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DR LOVE: Ed, what treatment would you be thinking about for this patient?

DR KIM: We would talk with a radiation oncologist and plan on concurrent chemoradiation therapy. Many different agents are available that could be used.

The two regimens that I usually prefer are the SWOG-S9504 regimen — using cisplatin and etoposide followed by consolidation docetaxel — or cisplatin and docetaxel, each administered weekly (Gandara 2003, 2005; [2.1]).

Of course, you can also consider this patient for a clinical trial. He sounds like a fit person, and a trial with bevacizumab or some other agent, even cetuximab, is something to consider.

DR LOVE: What happened with this man?

DR GRABELSKY: He was treated a few months ago, so the bevacizumab trials were not yet open. He received etoposide and cisplatin with concurrent radiation therapy as in the SWOG study, followed by docetaxel every three weeks at 75 mg/m² (Gandara 2003, 2005a, 2005b; [2.1]).

He tolerated it fairly well. Toward the end of his combined-modality therapy, he had Grade II esophagitis and a moderate degree of anemia, which was treated with an erythropoietin agent. We decided to prophylactically treat him with pegfilgrastim with the docetaxel, and he had no significant problems with neutropenia.

He’s now approximately six months out, and so far he is doing beautifully. A repeat PET scan on completion of therapy was negative, and CT scans and MRI of the brain were also negative.

DR LOVE: Roy, how do you approach the selection of a chemotherapeutic regimen to combine with radiation therapy in this situation?

DR HERBST: I believe the therapy this patient received was a good choice. The data from the SWOG Phase II report and the recent data from the Phase III report of SWOG-S0023 suggest that this combination continues to look like a winner (Kelly 2005).

I believe all the data over the last five or more years tell us that concurrent chemoradiation therapy is the way to go. One could do it with cisplatin and etoposide followed by docetaxel in the consolidation setting (2.2).

Many doctors in Houston at MD Anderson also use weekly carboplatin with paclitaxel during the radiation therapy, followed by two cycles of consolidation carboplatin and paclitaxel, because of the ease of administration.

I think that’s also reasonable. In the next year or so we’ll start seeing bevacizumab brought into this setting as well.

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