I just recently wrote a post (here) that describes how I became convinced that under certain circumstances there could be a genuine value in determining whether a particular lung cancer patient has a tumor with an EGFR activating mutation.

Probably the most contentious areas of lung cancer management is stage IIIA NSCLC, with N2 nodal involvement, the nodes outside of the lungs, toward the middle of the chest but on the same side as the main tumor. One of the key issues is that the staging is the same whether there's a single microscopically involved lymph node or multiple enlarged lymph nodes in a few areas of the mediastinum (mid-chest, between the lungs). But the outcomes of these groups of patients is very different, so it may be worth thinking about them a little differently.

Though EGFR inhibitors like tarceva can produce some terrific and long-lasting results in many patients, they aren't toxicity-free. The "targeted therapies" we use just have a very different side effect profile from standard chemo, and the EGFR inhibitors are well known to have skin-related side effects as the leading problem, with loose stools/diarrhea as a less nearly ubiquitous second place issue.

The general approach to NSCLC is in transition right now, as the line between first and second line therapy are becoming increasingly blurred. A few years ago, the clear standard was that we usually stop first line chemo after four to six cycles, then follow a patient clinically and radiographically until they show evidence of progression, at which time we’d start second line treatment.

One of the central ideas in medical oncology is that if you have two or more anticancer treatments that are active, you test them together to determine whether it's safe and whether the combination works better than each individually. We've been doing this with chemotherapy combinations for decades, but it's only been in the last few years that we have had more than one targeted therapy in lung cancer with enough activity to move ahead with combination work.

With last week's FDA approval of alimta in the first line setting for NSCLC, we're likely to see a lot of alimta (pemetrexed) use shift from the second and third line setting to first line. Alimta's been a very popular choice for previously treated patients, based on issues like the relatively convenient schedule of a ten minute infusion one day every three weeks, no hair loss, and typically less of a drop in blood counts than seen with some other regimens.

Yesterday, as described in a press release, the FDA approved the regimen of cisplatin and alimta as a first line therapy for advanced NSCLC, based on the positive results from a trial called "JMDB" by the sponsor company (Eli Lilly).

There are two widely tested epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) -- iressa (gefitinib) and tarceva (erlotinib).

Last week, updated information on the AVAiL (AVAstin in Lung cancer) trial (see prior post) of cisplatin/gemcitabine with either placebo or a low or higher (full) dose of avastin was presented in a meeting in Stockholm.

One of the topics that frequently occurs in the clinic, and that patients often ask about, is the situation in which there is some suggestion of slight progression. This can take the form of many different situations: a rising tumor marker (see