Appropriate Chemo Regimens with Radiation for Locally Advanced NSCLC

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Dr. Nasser Hanna, Indiana University Health, lists chemo regiments appropriate for use with radiation in locally advanced NSCLC.



I’m often asked, “what is the preferred chemotherapy treatment that we should be giving to patients when combining it with radiation for those with stage III disease?” We know that for patients who have stage IV disease, we commonly give a two drug chemotherapy regimen. One of those drugs is a platinum agent, either carboplatin or cisplatin, and then the second drug really depends upon the histology or the particular subtype of lung cancer the patient has. Today, if a patient has an adenocarcinoma, that chemotherapy drug is most oftentimes going to be pemetrexed; if the patient has a squamous cell cancer, that drug oftentimes with be either paclitaxel or docetaxel, or gemcitabine.

So how do those drugs behave, or how do those drugs work in the stage III setting? Well we’ve learned some lessons: first we’ve learned that it’s very difficult to give one of those drugs, gemcitabine, in combination with radiation therapy, so as a result we’ve largely been giving paclitaxel and carboplatin. Some people use docetaxel, although most of the data is with paclitaxel. More recently, people are using pemetrexed and cisplatin, and historically we’ve used cisplatin and etoposide because in previous years that was our standard of care for patients who had metastatic disease, but really was the most well established regimen when giving radiation combined with chemotherapy in the stage III setting.

In the United States the two most commonly used regimens are cisplatin and etoposide combined with radiation, or carboplatin and paclitaxel combined with radiation. So which regimen should we preferentially give? Well those two regimens have never been compared head to head. We have looked at a number of clinical trials in which different strategies have been tested, but never the strategy of testing those two regimens head to head. Now we’ve recently gotten indirect evidence on what is the efficacy or the effectiveness of those two regimens and how would they compare if we were to do head to head comparisons, and these analyses suggest that it probably doesn’t make much difference — that the regimens are probably very, very similar. Most recently there was a clinical trial of cisplatin and pemetrexed with radiation against cisplatin and etoposide with radiation and that head to head comparison really showed no difference in outcomes between those two strategies.

Today we can say that really any one of those regimens is reasonable. Some people are wedded to the cisplatin and etoposide regimen because it’s what they’ve been most familiar with and they understand how to handle the side effects, lots of people like the convenience of carboplatin and paclitaxel  because it’s given weekly, and some people are drawn to the newest regimen which is cisplatin and pemetrexed. But I really don’t think that there are discernible differences. There may be some differences in the side effects, but I think in terms of outcomes they all seem to be fairly comparable.


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