Adjuvant chemotherapy is chemotherapy that’s given after surgery to try to improve the chance of cure, and usually this chemotherapy utilizes a specific drug called cisplatin. Cisplatin is a chemotherapy drug that’s been around for a while but we know is highly effective. Traditionally that drug is given every three weeks, it’s given by vein, and it takes a pretty long amount of time because it’s important that a patient receiving cisplatin gets a lot of fluid, gets a lot of hydration at the same time.
In a typical day, a patient would come in, get a lot of IV hydration, get some anti-nausea medications, and then get the chemotherapy drug only over about an hour — they will often get a second drug and we’ll talk about what those are in a second — finish up the day with hydration with the cisplatin, then normally would get about four days of oral anti-nausea medications just to help control nausea. That regimen is usually pretty effective. Some patients have to come in for additional fluid hydration the second or third day, then get two and a half to three weeks off and then come back to get the next cycle of chemotherapy with cisplatin and the other drug. That’s repeated for a total of four cycles of chemotherapy — so that’s traditional adjuvant chemotherapy.
The cisplatin is not the whole story though, it’s usually given with a second drug and there are multiple different drugs that have been studied to be given in that way. The one with the most data is a drug called vinorelbine. That drug is given weekly, so the first week you get the cisplatin and the vinorelbine, the second week you would just get the vinorelbine, and the third week depending on how it’s being given you either would or would not get it.
Another drug that’s frequently used is called docetaxel and that’s given just once every three weeks with the cisplatin. For patients who have the adenocarcinoma type of non-small cell lung cancer, or anything that’s not a squamous cell type, they’re eligible to get a drug called pemetrexed. We don’t have a lot of data yet for patients after surgery getting the cisplatin and pemetrexed but it’s very commonly used in the United States because we know that regimen tends to be well tolerated and we know it’s very active for patients who have more advanced types of lung cancer. That’s used quite a bit, and occasionally there will be a drug called gemcitabine used in combination with the cisplatin.
So those are the four most common, there are some others — cisplatin and etoposide is another regimen that’s been used as well. We don’t yet have any data comparing those regimens to each other in this type of a setting for patients who have already had their tumor removed — in that time you don’t have a way to measure whether the chemotherapy is actually helping or not so you don’t have a good way to compare against each other. We know from metastatic lung cancer that those drugs all tend to be fairly equivalent, those combinations, and that’s why they’re all used. It gets to be a discussion about the different toxicities, the different side effects, the different schedules, and then some specifics about the tumor, especially whether it was adeno or non-adeno, and making those decisions with the physician.
We do know from clinical trials that have been conducted that if you look at a group of patients who have had their tumors removed with surgery and half get chemotherapy and half did not, in these trials, the group getting chemotherapy, on average, did have a higher chance of cure. Now that chance of cure improvement unfortunately was not huge, it was somewhere in the order of five to ten percent depending on the trial, and so the decision about getting adjuvant chemotherapy is a complicated one and one that involves a discussion with your physician and care team, trying to make that decision about whether the potential benefits of chemotherapy make sense, versus the potential downsides. It ends up being about a three month regimen of chemotherapy. Again, you’re coming in only maybe four times to get those chemotherapy drugs, but during that time, in those three months, you’re going to not be 100% as far as energy level. We are very good at controlling nausea now, but the fatigue can be a particular issue for patients and sometimes in that time where you’re recovering from surgery, it’s difficult to get through, but it has been shown to show a survival benefit.
We do recommend that if chemotherapy is going to be given after surgery, that it starts somewhere in the four to, at most, twelve week period after surgery, so if it’s taking longer to recover, we don’t recommend starting after that time period.
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