In 2007 there was much excitement about the publication of a study by the researchers behind the landmark IALT adjuvant chemotherapy trial, which suggested that patients with early stage NSCLC could be divided into those who benefited greatly from cisplatin-based adjuvant chemotherapy and those who did not.

Post-operative, or adjuvant, chemotherapy is a standard approach for higher risk patients with resected early stage NSCLC, based on several randomized trials that have been presented and published in the last few years that show a survival benefit from chemotherapy. All of the trials that have shown a statistically significant survival benefit have given chemotherapy after surgery, but it’s hard to envision why the same chemotherapy given before surgery wouldn’t be just as good or better.

Over the last 5 years, it’s become standard to consider and often recommend post-operative chemotherapy to patients with higher risk, early stage lung cancer in order to reduce the risk of it recurring and increase the cure rate. In that time, we’ve also seen that there are subgroups of patients who may be harmed by chemo. This may be because their risk of recurrence is not high enough to justify the potentially detrimental effects of adjuvant chemotherapy, or because they are relatively resistant to chemo, or a combination of these issues.

The average age at which lung cancer is diagnosed in the US is 71. Would it be fair to say that at least half of those who are diagnosed with lung cancer are elderly? How do we define “old”? How does age impact the effect of chemotherapy?

Interview by medical oncologist Dr. Howard (Jack) West with fellow medical oncologist and lung cancer expert Dr. Janessa Laskin from the British Columbia Cancer Agency in Vancouver, BC, Canada on current standards and controversial topics in post-operative (adjuvant) chemotherapy for early stage, resected NSCLC.

[powerpress]

Transcript here: Transcript Laskin on Adjuvant Chemo

In my last post I described the results of the ChEST trial that showed a borderline statistically significant improvement in survival of patients who received cisplatin/gemcitabine chemotherapy for stage IB to IIIA NSCLC prior to surgery. This study was very similar to another neoadjuvant chemotherapy trial, known as SWOG 9900, which also randomized patients to upfront surgery or 3 cycles of pre-operative chemotherapy followed by surgery.

Over the past few years, the role of post-operative, also known as adjuvant, chemo has become increasingly accepted as a standard of care. Several trials have shown an improvement in survival at about 5 years that is in the 5-15% range for recipients of chemo.

Throughout multiple discussions of adjuvant chemotherapy, I've focused on the traditional approach used in the US and Europe of 3-4 cycles of platinum-based chemo, treating for up to about three months with a rather intensive approach. However, in Japan, they've studied the value of a different form of adjuvant treatment, with a drug called UFT that is generally well-tolerated, mild, and taken for 1-2 years by mouth.

While there are good reasons to not pursue chemo after surgery for stage I NSCLC, there are several factors that argue at least for strong consideration of adjuvant chemotherapy for higher risk patients. Because stage IB generally has a less favorable prognosis than stage IA, it's not suprising that the debate about which patients should or should not be receiving post-op chemo has centered more on the stage IB population, which have much more commonly been included in trials testing the value of adjuvant chemotherapy.

At long last, and after years of planning, a new large phase III randomized clinical trial is getting underway to determine whether adding avastin to chemotherapy as post-operative (adjuvant) treatment for early stage NSCLC provides added benefit compared to chemotherapy alone.