What line of treatment? - 1247019

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What line of treatment? - 1247019

I feel like a newbie asking this question, but I don't know the answer and hope that others may also benefit from an explanation from an expert.
My question is how does one define a line of treatment?
In my case, I received my dx of stage IV adenocarcinoma in July, 2010. I began treatment with radiation therapy in August, 2010 to address bone pain due to met in my pelvis. Then I began treatment with Tarceva in January 2011 which I stayed on for nearly one year. After serious progression while on Tarceva, I was switched to IV chemo with Carbo/Alimta and concurrent radiation therapy to my right femur beginning in December 2011. In April, 2012, I went on to maintenance therapy using Alimta only and that is the current treatment I am receiving. During the two years since my dx, I have also received infusions of Zometa followed by Pamidronate and found I could not tolerate either. I then proceeded with Xgeva with no trouble and remain on Xgeva today.
Given the above information, how many lines of treatment have I received?
Thanks in advance!

Reply To: What line of treatment?

Dr. West made the distinction between 2nd line treatment and maintenance in this faq,
"It’s worth clarifying that as maintenance therapy is increasingly being considered as an option after first line therapy, a distinction between this and second line therapy. Maintenance therapy is given to prolong the period before someone who has achieved a response or stable disease on first line treatment demonstrates progression for the first time, while second line therapy is the term more commonly reserved for treatment after someone has demonstrated evidence of progression for the first time after first line therapy."

Treatments for stage IV lung cancer are described as lines of treatment. For those without an activating mutation first line treatment is usually a doublet or triplet combination of a platinum based drug, carboplatin or cisplatin paired with another drug such as gemzar or for non-squam alimta and sometimes a third drug avastin (Bevacizumab). 4 to 6 courses of this combo are found to be about as much as one can take before toxicity begins to outweigh benefit. After this a person can either begin maintenance therapy or break with treatment until progression when 2nd line it started. (also described in the link above)

However for those with an EGFR mutation or an ALK rearrangement there are new drugs, tarceva (Erlotinib) and iressa (gefitinib) for EGFR mutation and Xalkori (crizotinib) for those with an ALK rearrangement. These are given for 1st line treatment till progression. After progression a person can move to traditional chemo doublet described above (including maintenance phase).

Subsequent lines may be given until progression or become too toxic. Dr. Pennell wrote a very good blog/post on benefits of more treatment. http://cancergrace.org/lung/2009/11/24/who-benefits-from-third-line-trea...

Clinical trials are offered at transitions.

Reply To: What line of treatment?

Hello dback, I hope you are doing alright. I'm sure you feel better with that dog by your side. My husband often threatens to take ours to the treatment center and declare him a working dog.
As you may know I'm not an expert but I'll make sure Dr. West sees this and comments with corrections as needed.

The doctors here often call questions about what line something may be "semantics" however when you are thinking about trials it really makes a difference how the trialist counts them. Our faculty encourage looking into trial options at each transition.

I wonder if you would comment on the side effects you experienced with zometa and Pamidronate and how they differ from xgeva. There has been a handful of conversations about this and I've become curious-er.

forum moderator

Dr West
Reply To: What line of treatment?


It's a good question, and not that simple (I actually think you could get some different answers from different health care professionals, so don't feel like a newbie). The maintenance therapy role kind of throws in a monkey wrench, for which I think the consensus is to only consider a therapy as a next line if it is initiated due to progression. Therefore, second line treatment is the systemic therapy started after someone has progressed following either first line chemo or maintenance therapy, at least continuation maintenance (continuing with one or more of the same drugs started in the first line setting). However, "switch maintenance" with a new agent could be defined any which way...possibly a line of therapy, or possibly a new treatment just "shoe-horned" in between two lines of therapy.

You really don't count focal radiation as a line of therapy. You also don't count the treatments like Zometa (zoledronic acid) or XGEVA (denosumab). They're more modifiers than central anticancer treatments.

In summary, I'd say that you've received two lines of therapy, with first line Tarceva (erlotinib), then the second line chemo-based treatment, with the maintenance just being a long tail on the second line treatment. However, different clinical trials might have some variability in their definitions, so it's really not simple anymore.

-Dr. West

Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education