Non-Driver NSCLC: Practice Considerations - Episode 3
Mark Socinski, MD:In patients with a good performance status with recently diagnosed stage 4 squamous carcinoma, the standard of care is a platinum-based doublet. Now, the choice of platinum that we have is really either cisplatin or carboplatin. I tend to use carboplatin; it’s a little easier, with a more favorable toxicity profile. And then you pair that with a second drug. Now, that second drug typically is one of the taxanes, and we have 3 choices. Paclitaxel or nab-paclitaxel as well as docetaxel are all reasonable, or gemcitabine. In this case, our patient was treated with gemcitabine, which is an option in this setting. In my practice, I tend to use nab-paclitaxel in combination with carboplatin because of the higher response rates seen in that. And the justification for that is that almost all patients with stage 4 disease with squamous have some symptom burden. And since the higher response rate is there, it’s more likely to have a palliative effect at symptom relief. And there is actually evidence in the literature to support that.
The worsening fatigue typically occurs after 3 or 4 cycles or so. Fatigue can be present at the time of diagnosis. Fatigue is obviously a very nonspecific symptom. Sometimes it can be related to anemia, sometimes it can be related to the disease or the treatment, and sometimes it can be an early sign of depression and other things ongoing. So, I think you have to kind of cast a wide net in terms of thinking about fatigue in these patients in trying to address it, because in many studies that tends to be the most common toxicity we see in these patients. But it’s also a very complicated toxicity.
What we’ve addressed so far is the treatment of good performance status patients. And those would be an ECOG performance status of 0 to 1. When you get a little bit more compromised either by your disease or by your comorbidities and you get to PS of 2, for the most part, I still use platinum-based doublets if I think the cancer is driving the performance status. Sometimes, there are patients who have such extensive comorbidities that I may not use a platinum-based doublet. I may use single-agent therapy in that setting.
If the performance status erodes to a performance status of 3 or 4unless you have an oncogenic driver, which is exceptionally rare in these patients—then the standard of care is best supportive care in that population, and I would consider hospice care in the very poor ECOG performance status 3 or 4 patient.
Transcript edited for clarity.