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LUNG CANCER Beyond Second-Line Treatment in Non–Small Cell Lung Cancer and Small Cell Lung Cancer: What to Do When the Data End? CHAIR Craig H. Reynolds, MD US Oncology Research Ocala, FL SPEAKERS Gregory J. Riely, MD, PhD Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College New York, NY Renato G. Martins, MD Seattle Cancer Care Alliance, University of Washington Seattle, WA
MARTINS, REYNOLDS, AND RIELY Beyond “Second-Line” in Non–Small Cell Lung Cancer: Therapy and Supportive Care Renato G. Martins, MD, Craig H. Reynolds, MD, and Gregory J. Riely, MD, PhD OVERVIEW Although there once was a single algorithm for the treatment of patients with advanced lung cancer, the modern treatment of advanced lung cancer has multiple treatment pathways that depend on multiple factors, including histology and molecular subtype of disease. New molecular targets, targeted agents, and modes of therapy for patients, including immunotherapy, are being identified at an accelerating pace. These advances are changing outcomes and the treatment landscape, but they also highlight situations with inadequate data to support the use of cytotoxic chemotherapy. In this article, we provide an overview of data regarding cytotoxic chemotherapy and targeted therapy and their value after second line, review the critical role of supportive care and palliative care, and emphasize the importance of advance care planning with our patients. Although this article focuses primarily on NSCLC, the comments about palliative care and advanced care planning also apply to patients with small cell lung cancer. Although there once was a single algorithm for the treatment of patients with advanced lung cancer, the modern treatment of advanced non–small cell lung cancer (NSCLC) has multiple treatment pathways that depend on many factors including histology and molecular subtype of disease. In addition, new molecular targets, targeted agents, and modes of therapy, including immunotherapy, are being identifıed at an accelerating pace. These advances are changing outcomes and the treatment landscape, but the rapid introduction of many new therapies may be somewhat bewildering for the practicing oncologist. In this context, a discussion of therapy’s role beyond second line is outdated. However, more relevant than ever is the medical oncologist’s role in advocating for patients to have access to these advances, discerning the patient’s care goals, and sparing them from the toxicities of unproven therapies. 1 This article will review critical factors for decision making in this changing treatment environment. THE ROLE OF CHEMOTHERAPY IN THIRD-LINE AND BEYOND Unlike the data establishing the role of docetaxel in the second-line treatment of advanced NSCLC, 2 there are no randomized trials evaluating chemotherapy in the third- and fourth-line treatment of advanced NSCLC. There are multiple single-institution and retrospective analyses (selected data is presented in Table 1). The results of chemotherapy in the third and fourth line are strikingly variable across these studies. This may reflect different patient characteristics or underlying tumor biology. Results from Asia—which are generally more favorable than those from the West—are consistent with previous observations that Asians have a better prognosis. There clearly is some heterogeneity in progressive lung cancer, and some patients will respond better than others to further treatment. There is a suggestion that response to previous treatment and continued good performance status are predictors of benefıt from third- and fourth-line chemotherapy, but these conclusions must be viewed with caution given the absence of randomized data. TARGETED THERAPIES FOR PATIENTS WITH A TARGET Today broad molecular profıling is the standard of care for patients with lung adenocarcinomas, 3 and the identifıcation of actionable molecular targets in squamous NSCLC is an area of active investigation. 4 Furthermore, the number of effective therapies has expanded. As an example, for patients with ALK-positive lung cancers, four lines of therapy have shown meaningful clinical benefıt (two “targeted” and two “conventional”). Survival for some molecular subtypes of NSCLC is now measured in years rather than weeks. Although evidence supporting the use of third- and fourthline standard cytotoxic chemotherapy is largely retrospective and of poor quality, prospective data support the use of targeted therapies in patients with defıned molecular targets, even when patients have had multiple prior lines of therapy. From Seattle Cancer Care Alliance, University of Washington, Seattle, WA; US Oncology Research, Ocala, FL; Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY. Disclosures of potential conflicts of interest are found at the end of this article. Corresponding author: Craig Reynolds, MD, US Oncology Research, 433 SW 10th St., Ocala, FL; email: craig.reynolds@usoncology.com. © 2015 by American Society of Clinical Oncology. e414 2015 ASCO EDUCATIONAL BOOK | asco.org/edbook
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AMERICAN SOCIETY OF CLINICAL ONCOLO
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American Society of Clinical Oncolo
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Controversies in Neoadjuvant Therap
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Clinical Trials of Precision Medici
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Managing Ovarian Cancer in the Olde
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Updates in the Multimodality Manage
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PEDIATRIC ONCOLOGY Real-Time Molecu
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2015 ASCO Annual Meeting Disclosure
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2015 Educational Book Expert Panel
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James Marshall, PhD Roswell Park Ca
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2015 Annual Meeting Supporters* MIS
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David Yurman Corporate Allies Conqu
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INVITED ARTICLES This year’s invi
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WONG, CAPASSO, AND ECKHARDT 3 3 sc
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WONG, CAPASSO, AND ECKHARDT terize
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STEPHEN T. SONIS portantly, patient
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HUSSAIN AND DIPAOLA TABLE 1. U.S. F
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EDWARD S. KIM TABLE 1. Selected Umb
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GILBERT ET AL tional scholars, lead
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ENG ET AL colorectal cancer. Indeed
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BREAST CANCER Individualizing the A
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REFORMING THE BUY-AND-BILL CHEMOTHE
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CARE DELIVERY AND PRACTICE MANAGEME
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THE PATIENT-CENTERED MEDICAL HOME c
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MICHAEL A. POSTOW Managing Immune C
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ABOU-ALFA ET AL HCC (Anti-Programme
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AHN ET AL Pancreatic cancer has bee
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EGIDIO DEL FABBRO tion of precachex
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EGIDIO DEL FABBRO FIGURE 3. Mechani
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GERM CELL TUMORS: LOOKING TO THE FU
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SALVAGE CHEMOTHERAPY Salvage Therap
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NOVEL IMMUNOTHERAPY AGENTS IN METAS
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PROMISING STRATEGIES IN BLADDER CAN
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GYNECOLOGIC CANCER Cervical Cancer
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MACKAY, WENZEL, AND MILESHKIN ing s
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MACKAY, WENZEL, AND MILESHKIN 59. F
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GYNECOLOGIC CANCER Managing Ovarian
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DUSKA, TEW, AND MOORE KEY POINTS A
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DUSKA, TEW, AND MOORE FIGURE 2. Sur
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DUSKA, TEW, AND MOORE 10. Griffıth
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GYNECOLOGIC CANCER Treatment of the
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CHEMOTHERAPY FOR PATIENTS WITH BMOC
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PROGRESS IN HEAD AND NECK SQUAMOUS
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HEAD AND NECK CANCER PI3-Kinase: Ge
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ISAACSSON VELHO, CASTRO JR, AND CHU
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SHARON H. GIORDANO Comparative Effe
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HEALTH SERVICES RESEARCH AND QUALIT
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INDUSTRY AND ONCOLOGY KEY POINTS F
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INDUSTRY AND ONCOLOGY has been “l
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INDUSTRY AND ONCOLOGY by (covered)
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INDUSTRY AND ONCOLOGY 42. World Hea
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CANCER CARE QUALITY: CURRENT STATE
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MANAGING OLDER PATIENTS WITH ALL Th
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MANAGING OLDER PATIENTS WITH ALL TA
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MANAGING OLDER PATIENTS WITH ALL FI
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MANAGING OLDER PATIENTS WITH ALL FI
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MANAGING OLDER PATIENTS WITH ALL ra
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TREATMENT OF PHILADELPHIA CHROMOSOM
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CD19 CAR THERAPY FOR ALL FIGURE 1.
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CD19 CAR THERAPY FOR ALL 5. Zhou G,
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NEW TARGETED THERAPIES FOR iNHL New
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NEW TARGETED THERAPIES FOR iNHL TAB
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NEW TARGETED THERAPIES FOR iNHL TAB
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NASSER HANNA culty of this task. Va
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LYMPHOMA AND PLASMA CELL DISORDERS
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NOWAKOWSKI AND CZUCZMAN sociated wi
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DAVID W. SCOTT Cell-of-Origin in Di
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DAVID W. SCOTT FIGURE 1. The Origin
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DAVID W. SCOTT FIGURE 2. Immunohist
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DAVID W. SCOTT FIGURE 3. The Lymph2
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STEPHEN ANSELL Disclosures of Poten
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MATEOS AND SAN MIGUEL Smoldering Mu
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LYMPHOMA AND PLASMA CELL DISORDERS
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MANAGEMENT OF CLL Up-Front Manageme
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MANAGEMENT OF CLL than 17p-/TP53mut
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MANAGEMENT OF CLL could be associat
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MANAGEMENT OF CLL tion by nonmalign
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MANAGEMENT OF CLL lymphocytic leuke
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PROGNOSTIC FACTORS AND ADJUVANT RAD
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MERKEL CELL CARCINOMA Merkel Cell C
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MERKEL CELL CARCINOMA tions in PIK3
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MERKEL CELL CARCINOMA treating MCC
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MERKEL CELL CARCINOMA 32. Leonard J
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MELANOMA/SKIN CANCERS Locoregional
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PERFUSION AND INFUSION IN THE ERA O
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NEOADJUVANT THERAPY OF MELANOMA Neo
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NEOADJUVANT THERAPY OF MELANOMA TAB
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NEOADJUVANT THERAPY OF MELANOMA ity
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MELANOMA/SKIN CANCERS Targeted Mole
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SULLIVAN ET AL FIGURE 1. Relevant S
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SULLIVAN ET AL Resistance to BRAF i
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SULLIVAN ET AL 17. Halait H, Demart
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SULLIVAN ET AL NRAS-mutant melanoma
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KLEPIN, RODIN, AND HURRIA Treating
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KLEPIN, RODIN, AND HURRIA plication
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PERIPHERAL NEUROTOXICITY IN CANCER
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PARTRIDGE, JACOBSEN, AND ANDERSEN C
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PARTRIDGE, JACOBSEN, AND ANDERSEN c
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PARTRIDGE, JACOBSEN, AND ANDERSEN w
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PARTRIDGE, JACOBSEN, AND ANDERSEN v
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LESLIE R. SCHOVER Sexual Healing in
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LESLIE R. SCHOVER tinuous ADT in pr
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LESLIE R. SCHOVER 12. Potosky AL, H
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CATHERINE H. VAN POZNAK TABLE 1. Wo
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CATHERINE H. VAN POZNAK (tamoxifen,
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CATHERINE H. VAN POZNAK TABLE 3. FD
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CATHERINE H. VAN POZNAK premenopaus
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SHARI GOLDFARB KEY POINTS Brea
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SHARI GOLDFARB and friction with va
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SHARI GOLDFARB importance both duri
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PATIENT AND SURVIVOR CARE Moving Su
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MAYER ET AL TABLE 1. Quality Metric
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MAYER ET AL to enhance the quality
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MAYER ET AL FIGURE 2. (A) Infertili
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MAYER ET AL efıcial suggests that
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PATIENT AND SURVIVOR CARE The Chall
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BRUERA AND PAICE Choice of Opioid a
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BRUERA AND PAICE toxicity and proce
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BRUERA AND PAICE effective. Basic s
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PEDIATRIC ONCOLOGY Real-Time Molecu
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CARROLL, RAETZ, AND MEYER KEY POINT
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CARROLL, RAETZ, AND MEYER most are
Page 824 and 825:
CARROLL, RAETZ, AND MEYER markers a
Page 826 and 827:
PEDIATRIC ONCOLOGY Translating Surv
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REDUCING THE BURDEN OF LATE EFFECTS
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Page 832 and 833:
Page 834 and 835:
Page 836 and 837:
PROFESSIONAL DEVELOPMENT The Challe
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ADVANCES IN WEBSITE INFORMATION RES
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Page 842 and 843:
Page 844 and 845:
Page 846 and 847:
COMMUNICATION AND TECHNOLOGY: IT’
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Page 850 and 851:
Page 852 and 853:
PATIENT-REPORTED OUTCOMES IN ONCOLO
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PATIENT-REPORTED OUTCOMES IN ONCOLO
Page 856 and 857:
PROFESSIONAL DEVELOPMENT Trends, An
Page 858 and 859:
CLINICAL ONCOLOGY PRACTICE 2015 FIG
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CLINICAL ONCOLOGY PRACTICE 2015 (6.
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CLINICAL ONCOLOGY PRACTICE 2015 Pro
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ADJUVANT/NEOADJUVANT MEDICAL THERAP
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Page 868 and 869:
Page 870 and 871:
INDICATIONS FOR ADJUVANT RADIATION
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Page 874 and 875:
Page 876 and 877:
Page 878 and 879:
SARCOMA Latest Advances in Systemic
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SYSTEMIC THERAPY FOR OSTEOSARCOMA A
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SYSTEMIC THERAPY FOR OSTEOSARCOMA A
Page 884 and 885:
RETHINKING TREATMENT FOR CHONDROSAR
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Page 888 and 889:
Page 890 and 891:
Page 892 and 893:
BONE SARCOMAS IN ADULTS local disea
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BONE SARCOMAS IN ADULTS structure a
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SARCOMA Well-Differentiated and Ded
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ABBAS MANJI ET AL ticular region. 7
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ABBAS MANJI ET AL MYXOID (ROUND CEL
Page 902 and 903:
ABBAS MANJI ET AL versus doxorubici
Page 904 and 905:
SHLUSH AND HERSHKOVITZ Clonal Evolu
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SHLUSH AND HERSHKOVITZ FIGURE 1. Ti
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TUMOR BIOLOGY New Strategies to Und
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KNAPP, DHAWAN, AND OSTRANDER in dog
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KNAPP, DHAWAN, AND OSTRANDER TABLE
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KNAPP, DHAWAN, AND OSTRANDER 14. Fe
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SOURBIER, SRINIVASAN, AND LINEHAN M
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SOURBIER, SRINIVASAN, AND LINEHAN F
Page 920 and 921:
SOURBIER, SRINIVASAN, AND LINEHAN T
Page 922:
Author Index Abbas Manji, Gulam ...
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