For many years, patients with malignant pleural mesothelioma (MPM) were often not offered treatment. Surgery was offered to rare, selected patients who tended to be much younger and more fit than a typical patient with MPM, but we'll talk about surgery later. Chemotherapy was only very inconsistently offered to the vast majority of unresectable patients with MPM, because it was not felt to clearly be beneficial. This is pretty similar to the view of advanced NSCLC until the mid- to late-1990s.

I'm heading off today to Hawaii (Maui), which I must hasten to add is for a conference, the Eighth International Lung Cancer Congress, not just a vacation, although working in Hawaii often seems better than time off at home. The meeting not only includes a lot of good lectures and debates, but it gives us the opportunity to actually discuss the importance and implications of the trials that were just presented a few weeks before at ASCO.

One of the central ideas in management of advanced NSCLC is that many two-drug chemo combinations have been compared and show essentially superimposable results, as I described in a prior post.

As described in one of my first posts, Avastin was approved by the US FDA for the first line treatment of advanced NSCLC in patients with non-squamous cancers, no history of coughing up blood, and no brain metastases, based on the positive trial ECOG 4599 (abstract here) that demonstrated a survival benefit for carbo/taxol/a

I had previously mentioned in prior posts that there have been a few studies in advanced NSCLC that indicate that about 4 cycles provides as much treatment benefit as continuing first-line chemo until progression. I also noted that the ECOG 4599 trial (abstract here) gave up to 6 cycles of chemo (with carbo/taxol) and avastin, followed by avastin alone as a maintenance therapy until progression of the cancer.

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.

A member recently asked me whether treatment in the second-line or later setting for advanced lung cancer would potentially improve survival at a cost of quality of life, or whether patients can benefit not only in terms of how long they live but also how they live during that time. Since advanced lung cancer, both NSCLC and SCLC, aren't generally able to be approached with curative intent, it's important for the treatment not to be worse than the disease. Ideally, patients will even feel better with treatment, rather than have to choose between quality of life (QoL) and quantity of life.

One of the themes that we've covered in some of the posts introducing the clinical entity of BAC is the variability in its natural history. In fact, much of what we've been learning about BAC has been in the last several years, and we're still learning more about it all the time. One of the things we've struggled with is the range of outcomes, that some patients can experience rapid deterioration and no response at all to EGFR inhibitors, while other patients can have a remarkably slow progression, and they sometimes will have an astounding regression of disease from EGFR inhibitors.

While we are still working on figuring out the mechanisms underlying differences in the lung cancers of women vs. men, the efficacy and survival paint a consistent picture that women with lung cancer live longer than men regardless of the lung cancer subtype, stage, or treatment used (summary here). Large studies have reported that women have an approximately 15-20% improvement in survival, controlling for other variables, when compared to men.

One of the more common approaches to treating stage IIIA NSCLC with N2 lymph nodes (mediastinal, or mid-chest, on the same side as the primary tumor) is chemotherapy or chemoradiation before surgery. For those who recommend induction therapy (treatment before planned resection), there is a pretty even split between those who recommend chemotherapy alone and those who recommend chemo with concurrent radiation. So how do knowledgeable people come to different conclusions, and who is right?