NSCLC Management Before and After the PACIFIC Trial

Mark A. Socinski, MD:In the United States we have 2 platforms that I would consider the standard of care for patients like this. One platform is the use of cisplatinum and etoposide at full systemic doses during chemoradiation. And physicians would sometimes use induction or consolidation therapy in the pre-PACIFIC era. So CIS [cisplatin]/etoposide radiation was one standard of care. The other platform that many physicians use is low-dose weekly carboplatin and paclitaxel, again, with either induction or consolidation therapy. They were part of the armamentarium. And I would say in the United States probably 90% or more of patients would be treated with one of those platforms.

There are certainly data on other drugs like cisplatinum/vinorelbine, cisplatinum/docetaxel. A number of trials have been done. But there’s no advantage for those drugs either from an efficacy or toxicity point of view. So most people would use either the CIS/etoposide or carboplatin/paclitaxel platforms.

Interestingly, we’ve never done a definitive trial to determine whether CIS/etoposide or CARBO/TAX [carboplatin/paclitaxel] is better. We do have some interesting retrospective case cohort trials suggesting that the use of the low-dose CARBO/Taxol results in equal outcomes with less toxicity. And so I think probably the majority of treating oncologists would use the low-dose weekly carboplatin/paclitaxel approach.

When I would see a stage III patient prior to PACIFIC, I would say “My goal is to cure you,” for a good performance status patient, but I would also say that the likelihood that we’re going to cure you is 1-in-4. So 3 out of 4 patients would fail. We didn’t know how to identify the 1 patient from the beginning, who was going to be cured. It was a very difficult time for patients with stage III disease prior to PACIFIC. “My doctor says I can be cured, I’m going to get through this chemoradiation and hope for the best.” You would get through the chemoradiation; that would typically take 3 months.

You would do a follow-up CT [computed tomography] scan and at that point in most patients, things looked good. And then the patient would say, “Well, is there anything else we can do at this point to improve my chance of being cured?” And, again, we had tried a number of things that never really worked out to show an advantage. So the standard of care was this 2-to-3-month platform of chemoradiation. And then that was it, and then it was time. Time would tell you whether you were cured. And most patients feel best when they’re actively doing something about their cancer. It’s tough for patients when you did everything that you could do. It takes 2 or 3 months, and then it’s just the waiting game.

The thing that’s tough for any of us, but particularly for cancer patients, is that uncertainty that’s out there. What’s going to happen to me? Is my cancer cured, or am I going to have to deal with this at some point in the future?

As I mentioned before, I think the cisplatin/etoposide platform is a perfectly reasonable standard of care platform. Many physicians use it. It’s been the standard in many clinical trials in cooperative groups. So I think it’s perfectly reasonable to use it. In my experience, I’ve used it many times. I find it to be a bit more toxic than the weekly carboplatin/paclitaxel. But, again, I could never fault any oncologist for using that particular platform because I think it’s been a time-proven cooperative group phase III standard platform for this stage of the disease, and it would be perfectly reasonable to use it. It’s typically not what I use in my practice. I tend to use weekly carboplatin/paclitaxel. But, again, I think it’s perfectly reasonable to use that platform in patients who we’re discussing today.

Transcript edited for clarity.

Case: A 52-Year-Old Male With Stage IIIA NSCLC

Initial presentation

• A 52-year-old man presented with a 15-lb weight loss and worsening dyspnea
• PMH: HTN
• SH: Computer programmer; Smoked a pack/day for 30 years; Quit smoking 2 years ago; Married with 4 kids
• PE: Unremarkable

Clinical workup

• Imaging:
  • Initial CT showed a 5-cm left upper lobe mass with aortopulmonary window and left paratracheal adenopathy measuring up to 2.5 cm
  • Subsequent PET scan showed activity in the left upper lobe mass and all nodal areas
  • No extrathoracic disease was identified
  • MRI showed no brain metastases
• Mediastinal sampling: EBUS was performed and documented squamous carcinoma in the left paratracheal lymph nodes
• Staging: T2N2M0
• ECOG PS 1
• Multidisciplinary tumor board deemed his tumor unresectable due to multistation N2 disease

Treatment

• Concurrent cisplatin/etoposide with external-beam radiotherapy
• Repeat CT 4 weeks after completion of concurrent chemoradiotherapy showed a PR with no new sites of disease