Select Excerpts from the Discussion

Track 15

DR LOVE: Ed, how do you approach the choice of an adjuvant chemotherapy regimen?

DR KIM: I generally use cisplatin-based therapy. I use cisplatin/docetaxel 60 to 70 percent of the time and cisplatin/vinorelbine 30 to 40 percent of the time.

DR LOVE: Nasser?

DR HANNA: I use docetaxel/cisplatin. The logic behind that is docetaxel is a slightly superior drug compared to vinorelbine in the metastatic setting, and vinorelbine is the drug for which we have the most data in the adjuvant setting. I extrapolate that docetaxel will be more effective in the adjuvant setting. However, I have no qualms with colleagues using cisplatin/vinorelbine or other regimens from the trials.

DR LYNCH: I agree with Nasser. I answered the question as 90 percent cisplatin/docetaxel and 10 percent cisplatin/gemcitabine. However, if I see a 69-year-old patient six weeks postoperatively with a creatinine level of 1.7 mg/dL who doesn’t look so great, I would likely use carboplatin/paclitaxel.

Tracks 21-22

DR LOVE: Joan, can you discuss ECOG-E1505, which randomly assigns patients to adjuvant therapy with a cisplatin-based regimen with or without bevacizumab (1.1)?

DR SCHILLER: ECOG-E1505 is a Phase III trial for patients with selected Stage IB to IIIA NSCLC, who will be randomly assigned to four cycles of chemotherapy versus four cycles of chemotherapy and up to one year of bevacizumab. To some degree, the chemotherapy will be “dealer’s choice.” The referring physician can choose among cisplatin/gemcitabine, cisplatin/docetaxel and cisplatin/vinorelbine.

Eligible patients will have Stage IB to IIIA disease, with eligible IB tumors measuring greater than four centimeters in size. The reason for that is based on a subset analysis CALGB conducted of their adjuvant study, in which patients with larger Stage IB tumors were the ones who seemed to benefit (Strauss 2006). We’ll apply the typical bevacizumab exclusion criteria. Patients will be allowed to have had squamous cell carcinoma, however, because the disease will be removed. It is hoped that the histology will not be important if the tumor is not there.

DR GRECO: I believe the scientific aspects of the study are good, but we see a lot of arbitrary thinking about which adjuvant regimens we should use. People have strong feelings about cisplatin, and although I prefer to be more lenient with the type of chemotherapy allowed, many purists are designing the studies.

DR SANDLER: : I agree. The study was originally for all patients with Stage IB to IIIA disease. Then the CALGB update reported on this 4-cm concept, and the NCI was adamant that we use the 4-cm cutoff. So we’re using the 4-cm cutoff based on retrospective data from the CALGB-9633 study, which used paclitaxel/carboplatin (Strauss 2006), but they won’t allow paclitaxel/carboplatin in the E1505 study, which has been the only regimen to report survival data with bevacizumab (Sandler 2006).

DR SOCINSKI: I believe patients will balk not at the randomization between chemotherapy with or without bevacizumab but at receiving bevacizumab for a year. I speak with a lot of patients about adjuvant therapy — it usually is three or four cycles, and then they’re done. Now you have the patient who is postthoracotomy thinking about treatment that is either nine weeks or 12 months.

Track 51

DR LOVE: Tom, our faculty has treated patients between 70 and 83 years of age with adjuvant chemotherapy. What are your thoughts?

DR LYNCH: I believe that is a reasonable range. I don’t believe it’s wrong if you have an 83-year-old woman without other medical problems. It’s difficult to imagine she has lung cancer with no other medical problems, but if that’s the case, it’s reasonable to treat someone regardless of age. The catch is that there are very few patients who fit this description exactly. In general, we do consider age as a factor. Early eighties is probably as high as one should go.

DR SOCINSKI: When you use adjuvant therapy in older patients, what are you using? My practice has been to use cisplatin for all patients when I can, but we know cisplatin is a more toxic drug in the elderly. I was the one who used adjuvant therapy in the 83-year-old, and I used carboplatin/paclitaxel.

Select Publications