At the recent Chicago lung cancer meeting, the idea of maintenance therapy emerged as a hot topic that is experiencing ongoing changes in our treatment approaches over time. The controversies about this topic begin with the very terminology. Here are four proposed names for the same basic idea:

1) maintenance therapy, which implies that one of the initial treatments is being continued on a longitudinal basis

2) consolidation therapy, which suggests that a new treatment is being used to induce an additional response in patients responding to first line therapy

3) sequential therapy, which indicates a prospectively planned transition from first line to the next treatment from the very beginning

4) early second line therapy, which emphasizes that this is basically just focusing on the timing of when to move to your second line treatment

At the Chicago meeting, the results from the previously described trial of immediate vs. delayed second line taxotere (docetaxel) (prior post here) was presented again, as was the trial of alimta (pemetrexed) vs. placebo as "maintenance" therapy (prior post here). Both trials initiated this randomization only in patients who had shown no progression after four cycles of first line therapy and weren't receiving any other maintenance therapy like avastin (bevacizumab) or erbitux (cetuximab) -- in this case, using maintenance in the arguably more correct form, since this would usually be continuing these after first line treatment with chemo and one of these agents.

There was also some discussion of the SATURN trial of tarceva (erlotinib) vs. placebo after four cycles of first line chemo. As described in a prior post, this trial was positive for its primary endpoint of progression-free survival, and we don't know yet about any differences in overall survival. So now we have three trials that all support an early transition from first line to the next treatment, with each of the three best studied agents for second line treatment of advanced NSCLC.

The only really new information presented at the meeting was the finding that, in the trial of immediate vs. delayed taxotere, the patients on the delayed chemo arm actually showed the exact same median survival that was seen in the patients on the arm receiving immediate chemotherapy (12.5 months for both). Many of the detractors of the concept of pursuing an immediate transition to second line therapy have pointed out that these trials may just highlight that second line treatment is effective, but only if you actually get it, and that if patients become too sick to receive it, they do worse. I completely agree with that point, but unlike the detractors, I believe that these findings suggest that in practice, leaving a significant gap of time between first and second line therapy is tempting fate.

Overall, I think there's movement toward a middle ground now, a consensus that if you're not going to recommend early second line therapy, you should at least follow patients closely, such as with repeat clinic visits and scans every 6-8 weeks at the most, and so much the better if the follow up is closer than that. At the same time, someone like me, who has become convinced enough of the value of early second line therapy (or sequential therapy, or whatever term you prefer), can also acknowledge that a break of a few weeks or a month or so is often just fine and even a good idea. Some of the people less impressed by the concept of early second line therapy may move toward a common ground by recommending planned second line therapy after a delay of a few weeks following first line therapy. So we come from different directions but meet on common ground.

Moreover, I think that with this evidence that the main issue is just ensuring that people are well enough to receive more treatment highlights that the patients with slower growing cancer may not need an automatic transition to their next line of treatment, and the timing may be appropriate to individualize as well (i.e., a longer interval between scans may be very appropriate). It will probably be a long while before we can actually capture this issue in clinical trials, but to me it's one of the reminders of why we don't just treat patients with lung cancer on autopilot.

I suspect we're going to see an ongoing and gradual change in treatment practices here. We'll see that as these trials become more widely discussed and new data are presented, the old standard of waiting for patients to show clear evidence of progression before starting second line therapy will shift to a new standard of planned sequential therapy, with earlier second line treatment not waiting for progression, even if it's still very reasonable for patients and their oncologists to decide to take a hiatus between first and second line therapy.