By Edward C. Li, PharmD, BCOP, Manager, Oncology Pharmacy
Historically, the chemotherapy regimen of choice for advanced or metastatic Non-Small Cell Lung Cancer (NSCLC) was a platinum-containing doublet. These regimens included either cisplatin or carboplatin in combination with other agents such as gemcitabine, taxanes, or vinorelbine. In the past, platinum doublets were seen as equivalent, as interpreted by the results of a comparative effectiveness analysis of four such regimens published by Schiller, et al in 20021. In recent years, newer agents such as bevacizumab and pemetrexed have been demonstrated to be effective in the treatment of NSCLC, in specific patient subgroups.
Data from an NCCN Trends™ Survey conducted at the 2010 NCCN Annual Conference show that clinicians have embraced the use of these newer agents for the first-line treatment of metastatic NSCLC (with non-squamous histology, no history of hemoptysis, performance status 0-1). According to this survey, 53 percent of medical oncologists prefer using bevacizumab with a platinum-based doublet in the aforementioned scenario. Furthermore, 22 percent of medical oncologists prefer using pemetrexed (with a platinum analog) instead. The majority of the remaining medical oncologists (19 percent) prefer the traditional platinum doublets (without pemetrexed or bevacizumab).
For a patient with metastatic NSCLC (non-squamous histology, no history of hemoptysis) with a performance status of 0-1, which of the following is your USUAL preferred first-line therapy? (n = 277)
The NCCN Drugs & Biologics Compendium (NCCN Compendium™), based directly on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™), lists the NCCN recommended uses for bevacizumab and pemetrexed in NSCLC. In the first-line metastatic setting, NCCN recommends using these drugs in combination with platinum-based chemotherapy if patients meet specific criteria for use (although pemetrexed is recommended as a single agent for elderly patients or for patients with an Eastern Cooperative Oncology Group Performance Status of 2).
Related to metastatic NSCLC, the NCCN Guidelines™ recommend the choice of either induction chemoradiation, induction chemotherapy, or surgery as initial treatment for Stage IV M1a disease with separate pulmonary nodules in the contralateral lung. Survey respondents favored using induction chemotherapy in this situation (76 percent), followed by induction chemoradiation (17 percent), then surgery (4 percent).
For a NSCLC patient presenting with stage IV, M1a disease with separate pulmonary nodules in the contralateral lung, which of the following is your preferred initial treatment? (n = 285)
Lastly, radiation oncologists were asked to select the most commonly used chemoradiation therapy regimen recommended by the NCCN Guidelines for NSCLC. Just over half of radiation oncologists reported that paclitaxel/carboplatin was most commonly used (56 percent), followed by cisplatin/etoposide (41 percent).
The following are concurrent chemotherapy agents used in chemoradiation protocols in the NCCN Guidelines for NSCLC. Which of the following is MOST COMMONLY used in your institution? (n = 27)
 Schiller JH, Harrington D, Belani CP, et al. Comparison of Four Chemotherapy Regimens for Advanced Non-Small Cell Lung Cancer. N Engl J Med. 2002;346:92-8.