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Advanced lung cancerConcept:At present, the concept of maintenance therapy can be divided into two types: maintenance therapy and maintenanc

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Advanced lung cancer

Concept:

At present, the concept of maintenance therapy can be divided into two types: maintenance therapy and maintenance therapy.

Maintenance therapy is a treatment that uses at least one drug that has been used in first-line therapy if there is no disease progression after first-line treatment of the 4-6 cycle.

Change maintenance therapy refers to the first line treatment of 4-6 cycle, if there is no disease progression, began to use another not included in the first-line regimen of drugs for treatment. The ideal therapeutic drugs should be effective, low side effects and easy to use.

Chemotherapy for maintenance therapy

In 2008 Ciuleanu et al. Presented a randomized, double-blind, multicenter, phase III clinical trial (JMEN) for evaluation of pemetrexed maintenance therapy at the ASCO annual meeting. In 2009, Belani reported the study result, the median survival period of pemetrexed group (OS) than the placebo group (died 13.4 months and 10.6 months, a 21% reduction in the risk, including non survival of patients with squamous cell carcinoma (benefit more than 15.5 months and 10.3 months), the lower risk of death 30%, so that the advanced non-small cell lung cancer after first-line chemotherapy benefit with pemetrexed maintenance therapy is a new treatment mode, especially for non squamous cell carcinoma patients. Since the study of scientific design, and obtained a prolonged survival, the United States and the European Union approved pemetrexed for platinum therapy without disease progression after non squamous cell carcinoma patients with maintenance treatment, and is recommended in the NCCN guidelines, maintenance treatment finally ushered in a ray of light.

Targeted therapy for maintenance therapy

Due to the advantages of small side effects and convenient use, targeted drugs have attracted more and more attention.

2009 Italy scholar Cappuzzo) will report the erlotinib maintenance in a multicenter phase III study in the treatment of ASCO (SATURN) of the preliminary results, then in the society when the World Conference on lung cancer and European Oncology (ESMO) conference were added to the test results. The results showed that erlotinib group PFS was significantly prolonged compared with the placebo group (12.3 weeks and 11 weeks); OS maintenance group has also been extended, respectively 12 and 11 months, especially more prolonged survival of patients with squamous cell carcinoma of the maintenance group, maintenance group (272 cases) for 13.7 months, the placebo group (257) for 10.5 months. Subgroup analysis showed that different gender and different pathological types, different races, different smoking status and EGFR wild type or mutant patients can benefit from erlotinib maintenance therapy benefit. In addition, maintenance therapy also delays the onset of pain and the use of analgesics. Erlotinib maintenance therapy has good safety. The positive results of the SATURN study have led to a better understanding of maintenance therapy. In view of the SATURN study, no progress in the 2010 NCCN guidelines recommend first-line chemotherapy for advanced NSCLC patients after erlotinib maintenance therapy can change.

This year ASCO annual meeting of Chinese scholars tension also reported a gefitinib maintenance phase III clinical study treatment (INFORM), this study has Chinese 27 tumor centers participated, results showed that gefitinib group PFS was significantly longer than that of the control group (4.8 months and 2.6 months), group of diseases progress in maintenance risk decreased by 58%, OS has not yet announced. Patients were well tolerated. The patients in 79 cases were detected by EGFR. The mutation rate was 38%; the mutation in patients with gefitinib group and control group PFS were 16.6 months and 2.7 months, the risk ratio is 0.16, so EGFR mutation patients benefit more, but because of the small sample, still need further verification.

Clinical options for maintenance therapy

Current guidelines for the treatment of advanced non-small cell lung cancer (4-6) are recommended for first-line therapy or maintenance therapy. If the end of the first-line treatment, determine the choice of maintenance treatment, in addition to considering these factors in patients with general condition, the willingness of patients and economic conditions, in particular the choice of drugs should also be selected according to the specific circumstances of the patient and the pros and cons.

The choice of chemotherapy drugs: the 2011 NCCN guidelines recommend (2B) pemetrexed maintenance therapy can be used in patients with non squamous cell carcinoma to continue maintenance therapy and dressing change maintenance treatment. Clinical trials have shown that compared with placebo, pemetrexed maintenance therapy can prolong the survival of 2.8 months, especially non squamous cell carcinoma can prolong the survival of 5.2 months, so the choice of chemotherapy drug, for patients with squamous cell carcinoma, pemetrexed should be preferred.

Selection of targeted drugs

The 2011 NCCN guidelines recommend (2B) in the two platinum drug regimen chemotherapy after 4-6 cycles, erlotinib maintenance therapy can change. Clinical trials have shown that compared with placebo, erlotinib maintenance therapy to prolong the survival time of 1 months (12 months and 11 months), compared with intravenous drug targeting, erlotinib has convenient oral administration, low side effect, do not need hospitalization and other advantages, so the clinical use of erlotinib is to maintain according to the specific circumstances of patients. Because of erlotinib survival advantage is not, of the British National Health and Clinical Excellence (NICE) released in June this year, the guide said, not sure of erlotinib in the high cost of whether can give patients bring enough benefits, so it is not recommended for maintenance treatment. About erlotinib maintenance therapy, we expect more clinical trials to verify.

Bevacizumab and cetuximab were recommended for treatment as NCCN continues to maintain, because not to maintain a dressing, combined with chemotherapy for 4-6 cycles, very expensive, delivery is not convenient and can not ignore the non hematologic toxicity, although 1 is recommended, in China's current national conditions may be only a handful people can choose. In the selection of patients with non squamous cell carcinoma for bevacizumab, cetuximab is suitable for patients with high expression of EGFR.

A display of 3 clinical trials, compared with observation group or placebo group, gefitinib maintenance therapy can prolong progression free survival period of 1.2-2.2 months, a study found that the survival of patients with adenocarcinoma is prolonged, our tension reported another study found that EGFR mutation analysis of patients without disease progression very obviously prolonged the survival period (16.6 months and 2.7 months). Although the test no survival benefit, because of gefitinib and erlotinib has the advantages of the same, and the cost is relatively lower, so for special populations, such as cancer, women and not smoking EGFR mutation in high-risk population, gefitinib maintenance treatment can be used as an option.

 

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