Long-Term Care for Metastatic Large Cell Lung Cancer

Lyudmila Bazhenova, MD:I believe this patient should receive maintenance therapy based on the fact that she was treated as per the ECOG-4599 trial, which took carboplatin, paclitaxel, and bevacizumab and continued bevacizumab as maintenance therapy upon the completion of 6 cycles of treatment. I believe that one of the choices for this patient could be maintenance bevacizumab. The other choice could be maintenance pemetrexed or one can even select maintenance pemetrexed and bevacizumab.

We do not have any single study comparing all of the 3 maintenance options I have described. We have a study called AVAPERL, which compared maintenance bevacizumab and pemetrexed to maintenance bevacizumab by itself, showing that double maintenance improved progression-free survival. There was a numeric improvement in overall survival, but that did not meet statistical significance. Therefore, at this point, I believe that anybody can choose. There is no scientific rationale on how to correctly choose maintenance therapy, so I would recommend seeing how your patient is doing. If the patient is having significant hypertension from bevacizumab or other complications, I would probably drop bevacizumab and just do pemetrexed maintenance. If the patient is having too much fatigue from chemotherapy, then you can consider dropping pemetrexed and do bevacizumab maintenance by itself.

Basic supportive care is important, making sure that we check their blood tests for neutropenia. Pain control is important. I strongly believe in palliative care. As I mentioned, we have randomized clinical trials showing that early palliative care for patients with stage 4 lung cancer improve survival. In our institution, we have access to palliative care. Palliative care is highly integrated in the management of our patients. Specialists usually adjust their appointments so they can see the patient right after I saw the patient, without having them coming on separate visits. I think that makes the integration of palliative care into general oncology very seamless for a physician, but more importantly for the patient.

Transcript edited for clarity.

• A 70-year old woman presented with persistent cough and congestion lasting more than 6 months
  • She is a non-smoker; drinks alcohol 1-2 times/week
  • PMH: Crohn’s disease managed on infliximab; hypothyroidism, moderately well-managed on levothyroxine; osteoarthritis managed PRN on naproxen
  • Her physical exam and cardiac workup were normal
  • CBC; WNL
  • PS by ECOG assessment is 2
• Chest X-Ray showed mass in the upper right lung
• CT of the chest, abdomen, and pelvis showed a solid 6 X 8 cm. Right-sided pleural mass abutting the apical aspect of the chest wall and 2 small hepatic nodules measuring 1.5 cm and 2 cm.
• Bronchoscopy and biopsy of the lung mass was performed; pathology was consistent with large cell carcinoma
  • Genetic testing was negative for known driver mutations
  • PD-L1 testing by IHC showed expression in 2% of cells
• Brain MRI showed no evidence of CNS disease
• Diagnosis; stage IV NSCLC
• The patient was started on therapy with carboplatin and paclitaxel and bevacizumab