|Single-agent vs combination therapy|
|•||Overall survival with cisplatin(Drug information on cisplatin)-gemcitabine and bevacizumab(Drug information on bevacizumab) [Avastin] or placebo as fi rst-line therapy for nonsquamous non-small-cell lung cancer: Results from a randomized phase III trial (AVAiL), Ann Oncol online, February 11, 2010.|
|•||Single-agent vs combination chemotherapy in advanced non-small-cell lung cancer: The Cancer and Leukemia Group B (CALGB study 9730), J Clin Oncol 23:190-196, 2005.|
|•||Vinorelbine plus cisplatin vs observation in resected non-small-cell lung cancer, N Engl J Med 352:2589-2597, 2005.|
|Treatment in elderly patients|
|•||Adverse events among the elderly receiving chemotherapy for advanced non-small-cell lung cancer, J Clin Oncol 28:620-627, 2010.|
|•||Outcomes for elderly, advanced-stage non-small-cell lung cancer patients treated with bevacizumab [Avastin] in combination with carboplatin(Drug information on carboplatin) and paclitaxel(Drug information on paclitaxel): Analysis of Eastern Cooperative Oncology Group Trial 4599, J Clin Oncol 26:60-65, 2008.|
Toxicity with the combination therapy was acceptable, according to Dr. Quoix. There were more instances of moderate to severe neutropenia with the combination therapy compared with the single-agent therapy (47.8% vs 12.2%). As expected, she said, there was more neurotoxicity in arm A, with nine toxic deaths vs three toxic deaths in arm B.
MARTIN EDELMAN, MD
In the major lung cancer trials to date, the median age for of the subjects has been 62, but the majority of lung cancer patients today are 70 and over. "There are significant physiologic differences and frequent comorbidities in the elderly that make the applicability of these studies of younger patients questionable in the older age group," said Dr. Edelman, who is a professor of medicine at the University of Maryland Greenebaum Cancer Center in Baltimore.
Dr. Edelman and colleagues conducted a review of the SEER database and found that the majority of older lung cancer patients receive single-agent therapy (J Clin Oncol 28:2191-2197, 2010).
But in advanced disease, combination chemotherapy has conclusively demonstrated [itself] to be superior to single-agent cisplatin, he said. "Lung cancer is a disease of the elderly. Are these patients treated any differently than others? Should they be treated differently?"
The results from the French group clearly "support combination therapy for fit elderly patients," Dr. Edelman said. "This trial should change day-to-day practice and, once again, shows that there are benefits to the use of platinum-based combinations in this disease."
Dr. Edelman cautioned that the results should be not overextended as applying to all elderly patients; oncologists must be selective when deciding whether an older patient is a suitable candidate. The subjects in this trial were in good health, and while the combination treatment achieved superior efficacy, it came at a price of increased toxicity and mortality due to treatment, he said.
Dr. Edelman said that he was not "enthusiastic" about the choice of regimen in the experimental arm. "Carboplatin-paclitaxel, for better or worse, has been the comparative regimen since the mid-1990s in younger patients, but it has no real advantages over a number of other combinations and some disadvantages, most notably alopecia, myalgia, and neuropathy," he noted.
"I would have preferred to see a study with a single agent, either gemcitabine(Drug information on gemcitabine) or vinorelbine. A more intellectually satisfying study would have compared [gemcitabine or vinorelbine] to carboplatin and the same agent," he explained.
Also, the standard carboplatin-paclitaxel [regimen] is typically administered every three weeks; not the weekly dosing utilized in this study. "However, weekly paclitaxel was shown to be similarly effective and better tolerated, and I agree with this choice," he said.