Potential Treatment Options After First-Line Chemotherapy for Advanced NSCLC: Maintenance Treatment or Early Second-Line?

Abstract

Although substantial progress has been made in the therapeutic options currently available for patients with advanced non-small cell lung cancer (NSCLC), the overall survival profile remains poor for most patients. One of the strategies currently under investigation with the aim of prolonging survival in NSCLC patients is maintenance treatment with either a chemotherapeutic agent or a molecularly targeted agent after first-line chemotherapy. Moreover, this can consist of drugs included in the induction regimen or other noncrossresistant agents. With the currently available data, maintenance treatment with a different noncrossresistant agent (i.e., an early second-line treatment) is perhaps the most promising strategy. The drug chosen for the early second-line treatment should be a well-tolerated agent, considering that patients have just completed a particularly toxic platinum-based chemotherapy. Extending treatment with targeted agents rather than chemotherapy can provide longer progression-free and overall survival times without increasing toxicity. However, at the moment, only progression-free survival has been shown to be consistently superior with maintenance approaches; the evaluation of survival benefits is warranted before defining this strategy as a possible treatment option. Further studies are warranted to establish the role of maintenance chemotherapy in patients with advanced NSCLC.

Maintenance treatment of advanced non-small-cell lung cancer: Results of an International Expert Panel Meeting of the Italian Association of Thoracic Oncology

“…According to current guidelines [1][2][3][4][5], fit patients with advanced non-small-cell lung cancer (NSCLC) eligible for first-line treatment should receive platinum-based chemotherapy for a limited number (4)(5)(6) of cycles. In recent years, the opportunity of extending the duration of first-line treatment has received great attention, due to the positive results of several studies that tested "maintenance" strategies in patients without disease progression at the end of the planned cycles of chemotherapy.…”

“…In principle, prolonged duration of treatment can be realized with chemotherapy (continuing one or all the drugs previously administered as first-line, or switching to a different agent) or with a targeted agent (continuing the same agent previously administered with chemotherapy as with bevacizumab and cetuximab, or starting a new targeted agent such as erlotinib or gefitinib). Whether this strategy should be called "maintenance" treatment, or prolonged duration of treatment, consolidation therapy, or sequential treatment is a matter of semantics [6]. An important distinction, both from a conceptual and a practical point of view, should be made between "switch maintenance" (the use of mechanistically different drugs from those previously administered as first-line) and "continuation maintenance" (the prolonged administration of one or more drugs already used as part of first-line treatment).…”

Maintenance Therapy for Advanced Non-small Cell Lung Cancer: Current Status, Controversies, and Emerging Consensus

“…Because the overarching goals of cancer care are to prolong survival and improve patients' quality of life, an effective maintenance therapy should seek to achieve both of these goals, failing which it must be conclusively proven to not adversely impact the achievement of these goals. Maintenance therapy has also been referred to in the literature as "consolidation therapy" or "early second-line therapy" depending on the goal of the treatment and the type of therapeutic agent (9,10).…”

A cross-market cost comparison of erlotinib versus pemetrexed for first-line maintenance treatment of patients with locally advanced or metastatic non-small-cell lung cancer

“…6 An alternative treatment strategy that can be used to prolong first-line treatment duration and extend survival in locally advanced or metastatic NSCLC is first-line maintenance therapy. Maintenance therapy is defined as the prolongation of treatment duration with administration of additional treatment at the end of a defined number of initial chemotherapy cycles, after maximum tumour response has been achieved (this may be complete response, partial response or stable disease) [8][9][10][11]. Erlotinib (Tarceva ® ; F. Hoffmann-La Roche, Basel, Switzerland), an oral epidermal growth factor receptor tyrosine kinase inhibitor [2], is one of only two treatments approved for use as maintenance therapy by the European Medicines Agency, the other being pemetrexed (Alimta ® ; Eli Lilly, Indianapolis, IN, USA) [12].…”