bevacizumab, an antiangiogenic, to this patient. Certainly he fits in the non-squamous diagnosis category, so that would be a consideration. We know that he has no brain metastases, so that's not an issue. The history tells us that he has no history of hemoptysis. He does no have any significant co-morbidities that would make me shy away from a drug like bevacizumab.
He is 72, so I think age is a consideration. There is no absolute age in which I would decide not to use bevacizumab, but I think the data suggests that with increasing age, you run the risk of increasing toxicity. So this gentleman, I would probably reccomend most likely carboplatin and paclitaxel plus bevacizumab. I think if there were concerns about toxicity, for instance if he had any evidence on baseline exam of neuropathy or he had a wonderful head of hair and alopecia was important to him, then I think it would be very reasonable to use carboplatin with pemetrexed plus bevacizumab. That would be based on their equivalent outcomes in the PointBreak trial.
mNSCLC: Case 1
RP is a 72 year old whose past medical history is notable for hypertension (well-controlled), hyperuricemia, and gout. He presents to his PCP with fatigue, progressive dyspnea, and a persistent, nonproductive cough of approximately 1 month’s duration. He is a former smoker and quit approximately 30 years ago.
Chest X-ray in October 2015 showed a large mass in the upper left lobe and CT scan showed a left pleural effusion and enlargement of the left mediastinal and hilar lymph node.
MRI of the brain was negative for intracranial metastases.
The patient underwent resection of the primary mass which showed large cell carcinoma. Pleural fluid was tapped and also positive.
His lung cancer was staged as 4. His biopsy was sent for molecular testing and showed no actionable mutations in EGFR or ALK.
His current performance status is 1.