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Current Treatments for Advanced Stage Non–Small Cell Lung Cancer

¹ Multidisciplinary Thoracic Oncology Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina

Correspondence and requests for reprints should be addressed to Tom Stinchcombe, M.D., Multidisciplinary Thoracic Oncology Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Physicians Office Building, 3rd Floor, 170 Manning Drive, Cb 7305, Chapel Hill, NC 27599-7305. E-mail: Thomas_Stinchcombe{at}med.unc.edu

ABSTRACT

Lung cancer remains the leading cause of cancer mortality in the United States, and the majority of patients will have non–small cell lung cancer (NSCLC) and will present with locally advanced or metastatic disease. In the United States, the most common histology is adenocarcinoma, followed by squamous cell, large cell, and not otherwise specified. For patients with a preserved performance status (PS), double agent platinum-based therapy extends survival, improves quality of life (Qol), and reduces disease-related symptoms. The addition of a third cytotoxic agent increases toxicity without any clinical benefit. However, the addition of a targeted agent (bevacizumab, an antiangioegenesis agent, or cetuximab, an antibody against the epidermal growth factor receptor [EGFR]) to platinum-based therapy has yielded an improvement in survival compared with platinum-based therapy alone. To receive bevacizumab, patients are required to have nonsquamous histology, a PS of 0 or 1, and no evidence of brain metastases, hemoptysis, uncontrolled hypertension, and no need for therapeutic anticoagulation. The benefits of chemotherapy for patients with a poor performance status are less well defined, and the current recommendations are for treatment with single-agent chemotherapy. Elderly patients (defined as age 70 yr) derive a survival and Qol benefit from chemotherapy treatment, and for the majority of elderly patients single-agent chemotherapy is the standard. However, elderly patients with a good performance status and without co-morbidities can tolerate platinum-based therapy without excessive toxicity and appear to derive a survival benefit similar to that in younger patients. Recently, a separate population of patients defined by a light or never-smoking history has been identified. This patient population appears to have unique clinical and molecular characteristics, and may benefit from initial therapy with an EGFR tyrosine kinase inhibitor. Once patients have progressed on first-line therapy there are three agents available (docetaxel, pemetrexed, and erlotinib), but the efficacy of pemetrexed appears to be limited to patients with nonsquamous histology. Despite the improvements in care and number of therapeutic agents available, the survival for patients with advanced-stage NSCLC remains modest; novel approaches are required and participation in clinical trials should be encouraged.

Key Words: chemotherapy • targeted therapy • elderly • never smoking • poor performance status