Lung cancer now includes more treatment options

Lung cancer is the leading cause of cancer death among both men and women in the United States. According to the American Cancer Society, an estimated 163,510 deaths (90,490 in men and 73,020 in women) will be attributed to the disease in 2005. The five-year survival rate for lung cancer patients is approximately 14%. Late diagnosis is a significant obstacle to improving lung cancer outcomes.

Fortunately, the National Comprehensive Cancer Network (NCCN) recently updated its non-small cell lung cancer (NSCLC) treatment guidelines to offer clinicians and their patients more options for the treatment of advanced disease. NCCN Clinical Practice Guidelines in Oncology are available free of charge on CD-ROM, and can be ordered from NCCN by calling (215) 690-0300. The most up-to-date versions of the guidelines can also be found on the NCCN Web site at http:// http://www.nccn.org/

"Many of the changes we made focused on issues relevant to the principles of chemotherapy," explained David Ettinger, M.D., the Alex Grass Professor of Oncology at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, and chair of the NCCN Non-Small Cell Lung Cancer Panel that updated the guidelines. "We added that single agent erlotinib [Tarceva, Genentech/OSI Pharmaceuticals] has been proven superior to best supportive care in patients with advanced metastatic non-small cell lung cancer, after the failure of at least one prior chemotherapy regimen." Ettinger pointed out that erlotinib can be used as second- or third-line therapy.

Other changes the panel made included adding pemetrexed (Alimta, Eli Lilly) as a second-line treatment option. Carboplatin in combination with paclitaxel was also added as an alternate regimen to the cisplatin-based combination as adjuvant chemotherapy.

"The role of the newer oral drugs such as erlotinib is as second-line therapy," said Dennis Grossano, R.Ph., clinical oncology coordinator in the department of pharmacy at Memorial Sloan-Kettering Cancer Center in New York City. "What I am seeing here at our institution is that the first-line treatment for patients with good performance status, whom the oncologist feels can tolerate platinum-based therapy, is platinum-based therapy with an ancillary drug such as docetaxel [Taxotere, Sanofi-Aventis] or vinblastine." The guidelines list about seven to 10 possible ancillary drugs.

"When I reviewed the guidelines, one thing that struck me was the use of performance status, in that the studies reviewed have shown those with advanced NSCLC and a performance status of 0 to 2 are candidates for chemotherapy," Grossano explained. "Those with a performance status of 3 or 4 do not benefit from chemotherapy and should instead receive supportive care.

"My feeling is that at this institution we are using a lot more carboplatin compared with cisplatin," Grossano said. "Carboplatin has a better adverse-effect profile than cisplatin.

"Cisplatin requires a lot of supportive therapy, particularly hydration, because it is directly toxic to the kidneys," Grossano continued. "Those receiving cisplatin must have adequate kidney function, with good urine output." He said that 1 L to 1.5 L of a mannitol infusion should be administered right before giving cisplatin, if the dose exceeds 50 mg/m². More mannitol is required if the cisplatin dose exceeds 100 mg/m².

"On the flip side," Grassano said, "carboplatin does not directly affect the kidney tubules themselves." He did caution, however, that patients receiving carboplatin must still have good kidney function, because the drug is almost exclusively excreted by the kidneys.