Part 1: Using Adjuvant Chemotherapy for EGFR-Positive NSCLC

Article

During a live virtual event, Matthew A. Gubens, MD, MS, discussed adjuvant chemotherapy using carboplatin or cisplatin in patients with EGFR-positive non–small cell lung cancer.

Matthew A. Gubens, MD, MS (Moderator)

Thoracic Oncologist

UCSF Thoracic Surgery and Oncology Clinic

Helen Diller Family Comprehensive Cancer Center

UCSF Health

San Francisco, CA

Matthew A. Gubens, MD, MS (Moderator)

Thoracic Oncologist

UCSF Thoracic Surgery and Oncology Clinic

Helen Diller Family Comprehensive Cancer Center

UCSF Health

San Francisco, CA

DISCUSSION QUESTIONS

  • What is the role of adjuvant chemotherapy in your practice? What are the treatment goals?
  • Which regimen(s) do you typically employ?
  • Which parameters are important when deciding on whether to use adjuvant systemic therapy post resection?

MATTHEW GUBENS, MD, MS: Do you talk about goals with your patients? Are you giving numbers in your clinic? How is that conversation going?

MUJAHID RIZVI, MD: You are looking at the risk factors or the poor risk features—age, performance status, size of the tumor, all of those things—giving the patient the numbers as well. A lot of times if they are older, in my experience, when you give them the numbers, if the tumor is on the smaller side, a lot of them will say no [to adjuvant therapy]. But that is what usually happens.

TIMUR MITIN, MD, PHD: There is also an important component of what the surgeons have told the patient. If the surgeon said they got all [of the cancer], it is going to convince the patient [not] to get any other additional treatments. If the surgeon said that the tumor that has a tendency to recur, and they need to talk to a medical oncologist to reduce those chances, usually that is a better setup for further discussions.

GUBENS: That is an excellent point, especially when we are talking about smaller, node-positive tumors. They are not sure that some of those patients get to our clinic; the surgeon is confident that they got it all even if they are evidence based. Maybe it is just not foremost on their mind to think that a 4.1-cm tumor needs much more attention than surveillance, so a good point. There is priming being done all around the clinic.

What kind of regimens are people using for patients with adenocarcinoma? If you are deploying an adjuvant chemotherapy for a patient with stage IIB adenocarcinoma, what are you using?

MICHAEL HARRIS, MD: I tend to use pemetrexed [Alimta] and carboplatin for a patient with adenocarcinoma. I tell the patient that there are some options including taxanes, but when I describe neuropathy as being frequent accompanying it, that in a potentially curable situation, neuropathy can be long lasting or permanent, usually I gravitate back toward pemetrexed.

GUBENS: Do you want to weigh in on that cisplatin vs carboplatin age-old debate? I feel like there have been debates of the lectern since I was young. Are physicians reaching for cisplatin and are you talking about both with patients?

HARRIS: Usually, I will bring up cisplatin as being the more curative by 3% or 4%. I used to be more of a proponent of Anthony Greco, MD; he says for these patients, despite the small benefit of cisplatin over carboplatin, the quality-of-life issues are probably significant as well. So I will usually ask the patient. But if they are an elderly patient and they have impaired kidney disease or a creatinine elevation of any kind, it is difficult for me to push very hard with cisplatin.

RACHNA ANAND, DO: I also use a carboplatin-based doublet in most patients unless they are a young patient, early 60s or late 50s, who does not have too many medical conditions. In that case, I stick to a cisplatin-based doublet.

RIZVI: I try to give cisplatin as much as possible. I am usually very generous with fluids in the week they get cisplatin to keep their kidneys [healthy].

DIANA SUPERFIN, MD: I try to do cisplatin. I have to sometimes give hydration. Sometimes I may dose-reduce cisplatin, 20% on the first cycle…then if they tolerate it well, I will go up to the full dose on the second. If the patient cannot do that for whatever reason—renal function or a lot of comorbidities—I will do carboplatin.

GUBENS: There is a gradient, too. The older the patient, the more comorbidities, the quicker you are going to jump off this cisplatin wagon or accept that you need to go to carboplatin. I think that that is fair.

The National Comprehensive Cancer Network guidelines have a list of relative factors aside from the strict staging that might influence whether or not you choose chemotherapy.1 I think the most provocative one is probably the tumor size. Are there factors that make you treat someone with a tumor under 4 cm without nodes? That is a population for which there is not randomized control data favoring overall survival [OS] benefit.

HARRIS: This was looked at in the CALGB 9633 study [NCT00002852]; it was subset analysis [looking at] what we do for something 3.9 cm vs 4.1 cm.2 I think you have to use some judgment as well. I [am not sure] about the strength of the statistics in that subset analysis, but it is suggestive benefit if it is greater than 4 cm. So I usually tell the patients that.

GUBENS: Fair enough. Dr Superfin, you brought up DetermaRx. Are you using it in that setting?

SUPERFIN: Yes, I use DetermaRx in adenocarcinomas stage IA to IIA. Mostly IA because IB and IIA, [we’re usually] already giving chemotherapy. That is a gray area. In the high- or intermediate-risk patients, I offer chemotherapy. [DetermaRx] does give me EGFR results, but even with EGFR-positive disease, I cannot use [chemotherapy in] IA, because the study was done in IB or higher. I have used it in a couple of patients already. I give cisplatin-based doublets if I can.

References:

1. NCCN. Clinical Practice Guidelines in Oncology. Non-small cell lung cancer, version 2.2022. Accessed March 8, 2022. https://bit.ly/33qNCn6

2. Strauss GM, Herndon JE 2nd, Maddaus MA, et al. Adjuvant paclitaxel plus carboplatin compared with observation in stage IB non-small-cell lung cancer: CALGB 9633 with the Cancer and Leukemia Group B, Radiation Therapy Oncology Group, and North Central Cancer Treatment Group Study Groups. J Clin Oncol. 2008;26(31):5043-5051. Doi:10.1200/JCO.2008.16.4855

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