I recently took over the care of a patient who just relocated to my town to live with his children. He is a 70 year old gentleman who has metastatic lung adenocarcinoma EGFR/ALK negative. The metastatic sites include lungs, liver and bones. He just completed 4 cycles of carbo/taxol with partial response. He was never offered bevacizumab in the front line setting. Despite his age, he tolerated treatment well and maintained good performance status. Since he obviously still has residual disease, I recommend switch maintenance with pemetrexed. I am tempted to add bevacizumab because now seems to be a good time and he has no contraindication for bevacizumab. However there is little data to use it in this setting. Most of the maintenance bev was used as part of continuation maintenance.
I would like to get some input from the experts here.
Reply # - September 20, 2012, 10:14 PM
Reply To: switch maintenance with pemetrexed & bev
That's a tough one. No real data here, and this is the kind of question that is often answered by insurers if they refuse Avastin (bevacizumab) outside of the setting in which it's usually used.
If there were any relative contraindications, I wouldn't be inclined to pursue it, but if the patient is a great candidate, I'd want to talk about risks and benefits and see if it would be covered. If yes, I'd probably favor it. But I think this is a question for which you couldn't hope too see a strong consensus, given the lack of data.
I hope that non-answer helps.
-Dr. West
Reply # - September 20, 2012, 10:27 PM
Reply To: switch maintenance with pemetrexed & bev
Dr. West:
Isn't there data supporting the use of both Pemetrexed and Avastin as maintenance?
thanks
ssflxl
Reply # - September 21, 2012, 09:16 AM
Reply To: switch maintenance with pemetrexed & bev
ssflxl, Here is a discussion about the data that suggest Alimta is best used as continuation therapy as opposed to switch therapy (starting with alimta then continuing it without the platinum as opposed to starting with something else like taxol and platinum then changing to alimta). I know this isn't your question but I'm too trying to learn here and think it is useful background info. Bear with me as I try to figure this out. We always have a doctor to fall back on and show us/me faulty thinking where needed.
Dr. Socinski explains here, "You can see the slide lists the difference in one and two year survival, which is slightly over 10%
in favor of continuation maintenance pemetrexed in those patients receiving first line pemetrexed.
If you look at the final overall survival from induction, you see nearly 17 months median overall
survival with pemetrexed in this particular trial.
There had been some previous data suggesting that the real benefit of maintenance pemetrexed
was in those patients who had stable disease and at least pemetrexed as a switch maintenance
agent the data was not as strong for patients who had robust responses to first line chemotherapy
that did not contain pemetrexed. You see here in this particular trial looking at continuation
maintenance that both patients with responding disease as well as stable disease had very similar
impacts on overall survival as a result of continuation maintenance pemetrexed." from http://cancergrace.org/lung/2012/08/18/asco-12-paramount-os/ The link contains a podcast with slides, slides alone, and a pdf version.
Info on avastin to be continued...
Reply # - September 21, 2012, 10:19 AM
Reply To: switch maintenance with pemetrexed & bev
It seems the real answer is there is no data to suggest giving avastin after first line adds anything. So searching for the blog/post that explains that doesn't exist and is futile...at least for now. The info about maintenance avastin is continuation not switch maintenance, which is what we're talking about here.
Dr. West said in this thread, http://cancergrace.org/topic/alimta-vs-alimta-and-avastin
" We don’t know if Avastin (bevacizumab) adds anything significant as a maintenance or 2nd or 3rd line therapy. We generally don’t start Avastin after first line, and that’s partly because it’s quite expensive, the side effect risks aren’t negligible (even if typically modest), and there just isn’t evidence that it confers any significant advantage.
-Dr. West"
Reply # - September 21, 2012, 03:45 PM
Reply To: switch maintenance with pemetrexed & bev
There are certainly data that say that the Alimta/Avastin combination is feasible, and both the AVAPERL study and the PointBreak trial include data showing that the combination appears superior to Avastin alone in many ways. There aren't data yet to say that the combination is better than Alimta alone.
I'm pretty sure that what Dr. Socinski was speaking to was the question of whether maintenance therapy, or particularly continuation maintenance, is primarily or exclusively effective in patients who had significant tumor shrinkage first line, and not as much in the patients who achieved stable disease. The progression-free survival (PFS) data from the PARAMOUNT trial showed that patients with signficant tumor shrinkage were the ones with a real improvement in PFS from continuation maintenance Alimta, but the overall survival (OS) data presented this year showed that the benefit in OS is comparably improved in both patients with an objective response (tumor shrinkage) and stable disease in the first line setting.
-Dr. West