Frequently Asked Questions in Oncology: Lung Cancer
Members of the PracticeUpdate Oncology Advisory Board answer the most frequently asked questions by oncologists.
PracticeUpdate: What should be the sequence of treatment used for EGFR-mutant tumors?
Dr. Douillard: I am definitely convinced that the patient should be treated first with an EGFR TKI and then chemotherapy as the second-line. We are lacking data on that because the survival is the same, whatever the sequence. Some people prefer to start with chemotherapy rather than a TKI because they are never sure that, after TKI therapy, the patient will be fit to receive cisplatin- based chemotherapy. I think, given all the data that have been presented regarding quality of life, response rate, and the benefit of progression-free survival, that there is no doubt that a TKI should be used first.
PracticeUpdate: What is the best thing to do at disease progression?
Dr. Douillard: Of course, the best would be to rebiopsy. Actually, someone presented at the WCLC a series on more than 100 patients who were rebiopsied to try to better understand the mechanism of resistance. We will have to rebiopsy the patient at progression to understand which mechanism is at play in the development of resistance. This would be practice-changing. It will be difficult, but it will have to be done. I hope also that the so-called fluid biopsy, meaning the circulating free DNA analysis, could shed some light on the mechanism of resistance.
PracticeUpdate: Regarding chemotherapy, is maintenance or no maintenance better?
Dr. Douillard: Of course, we have the PARAMOUNT trial, which compared cisplatin to pemetrexed with pemetrexed maintenance or no maintenance. Results are clearly in favor of the maintenance. The community oncologists are concerned about the quality of life of the patient. This is a very good question because these patients die, with an average median survival of, let’s say, 12 to maybe 14 months. If patients respond, they could enjoy their life better if they use the maintenance. This is a question that people ask sometimes, and they're not really convinced of the benefit of it. It's the most frequently asked question for patients with metastatic disease.
The data on adjuvant chemotherapy are pretty convincing. It is generally well-accepted. I have to say that the overall benefit is not huge, but it is within the range of what we obtained with adjuvant chemotherapy in breast cancer and colon cancer. We are not curing everybody, but we are improving the 5-, 6-, 7-year survival. This is the endpoint, but it's not always accepted by the patients. Sometimes patients are referred for a second opinion to be convinced.
PracticeUpdate: What’s your feeling on smoking cessation?
Dr. Douillard: For most patients diagnosed with a metastatic NSCLC, the life expectancy is, as I said, 12 to 14 months. Whether they continue smoking or not will not dramatically change their life expectancy. For them to carry the burden of the diagnosis and the treatment and adding on top of that smoking cessation is, I would say, almost unethical. Because, for these patients who have been smoking for years, it's very difficult to stop. I never do, but I could easily say, listen, you're going to die in 1 year. So, enjoy living. Smoke and drink whatever you want to drink and smoke because it will not change the outcome.
The situation is totally different in resected patients and those with locally advanced disease treated with chemorediation. Patients may be cured. In those two situations, the smoking cessation is very, very important. There is a clear relationship between the rate of relapse and the continuation of smoking. These are the situations in which I do insist on the patient quitting smoking. It is known that the continuous exposure to tobacco increases the risk of relapse. However, if a patient is in stage IV, it's really difficult to push a recommendation for smoking cessation.
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