Selecting Treatment for First- Line Non-Squamous NSCLC

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The challenge facing many physicians who treat advanced non-small cell lung cancer (NSCLC) is determining the optimal approach for treating patients with non-squamous histology.

Mark A. Socinski, MD, begins by describing the criteria he uses to determine eligibility for treatment with bevacizumab (Avastin) in the first-line metastatic setting. He notes that patients with non-squamous NSCLC with recent hemoptysis, untreated brain metastases, recent stroke, or cardiac issues should not receive bevacizumab. In general, Socinski notes, he prefers to use the agent in patients with ECOG performance status 0 or 1, since this population was studied in the ECOG 4599, which led to the approval of bevacizumab in this space.

Socinski and Alan B. Sandler, MD, agree that bevacizumab has its greatest utility in the first-line setting. In general, both physicians treat patients with a combination of paclitaxel, carboplatin, and bevacizumab (PCB) for an initial 4 to 6 cycles followed by maintenance bevacizumab until progression.

Corey J. Langer, MD, notes that some evidence in colorectal cancer has supported continuation treatment with bevacizumab in the second-line. Currently, he notes, a trial is underway examining bevacizumab beyond progression with or without a standard second-line therapy. Langer also points out that another trial is comparing switch maintenance with pemetrexed to maintenance bevacizumab following 6 cycles of PCB in advanced non-squamous NSCLC.

Socinski notes that different chemotherapy combinations with bevacizumab have been examined. However, none of these trials have been able to outperform the results seen in the ECOG 4599 trial. The most recent, the POINTBREAK trial, combined pemetrexed with bevacizumab and carboplatin compared to PCB. Socinski believes this trial indicated that pemetrexed is best reserved as a maintenance therapy in the second-line. Moreover, the majority of the panel agrees that bevacizumab seems to be most effective when given in combination with taxanes.