Maintenance Following Chemotherapy in NSCLC

Benjamin P. Levy: It’s important to note that a maintenance strategy improves survival, specifically for patients with advanced lung adenocarcinoma. I have been very much a proponent of maintenance therapy from the start. I think patients who are on a good therapy, if they’re doing well and tolerating that therapy, should continue that therapy until they experience toxicities or disease progression.

A more granular explanation would be that generally, for my patients with lung adenocarcinomas, I give 4 cycles of carboplatin/pemetrexed. And, if they have at least stable disease after 4 cycles, I will drop the carboplatin and I will continue the pemetrexed. There are times, in some cases, where I’ll use bevacizumab as well: so, carboplatin/pemetrexed/bevacizumab. After 4 cycles, if it is at least stable disease, I will continue the pemetrexed and the bevacizumab. But I would say for most of my patients, I use a carboplatin/pemetrexed backbone.

It’s important to know that there have been some incorrect data out there, or a perception, that if patients don’t have a response after 4 cycles, they should not get maintenance therapy, and that’s not true. They just need to have at least stable disease and be tolerating the treatment. We’ll generally drop the carboplatin after 4 cycles and continue the pemetrexed every 3 weeks, and I think we’ve seen with the data, at least with the PARAMOUNT data, that it improves survival significantly versus no maintenance.

There’s a lot that goes into treatment options for maintenance. It’s very important that after 4 cycles, the patient is at least tolerating the treatment. If patients aren’t doing well or are having toxicity, maybe they’re not the right patient for maintenance. Or, maybe they’re the right patient for a treatment break with a reinitiation of maintenance therapy at some point. Secondly, I mentioned that if patients have progressive disease after 4 cycles—you give them 4 cycles and their tumor is growing—they are not a candidate for maintenance. Those patients probably need to go on second-line treatment with something else, either immunotherapy or another cytotoxic regimen with or without an antiangiogenic strategy.

I think, importantly, one of the things I like to do with my patients is have that discussion about maintenance at the beginning of treatment. So, I tell patients, “You’re going to get 4 cycles of a platinum doublet with pemetrexed, and if you’re doing well and your cancer has at least not grown—it stayed the same size or shrunk—we will continue you. We’ll drop the carboplatin and continue on with the single-agent drug.” After 4 cycles, there’s no confusion or curveballs for patients. They’re aware of the plan. They understand it. So, I think it’s very important to have that discussion up front.