While post-operative chemotherapy has emerged as the standard treatment for patients with stage II and resected IIIA NSCLCC, and some patients with stage IB disease, trials conducted over the past few years are providing information about the option of treating with initial chemotherapy before surgery. A couple of trials were presented at ASCO this year that did not demonstrate a significant survival benefit of pre-operative chemo compared with no treatment. The Southwest Oncology Group, in which I participate, presented more mature data from the SWOG 9900 trial of pre-operative chemo with carbo/taxol for three cycles vs. going straight to surgery (abstract here), and the findings with longer follow-up are now close to showing statistical significance to a similar degree as what is seen with post-operative chemo, but even if it became positive, the evidence for a post-op chemo standard has been stronger and would remain the more common approach. In the meantime, however, it remains a consideration for a subset of patients, but there isn’t much enthusiasm for studies directly comparing pre-op vs. post-op chemo at this point. One area in which pre-operative chemo remains appealing is a “window of opportunity” giving a few weeks of a targeted therapy to see the rapid clinical effects and then remove the tumor and see if the treatment had targeted effects on the tumor.

In addition to chemo as a treatment after surgery, a group from Europe looked at a vaccine to a protein called MAGE-A3 that is expressed on about 1/3 of NSCLC tumors (abstract here). They ran a randomized phase II study with about 180 patients (who had all been found to have MAGE-A3 expression on their tumor) in which 2/3 received the active vaccine and 1/3 received a placebo after surgery for stage IB or II NSCLC. They found that there was about a 25% improvement in progression-free survival among the recipients of the vaccine compared with the placebo group, although this difference wasn't quite statistically significant. While it wasn't quite statistically significant, it did generate major interest among the oncologists present, and even more interest, I think, among the Wall Street analysts covering the meeting. The maker of the vaccine, GlaxoSmithKline, is starting a larger phase III trial in the adjuvant setting that is just getting started.