Those who have followed my writings over time will know that I haven’t been inclined to adopt a reflexive strategy of ordering molecular testing without good evidence that having this information will improve outcomes. Testing tumors for EGFR mutations is advocated by a vocal minority of lung cancer experts in Boston and New York City, but this hasn’t been advocated by the broader lung cancer community yet, or adopted as routine clinical practice.
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.
In the last few years BAC has become increasingly studied and recognized as a distinct clinical subtype of lung cancer. The classic BAC syndrome is characterized by progression limited to the lungs, and its growth can be quite variable. The definition of BAC based on pathology has been applied pretty variably: although it should really be a non-invasive cancer that shouldn’t be able to spread outside of the lungs because it can’t invade into the bloodstream, most clinical trials now permit a combination of invasive adenocarcinoma with BAC features.
I think one of the most important lead stories from ASCO 2008 got buried. Nobody's really talking about it yet, but they should.
Although I've previously written about the question about optimal duration of therapy for first-line chemotherapy in advanced NSCLC (post here), these conclusions have been based on a limited number of trials. One study randomized patients to three or six cycles of rather old chemo and found no significant differences (abstract here).