Lung Cancer.pdf

160 R. Zinner
chemotherapy, in patients with sufficient performance status (PS),
chemotherapy palliates symptoms.
Further increases in overall survival in patients with good PS were
achieved in the 1990s through incorporation of third-generation chemotherapeutics
into platinum-based regimens. Phase III studies showed that
this strategy resulted in median survival times of about 8 to 10 months
and 1-year survival rates of about 30% to 40% (Schiller et al, 2000; Fossella,
2001; Kelly et al, 2001a; Rodriguez et al, 2001; Scagliotti et al, 2001; Van
Meerbeeck et al, 2001). Moreover, 2 recent phase II studies (Fossella et al,
2000; Shepherd et al, 2000) demonstrated a survival advantage and improved
symptom control and quality of life when docetaxel was used as
second-line therapy.
Currently, the goals of chemotherapy in the setting of advanced
NSCLC are palliation of symptoms, improvement in quality of life, and
prolongation of survival. Since the survival benefit from chemotherapy is
minimal, physicians need to balance the potential benefits of therapy with
the known risks of side effects and need to adequately discuss treatment
options with patients.
Selection of Patients for Treatment
and Selection of Regimens
In patients with advanced NSCLC, one of the most important predictors
of benefit is PS. In general, first-line chemotherapy is indicated in patients
with a PS score of 0 or 1, is considered on a case-by-case basis for patients
with a PS score of 2, and is rarely indicated in patients with a PS score of 3.
In decisions regarding the most appropriate type of chemotherapy for individual
patients, both PS and age are taken into account.
The bulk of the data available from phase III studies of chemotherapy
in patients with advanced NSCLC derive from patients with a PS score of
0 or 1; few patients with a PS score of 2 were enrolled in these trials. Patients
with a PS score of 2 typically are less likely to respond to therapy,
live fewer months, and are more likely to suffer side effects from
chemotherapy. In a retrospective study of 1,960 patients with advanced
NSCLC, patients with PS scores of 0 and 2 had median survival times of
9.4 and 3.3 months, respectively (Jiroutek et al, 1999). In a Southwest Oncology
Group retrospective study of 2,531 patients with advanced
NSCLC, patients with PS scores of 0 or 1 versus 2 had median survival
times of 6.4 and 3.4 months, respectively (Albain et al, 1991). In both studies,
PS was found to be a significant independent prognostic factor. In addition,
patients with poorer PS have an increased risk of side effects from
chemotherapy (Schiller et al, 2000). Since patients with a PS score of 2 have
short median survival times even with treatment and have worse side effects
from treatment, standard platinum-based doublets cannot be recom-